Anesth Pain Med.  2022 Apr;17(2):132-144. 10.17085/apm.22132.

Cardiovascular manifestation of end-stage liver disease and perioperative echocardiography for liver transplantation: anesthesiologist’s view

• Han S
• Park J
• Hong SH
• Park CS
• Choi J
• Chae MS

• KMID: 2531689
• DOI: http://doi.org/10.17085/apm.22132

Abstract

Liver transplantation (LT) is the curative therapy for decompensated cirrhosis. However, anesthesiologists can find it challenging to manage patients undergoing LT due to the underlying pathologic conditions of patients with end-stage liver disease and the high invasiveness of the procedure, which is frequently accompanied by massive blood loss. Echocardiography is a non-invasive or semi-invasive imaging tool that provides real-time information about the structural and functional status of the heart and is considered to be able to improve outcomes by enabling accurate and detailed assessments. This article reviews the pathophysiologic changes of the heart accompanied by cirrhosis that mainly affect hemodynamics. We also present a comparative review of the diagnostic criteria for cirrhotic cardiomyopathy published by the World Congress of Gastroenterology in 2005 and the Cirrhotic Cardiomyopathy Consortium in 2019. This article discusses the conditions that could affect hemodynamic stability and postoperative outcomes, such as coronary artery disease, left ventricular outflow tract obstruction, portopulmonary hypertension, hepatopulmonary syndrome, pericardial effusion, cardiac tamponade, patent foramen ovale, and ascites. Finally, we cover a number of intraoperative factors that should be considered, including intraoperative blood loss, rapid reaccumulation of ascites, manipulation of the inferior vena cava, post-reperfusion syndrome, and adverse effects of excessive fluid infusion and transfusion. This article aimed to summarize the cardiovascular manifestations of cirrhosis that can affect hemodynamics and can be evaluated using perioperative echocardiography. We hope that this article will provide information about the hemodynamic characteristics of LT recipients and stimulate more active use of perioperative echocardiography.

Keyword

Cirrhosis; Cardiomyopathies; Echocardiography; Liver transplantation

Reference

1. Martin P, DiMartini A, Feng S, Brown R Jr, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014; 59:1144–65.

2. Bang SR, Ahn HJ, Kim GS, Yang M, Gwak MS, Ko JS, et al. Predictors of high intraoperative blood loss derived by simple and objective method in adult living donor liver transplantation. Transplant Proc. 2010; 42:4148–50.

3. Adelmann D, Kronish K, Ramsay MA. Anesthesia for liver transplantation. Anesthesiol Clin. 2017; 35:491–508.

4. Lindsay AJ, Burton J, Ray CE Jr. Paracentesis-induced circulatory dysfunction: a primer for the interventional radiologist. Semin Intervent Radiol. 2014; 31:276–8.

5. Rudnick MR, Marchi LD, Plotkin JS. Hemodynamic monitoring during liver transplantation: a state of the art review. World J Hepatol. 2015; 7:1302–11.

6. Mitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2019; 32:1–64.

7. Prabhu M, Raju D, Pauli H. Transesophageal echocardiography: instrumentation and system controls. Ann Card Anaesth. 2012; 15:144–55.

8. VanWagner LB, Harinstein ME, Runo JR, Darling C, Serper M, Hall S, et al. Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: an evaluation of the evidence and consensus recommendations. Am J Transplant. 2018; 18:30–42.

9. Porter TR, Shillcutt SK, Adams MS, Desjardins G, Glas KE, Olson JJ, et al. Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2015; 28:40–56.

10. Soong W, Sherwani SS, Ault ML, Baudo AM, Herborn JC, De Wolf AM. United States practice patterns in the use of transesophageal echocardiography during adult liver transplantation. J Cardiothorac Vasc Anesth. 2014; 28:635–9.

11. Hofer RE, Vogt MNP, Taner T, Findlay JY. Influence of intraoperative transesophageal echocardiography and pulmonary artery catheter monitoring on outcomes in liver transplantation. Transplant Direct. 2020; 6:e525.

12. Canty DJ, Royse CF. Audit of anaesthetist-performed echocardiography on perioperative management decisions for non-cardiac surgery. Br J Anaesth. 2009; 103:352–8.

13. Kobal SL, Trento L, Baharami S, Tolstrup K, Naqvi TZ, Cercek B, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005; 96:1002–6.

14. Korean Network for Organ Sharing. Annual report of the transplant 2019. Seoul: Korean Network for Organ Sharing; 2020 Aug. Report No.: 11-1352159-001434-10. 262 p.

15. Tsochatzis EA, Bosch J, Burroughs AK. Liver cirrhosis. Lancet. 2014; 383:1749–61.

16. Kontos HA, Shapiro W, Mauck HP, Patterson JL Jr. General and regional circulatory alterations in cirrhosis of the liver. Am J Med. 1964; 37:526–35.

17. Abraldes JG, Iwakiri Y, Loureiro-Silva M, Haq O, Sessa WC, Groszmann RJ. Mild increases in portal pressure upregulate vascular endothelial growth factor and endothelial nitric oxide synthase in the intestinal microcirculatory bed, leading to a hyperdynamic state. Am J Physiol Gastrointest Liver Physiol. 2006; 290:G980–7.

18. Schrier RW. Water and sodium retention in edematous disorders: role of vasopressin and aldosterone. Am J Med. 2006; 119(7 Suppl 1):S47–53.

19. Dourakis SP, Geladari E, Geladari C, Vallianou N. Cirrhotic cardiomyopathy: the interplay between liver and cardiac muscle. How does the cardiovascular system react when the liver is diseased? Curr Cardiol Rev. 2021; 17:78–84.

20. Li X, Yu S, Li L, Han D, Dai S, Gao Y. Cirrhosis-related changes in left ventricular function and correlation with the model for end-stage liver disease score. Int J Clin Exp Med. 2014; 7:5751–7.

21. Rector WG Jr, Adair O, Hossack KF, Rainguet S. Atrial volume in cirrhosis: relationship to blood volume and plasma concentration of atrial natriuretic factor. Gastroenterology. 1990; 99:766–70.

22. Møller S, Søndergaard L, Møgelvang J, Henriksen O, Henriksen JH. Decreased right heart blood volume determined by magnetic resonance imaging: evidence of central underfilling in cirrhosis. Hepatology. 1995; 22:472–8.

23. Møller S, Hove JD, Dixen U, Bendtsen F. New insights into cirrhotic cardiomyopathy. Int J Cardiol. 2013; 167:1101–8.

24. Krag A, Bendtsen F, Henriksen JH, Møller S. Low cardiac output predicts development of hepatorenal syndrome and survival in patients with cirrhosis and ascites. Gut. 2010; 59:105–10.

25. Ma Z, Lee SS. Cirrhotic cardiomyopathy: getting to the heart of the matter. Hepatology. 1996; 24:451–9.

26. Møller S, Henriksen JH. Cirrhotic cardiomyopathy: a pathophysiological review of circulatory dysfunction in liver disease. Heart. 2002; 87:9–15.

27. Baldassarre M, Giannone FA, Napoli L, Tovoli A, Ricci CS, Tufoni M, et al. The endocannabinoid system in advanced liver cirrhosis: pathophysiological implication and future perspectives. Liver Int. 2013; 33:1298–308.

28. Gould L, Shariff M, Zahir M, Di Lieto M. Cardiac hemodynamics in alcoholic patients with chronic liver disease and a presystolic gallop. J Clin Invest. 1969; 48:860–8.

29. Wong F, Girgrah N, Graba J, Allidina Y, Liu P, Blendis L. The cardiac response to exercise in cirrhosis. Gut. 2001; 49:268–75.

30. Kelbaek H, Eriksen J, Brynjolf I, Raboel A, Lund JO, Munck O, et al. Cardiac performance in patients with asymptomatic alcoholic cirrhosis of the liver. Am J Cardiol. 1984; 54:852–5.

31. Liu H, Lee SS. Cardiopulmonary dysfunction in cirrhosis. J Gastroenterol Hepatol. 1999; 14:600–8.

32. Zardi EM, Abbate A, Zardi DM, Dobrina A, Margiotta D, Van Tassell BW, et al. Cirrhotic cardiomyopathy. J Am Coll Cardiol 2010;56:539-49. Erratum in: J Am Coll Cardiol. 2010; 56:1000.

33. Sampathkumar P, Lerman A, Kim BY, Narr BJ, Poterucha JJ, Torsher LC, et al. Post-liver transplantation myocardial dysfunction. Liver Transpl Surg. 1998; 4:399–403.

34. Monge García MI, Jian Z, Settels JJ, Hunley C, Cecconi M, Hatib F, et al. Determinants of left ventricular ejection fraction and a novel method to improve its assessment of myocardial contractility. Ann Intensive Care. 2019; 9:48.

35. Flachskampf FA, Blankstein R, Grayburn PA, Kramer CM, Kwong RYK, Marwick TH, et al. Global longitudinal shortening: a positive step towards reducing confusion surrounding global longitudinal strain. JACC Cardiovasc Imaging. 2019; 12(8 Pt 1):1566–7.

36. Russo C, Jin Z, Elkind MS, Rundek T, Homma S, Sacco RL, et al. Prevalence and prognostic value of subclinical left ventricular systolic dysfunction by global longitudinal strain in a community-based cohort. Eur J Heart Fail. 2014; 16:1301–9.

37. Stundiene I, Sarnelyte J, Norkute A, Aidietiene S, Liakina V, Masalaite L, et al. Liver cirrhosis and left ventricle diastolic dysfunction: systematic review. World J Gastroenterol. 2019; 25:4779–95.

38. Mittal C, Qureshi W, Singla S, Ahmad U, Huang MA. Pre-transplant left ventricular diastolic dysfunction is associated with post transplant acute graft rejection and graft failure. Dig Dis Sci. 2014; 59:674–80.

39. Møller S, Henriksen JH. Cirrhotic cardiomyopathy. J Hepatol. 2010; 53:179–90.

40. Møller S, Henriksen JH. Cardiovascular complications of cirrhosis. Gut. 2008; 57:268–78.

41. AlQudah M, Hale TM, Czubryt MP. Targeting the renin-angiotensin-aldosterone system in fibrosis. Matrix Biol. 2020; 91-92:92–108.

42. Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016; 29:277–314.

43. Izzy M, VanWagner LB, Lin G, Altieri M, Findlay JY, Oh JK, et al. Cirrhotic Cardiomyopathy Consortium. Redefining cirrhotic cardiomyopathy for the modern era. Hepatology. 2020; 71:334–45.

44. Møller S, Mortensen C, Bendtsen F, Jensen LT, Gøtze JP, Madsen JL. Cardiac sympathetic imaging with mIBG in cirrhosis and portal hypertension: relation to autonomic and cardiac function. Am J Physiol Gastrointest Liver Physiol. 2012; 303:G1228–35.

45. Ates F, Topal E, Kosar F, Karincaoglu M, Yildirim B, Aksoy Y, et al. The relationship of heart rate variability with severity and prognosis of cirrhosis. Dig Dis Sci. 2006; 51:1614–8.

46. Newton JL, Allen J, Kerr S, Jones DE. Reduced heart rate variability and baroreflex sensitivity in primary biliary cirrhosis. Liver Int. 2006; 26:197–202.

47. Umphrey LG, Hurst RT, Eleid MF, Lee KS, Reuss CS, Hentz JG, et al. Preoperative dobutamine stress echocardiographic findings and subsequent short-term adverse cardiac events after orthotopic liver transplantation. Liver Transpl. 2008; 14:886–92.

48. Baik SK, Fouad TR, Lee SS. Cirrhotic cardiomyopathy. Orphanet J Rare Dis. 2007; 2:15.

49. Bernardi M, Calandra S, Colantoni A, Trevisani F, Raimondo ML, Sica G, et al. Q-T interval prolongation in cirrhosis: prevalence, relationship with severity, and etiology of the disease and possible pathogenetic factors. Hepatology. 1998; 27:28–34.

50. Ward CA, Ma Z, Lee SS, Giles WR. Potassium currents in atrial and ventricular myocytes from a rat model of cirrhosis. Am J Physiol. 1997; 273(2 Pt 1):G537–44.

51. Wiese S, Hove JD, Bendtsen F, Møller S. Cirrhotic cardiomyopathy: pathogenesis and clinical relevance. Nat Rev Gastroenterol Hepatol. 2014; 11:177–86.

52. Huang WA, Dunipace EA, Sorg JM, Vaseghi M. Liver disease as a predictor of new-onset atrial fibrillation. J Am Heart Assoc. 2018; 7:e008703.

53. Wong F. Cirrhotic cardiomyopathy. Hepatol Int. 2009; 3:294–304.

54. Reddy YNV, Melenovsky V, Redfield MM, Nishimura RA, Borlaug BA. High-output heart failure: a 15-year experience. J Am Coll Cardiol. 2016; 68:473–82.

55. Lee SS. Cardiac abnormalities in liver cirrhosis. West J Med. 1989; 151:530–5.

56. Timoh T, Protano MA, Wagman G, Bloom M, Vittorio TJ. A perspective on cirrhotic cardiomyopathy. Transplant Proc. 2011; 43:1649–53.

57. VanWagner LB, Serper M, Kang R, Levitsky J, Hohmann S, Abecassis M, et al. Factors associated with major adverse cardiovascular events after liver transplantation among a national sample. Am J Transplant. 2016; 16:2684–94.

58. Razpotnik M, Bota S, Wimmer P, Hackl M, Lesnik G, Alber H, et al. The prevalence of cirrhotic cardiomyopathy according to different diagnostic criteria. Liver Int. 2021; 41:1058–69.

59. Namazi F, van der Bijl P, Hirasawa K, Kamperidis V, van Wijngaarden SE, Mertens B, et al. Prognostic value of left ventricular global longitudinal strain in patients with secondary mitral regurgitation. J Am Coll Cardiol. 2020; 75:750–8.

60. Krishnasamy R, Isbel NM, Hawley CM, Pascoe EM, Burrage M, Leano R, et al. Left ventricular global longitudinal strain (GLS) is a superior predictor of all-cause and cardiovascular mortality when compared to ejection fraction in advanced chronic kidney disease. PLoS One. 2015; 10:e0127044.

61. Kwon HM, Moon YJ, Jung KW, Park YS, Kim KS, Jun IG, et al. Appraisal of cardiac ejection fraction with liver disease severity: implication in post-liver transplantation mortality. Hepatology. 2020; 71:1364–80.

62. Oh JK, Miranda WR, Bird JG, Kane GC, Nagueh SF. The 2016 diastolic function guideline: is it already time to revisit or revise them? JACC Cardiovasc Imaging. 2020; 13(1 Pt 2):327–35.

63. Almeida JG, Fontes-Carvalho R, Sampaio F, Ribeiro J, Bettencourt P, Flachskampf FA, et al. Impact of the 2016 ASE/EACVI recommendations on the prevalence of diastolic dysfunction in the general population. Eur Heart J Cardiovasc Imaging. 2018; 19:380–6.

64. Park J, Lee J, Kwon A, Choi HJ, Chung HS, Hong SH, et al. The 2016 ASE/EACVI recommendations may be able to more accurately identify patients at risk for diastolic dysfunction in living donor liver transplantation. PLoS One. 2019; 14:e0215603.

65. Tiukinhoy-Laing SD, Rossi JS, Bayram M, De Luca L, Gafoor S, Blei A, et al. Cardiac hemodynamic and coronary angiographic characteristics of patients being evaluated for liver transplantation. Am J Cardiol. 2006; 98:178–81.

66. Keeling AN, Flaherty JD, Davarpanah AH, Ambrosy A, Farrelly CT, Harinstein ME, et al. Coronary multidetector computed tomographic angiography to evaluate coronary artery disease in liver transplant candidates: methods, feasibility and initial experience. J Cardiovasc Med (Hagerstown). 2011; 12:460–8.

67. Vanwagner LB, Bhave M, Te HS, Feinglass J, Alvarez L, Rinella ME. Patients transplanted for nonalcoholic steatohepatitis are at increased risk for postoperative cardiovascular events. Hepatology. 2012; 56:1741–50.

68. Targher G, Day CP, Bonora E. Risk of cardiovascular disease in patients with nonalcoholic fatty liver disease. N Engl J Med. 2010; 363:1341–50.

69. Johnston SD, Morris JK, Cramb R, Gunson BK, Neuberger J. Cardiovascular morbidity and mortality after orthotopic liver transplantation. Transplantation. 2002; 73:901–6.

70. Davidson CJ, Gheorghiade M, Flaherty JD, Elliot MD, Reddy SP, Wang NC, et al. Predictive value of stress myocardial perfusion imaging in liver transplant candidates. Am J Cardiol. 2002; 89:359–60.

71. Nguyen P, Plotkin J, Fishbein TM, Laurin JM, Satoskar R, Shetty K, et al. Dobutamine stress echocardiography in patients undergoing orthotopic liver transplantation: a pooled analysis of accuracy, perioperative and long term cardiovascular prognosis. Int J Cardiovasc Imaging. 2013; 29:1741–8.

72. Snipelisky D, Levy M, Shapiro B. Utility of dobutamine stress echocardiography as part of the pre-liver transplant evaluation: an evaluation of its efficacy. Clin Cardiol. 2014; 37:468–72.

73. Møller S, Bernardi M. Interactions of the heart and the liver. Eur Heart J. 2013; 34:2804–11.

74. Blankstein R, Di Carli MF. Integration of coronary anatomy and myocardial perfusion imaging. Nat Rev Cardiol. 2010; 7:226–36.

75. Carey EJ, Steidley DE, Aqel BA, Byrne TJ, Mekeel KL, Rakela J, et al. Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl. 2010; 16:1373–8.

76. Gatzoulis MA, Webb GD, Daubeney PEF. Diagnosis and management of adult congenital heart disease. 3rd ed. Philadelphia (PA), Elsevier. 2018, pp 615-21.

77. Slama M, Tribouilloy C, Maizel J. Left ventricular outflow tract obstruction in ICU patients. Curr Opin Crit Care. 2016; 22:260–6.

78. Yang JH, Park SW, Yang JH, Cho SW, Kim HS, Choi KA, et al. Dynamic left ventricular outflow tract obstruction without basal septal hypertrophy, caused by catecholamine therapy and volume depletion. Korean J Intern Med. 2008; 23:106–9.

79. Hioki H, Izawa A, Miura T, Motoki H, Aizawa K, Koshikawa M, et al. Dynamic left ventricular outflow tract obstruction due to anemia in a 71-year-old patient with sigmoid septum. J Cardiol Cases. 2010; 1:e144–6.

80. Maraj S, Jacobs LE, Maraj R, Contreras R, Rerkpattanapipat P, Malik TA, et al. Inducible left ventricular outflow tract gradient during dobutamine stress echocardiography: an association with intraoperative hypotension but not a contraindication to liver transplantation. Echocardiography. 2004; 21:681–5.

81. Robertson A. Intraoperative management of liver transplantation in patients with hypertrophic cardiomyopathy: a review. Transplant Proc. 2010; 42:1721–3.

82. Savale L, O'Callaghan DS, Magnier R, Le Pavec J, Hervé P, Jaïs X, et al. Current management approaches to portopulmonary hypertension. Int J Clin Pract Suppl. 2011; 169:11–8.

83. Swanson KL, Wiesner RH, Nyberg SL, Rosen CB, Krowka MJ. Survival in portopulmonary hypertension: Mayo Clinic experience categorized by treatment subgroups. Am J Transplant. 2008; 8:2445–53.

84. Gordon C, Collard CD, Pan W. Intraoperative management of pulmonary hypertension and associated right heart failure. Curr Opin Anaesthesiol. 2010; 23:49–56.

85. Porres-Aguilar M, Zuckerman MJ, Figueroa-Casas JB, Krowka MJ. Portopulmonary hypertension: state of the art. Ann Hepatol. 2008; 7:321–30.

86. Kawut SM, Krowka MJ, Trotter JF, Roberts KE, Benza RL, Badesch DB, et al. Pulmonary Vascular Complications of Liver Disease Study Group. Clinical risk factors for portopulmonary hypertension. Hepatology. 2008; 48:196–203.

87. Ramsay MA, Simpson BR, Nguyen AT, Ramsay KJ, East C, Klintmalm GB. Severe pulmonary hypertension in liver transplant candidates. Liver Transpl Surg. 1997; 3:494–500.

88. Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, et al. ESC Committee for Practice Guidelines (CPG). Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009; 30: 2493-537. Erratum in: Eur Heart J. 2011; 32:926.

89. Colle IO, Moreau R, Godinho E, Belghiti J, Ettori F, Cohen-Solal A, et al. Diagnosis of portopulmonary hypertension in candidates for liver transplantation: a prospective study. Hepatology. 2003; 37:401–9.

90. Kim WR, Krowka MJ, Plevak DJ, Lee J, Rettke SR, Frantz RP, et al. Accuracy of Doppler echocardiography in the assessment of pulmonary hypertension in liver transplant candidates. Liver Transpl. 2000; 6:453–8.

91. Bozbas SS, Bozbas H. Portopulmonary hypertension in liver transplant candidates. World J Gastroenterol. 2016; 22:2024–9.

92. Fauconnet P, Klopfenstein CE, Schiffer E. Hepatopulmonary syndrome: the anaesthetic considerations. Eur J Anaesthesiol. 2013; 30:721–30.

93. Porres-Aguilar M, Altamirano JT, Torre-Delgadillo A, Charlton MR, Duarte-Rojo A. Portopulmonary hypertension and hepatopulmonary syndrome: a clinician-oriented overview. Eur Respir Rev. 2012; 21:223–33.

94. Arguedas MR, Singh H, Faulk DK, Fallon MB. Utility of pulse oximetry screening for hepatopulmonary syndrome. Clin Gastroenterol Hepatol. 2007; 5:749–54.

95. Arguedas MR, Abrams GA, Krowka MJ, Fallon MB. Prospective evaluation of outcomes and predictors of mortality in patients with hepatopulmonary syndrome undergoing liver transplantation. Hepatology. 2003; 37:192–7.

96. Muralimohan R, Delu A, Ma T. Pericardial effusion of obscure origin. Dig Dis Sci. 2014; 59:2909–12.

97. Naschitz JE, Slobodin G, Lewis RJ, Zuckerman E, Yeshurun D. Heart diseases affecting the liver and liver diseases affecting the heart. Am Heart J. 2000; 140:111–20.

98. Garg A, Armstrong WF. Echocardiography in liver transplant candidates. JACC Cardiovasc Imaging. 2013; 6:105–19.

99. Sagristà-Sauleda J, Mercé AS, Soler-Soler J. Diagnosis and management of pericardial effusion. World J Cardiol. 2011; 3:135–43.

100. Park J, Lee M, Kim J, Choi HJ, Kwon A, Chung HS, et al. Intraoperative management to prevent cardiac collapse in a patient with a recurrent, large-volume pericardial effusion and paroxysmal atrial fibrillation during liver transplantation: a case report. Transplant Proc. 2019; 51:568–74.

101. Apple SJ, Lee J, Freeze M, Rizk D, Trimmingham A, McFarlane SI. Tense ascites causing extracardiac compression: a case report and literature review. Am J Med Case Rep. 2021; 9:402–6.

102. Homma S, Sacco RL. Patent foramen ovale and stroke. Circulation. 2005; 112:1063–72.

103. Falanga G, Carerj S, Oreto G, Khandheria B, Zito C. How to understand patent foramen ovale clinical significance - part II: therapeutic strategies in cryptogenic stroke. J Cardiovasc Echogr. 2015; 25:46–53.

104. Harinstein ME, Iyer S, Mathier MA, Flaherty JD, Fontes P, Planinsic RM, et al. Role of baseline echocardiography in the preoperative management of liver transplant candidates. Am J Cardiol. 2012; 110:1852–5.

105. Alba AC, Verocai Flaman F, Granton J, Delgado DH. Patent foramen ovale does not have a negative impact on early outcomes in patients undergoing liver transplantation. Clin Transplant. 2011; 25:151–5.

106. Werlang ME, Palmer WC, Boyd EA, Cangemi DJ, Harnois DM, Taner CB, et al. Patent foramen ovale in liver transplant recipients does not negatively impact short-term outcomes. Clin Transplant. 2016; 30:26–32.

107. Cabrera J, Falcón L, Gorriz E, Pardo MD, Granados R, Quinones A, et al. Abdominal decompression plays a major role in early postparacentesis haemodynamic changes in cirrhotic patients with tense ascites. Gut. 2001; 48:384–9.

108. Kang Y, Elia E. Anesthesia management of liver transplantation. In: Contemporary liver transplantation: the successful liver transplant program. Edited by Doria C: Cham, Springer. 2017, pp 143-87.

109. Kornberg A, Witt U, Kornberg J, Ceyhan GO, Mueller K, Friess H, et al. Prognostic impact of intraoperative blood loss in liver transplant patients with advanced hepatocellular carcinoma. Anticancer Res. 2016; 36:5355–64.

110. Jawan B, Wang CH, Chen CL, Huang CJ, Cheng KW, Wu SC, et al. Review of anesthesia in liver transplantation. Acta Anaesthesiol Taiwan. 2014; 52:185–96.

111. Krishnan S, Schmidt GA. Acute right ventricular dysfunction: real-time management with echocardiography. Chest. 2015; 147:835–46.

112. Feltracco P, Carollo C, Barbieri S, Pettenuzzo T, Ori C. Early respiratory complications after liver transplantation. World J Gastroenterol. 2013; 19:9271–81.

113. Smith NK, Kim S, Hill B, Goldberg A, DeMaria S, Zerillo J. Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) in liver transplantation: a case report and focused review. Semin Cardiothorac Vasc Anesth. 2018; 22:180–90.

114. Brezeanu LN, Brezeanu RC, Diculescu M, Droc G. Anaesthesia for liver transplantation: an update. J Crit Care Med (Targu Mures). 2020; 6:91–100.

115. Gouveia V, Marcelino P, Reuter DA. The role of transesophageal echocardiography in the intraoperative period. Curr Cardiol Rev. 2011; 7:184–96.

116. Manning MW, Kumar PA, Maheshwari K, Arora H. Post-reperfusion syndrome in liver transplantation-an overview. J Cardiothorac Vasc Anesth. 2020; 34:501–11.

117. Xu ZD, Xu HT, Yuan HB, Zhang H, Ji RH, Zou Z, et al. Postreperfusion syndrome during orthotopic liver transplantation: a single-center experience. Hepatobiliary Pancreat Dis Int. 2012; 11:34–9.