Attention for insertion of temporary cardiac pacemaker in liver transplant patients.

To the Editor,

Cardiac pacing is a lifesaving procedure for severe arrhythmias. Here, we would like to draw attention to the insertion of cardiac pacing via superior vena cava for a liver transplant (LT) candidate.

A 59-year-old male patient was diagnosed with multifocal hepatocellular carcinoma (HCC) (four nodules, dominant tumor 7 cm diameter, AFP: 7.1 ng/ml, no macrovascular invasion, and no extrahepatic spread) with cirrhosis due to hepatitis B infection (CHILD class B, MELD score 11). He had no cardiovascular complaint or concomitant disease. Live donor liver transplantation (LDLT) planned and preoperative evaluation for cardiac and pulmonary disease were uneventful. His son was suitable to be a live donor. With the start of the operation, hemodynamic instability of the patient began. A consultant cardiologist was called to the operating room and the operation was canceled due to the requirement for further cardiac evaluation. Because the patient had symptomatic bradycardia unresponsive to medical treatment, he was then transferred to the coronary intensive care, and a temporary cardiac pacemaker was inserted through the right femoral vein in the coronary angiography laboratory. The patient was stable hemodynamically and 4 days later he was transferred to the operating room again for LDLT. This time he was stable. The VCI clamped on suprarenal and subdiaphragmatic level and total hepatectomy performed. After removal of the cirrhotic liver, oozing hemorrhage from the opening of hepatic veins started due to the suprarenal clamp not having been closed properly. A second clamp was inserted and the hemorrhage was controlled. When the cavatomy performed we realized the cardiac pacemaker catheter was in the VCI (Fig. 1). Fortunately, cardiac pacing worked although double clamped and was not cut and the operation was completed uneventfully and there was no need for blood product transfusion. On postoperative day (POD) 1, the temporary cardiac pace removed and the recipient was discharged on POD 18, donor was discharged POD 7. The recipient is currently in the 31st postoperative month and lives without hepatitis B virus or HCC recurrence. During this period, his cardiac function decreased (ejection fraction from 60% to 40%).

FIGURE 1

(A) Yellow circle shows the pacemaker, the blue color, catheter in the vena cava inferior. Yellow arrow shows the clamp on subdiaphragmatic level of VCI. Black arrow shows the double clamp on suprarenal level of VCI. (B) Zoomed view of the pacemaker catheter.

The need for temporary cardiac pacing in LT patients was reported previously and it is an effective treatment for severe arrhythmias [1-3] but mostly performed in the post-transplant period. We draw attention to the risks of using the femoral vein for insertion of the pacemaker catheter in LT candidates during the perioperative period. Cardiologists should keep in mind not to use the femoral vein. In patients who are candidates for LT, a temporary cardiac pacemaker may have to be inserted into the superior vena cava via the jugular or subclavian vein. The use of vascular clamps can cut the catheter which is inserted through the femoral vein or make it dysfunctional and cause severe complications. This report is a good example of why there is a need for a multidisciplinary approach in LT procedure both for cardiologists and for surgeons. Surgeons should be as familiar as cardiologists with the cardiac procedure, and cardiologists should be as familiar as surgeons with LT procedure. Management of this kind of condition should be maintained in coordination with each discipline.