Case report
Devastating intracardiac and aortic thrombosis: a case report of apparent catastrophic antiphospholipid syndrome during liver transplantation

https://doi.org/10.1016/j.jclinane.2010.07.007Get rights and content

Abstract

Fewer than 80 cases of intracardiac thrombosis and intraoperative pulmonary thromboembolism during liver transplantation have been described. We present a patient who suffered an intraoperative fulminant intracardiac and aortic thrombosis and posthumously was found to have had high anticardiolipin immunoglobulin M concentration and markers of hyperfibrinolysis in preoperatively collected plasma. Hemostatic therapy in the presence of circulating antiphospholipid antibodies and the pathogenesis of a catastrophic antiphospholipid syndrome are discussed.

Introduction

Fewer than 80 cases of intraoperative intracardiac and pulmonary thromboembolism have been described during liver transplantation [1]. The great majority of these cases involved the right heart. Thrombus formation in all cardiac chambers and aorta as a clinical manifestation of a catastrophic antiphospholipid syndrome is presented.

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Case report

A 62 year old woman presented for liver transplantation secondary to decompensated cirrhotic liver disease [Model for End-Stage Liver Disease (MELD) score of 23] due to chronic hepatitis C. Preoperative evaluation showed significant hepatomegaly, splenomegaly, portal hypertension, mild renal insufficiency, and coagulopathy [prothrombin time (PT) of 16.9 sec, international normalized ratio (INR) of 1.7, platelet count of 55,000/μL]. Preoperative stress echocardiography indicated preserved left

Discussion

Antiphospholipid antibodies (aPL) are described as a family of autoantibodies directed against phospholipids and phospholipid-binding proteins. In low concentrations they are found in 1% to 5% of the general population, and they are more prevalent in elderly and chronically ill patients. Although these antibodies may prolong phospholipid-dependent reactions in in vitro coagulation assays (most often partial thromboplastin time) and interfere with both procoagulation and anticoagulation

Acknowledgments

Our thanks to Dr. David Lubarsky, MD, MBA, Emanuel M. Papper Professor and Chair, Department of Anesthesiology UM Miller School of Medicine; and Dr. Paul Martin, MD, FACP, Professor of Medicine, Chief, Division of Hepatology, University of Miami Miller School of Medicine, for their valuable suggestions in review of this manuscript.

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