Introduction

Better immunosuppressive regiments and advances in surgical techniques have improved survival of liver transplant recipients. We report about a patient who presented not so much for his diseased heart and liver but also for the astonishing multiplicity, variety and severity of complications he had to overcome.

Case Report

We refer to a 50-year old male who suffered from hepatitis B in 1988. In December 1990, the diagnosis of Hodgkin disease was made (specifically nodular sclerosis, stage IIB). In June 1991, he received six sessions of chemotherapy ABVD and in October 1991, he underwent radiotherapy and surgical debridement of the mediastinum. Some regression of the process of the disease was noted. In March 1992, he underwent interferon treatment. In May 1992, he suffered from acute pericarditis, probably of virus etiology (Coxsackie virus with a title of 1:520). An open biopsy of the pericardium was performed but a hemoperitoneum complicated the procedure necessitating a laparotomy.

A concomitant liver biopsy revealed active cirrhosis. Postoperatively he developed peritonitis and ascites, treated with diuretics and repeated paracentesis. In September 1992, he was referred to the hospital suffering from spontaneous bacterial peritonitis and hepatic encephalopathy (stage I-II).He was found to suffer from active cirrhosis, HbsAg +, hepatic failure final stage. It was decided he would be a candidate for a liver transplantation.

In February 1993, a liver transplantation was performed in France. During the surgical procedure he suffered from air embolism, then cardiac arrest and eventually he was resuscitated with cardiac massage. Subsequently, he was transferred to the ICU where he had asynchronus clonic movements of the head and upper and lower limbs. A diagnosis of air embolism was made. He was transferred to a another hospital for hyperbaric oxygen therapy where he suffered from perforation of the right tympanic membrane and eventually he recovered. On postoperative day 1,0 there was an acute rejection of the transplanted liver which was managed with a bolus of corticosteroids. The patient was discharged in March 1993 in good general condition. Ever since he has been regularly followed up by the University Department of Internal Medicine of the Hippokrateion Hospital in Athens.

In February 2000, he was transferred to the hospital suffering from acute myocardial infarction and a coronarography revealed a proximal LAD occlusion of 75% and a 50% distal occlusion of the same artery, a 65% occlusion of the OM and 50% of the RCA with an EF of 30%. Echocardiography with low dose of dobutamine revealed that the apex of the left ventricle was non viable. Myocardial perfusion scintigraphy with thallium revealed irreversible defects in the apex, the areas near the apex, and the apical- anterior till medial-inferior region of the left ventricle. In addition, a reversible ischemia of the inferiorlateral and the main inferior region could be found.

In July 2000, he underwent a PTCA. The right coronary artery was completely opened. A stent was placed in the left anterior descending artery.

In October 2000, the patient was transferred to the hospital because of angina pectoris. A coronary arteriography was performed which revealed that the left anterior descending was stenosed 70%, the first marginal 50-60%, and the right coronary 80%. EF was about 25%.

In January, he was admitted to the hospital because of recurrent attacks of angina (8-10 daily) after walking a small distance (20-25 meters) and eventually he was transferred to the Cardiothoracic Department where coronary artery bypass grafting took place in March 2001. During surgery, it was revealed that the dimensions of the right and left ventricle were beyond normal. Systolic pulmonary artery pressure was 55mmHg and systolic artery pressure was 90-95mmHg. Two saphenous vein grafts were placed on the LAD and RCA with beating heart and normothermia. Both IMAs were damaged during previous procedures. The patient was hemodynamically unstable and had to be assisted by an intraaortic balloon pump IABC. At the end of surgery systolic pulmonary artery pressure was 25mmHg and artery pressure was 110mmHg.He was transferred to the ICU. The same afternoon he suffered from atrial fibrillation, which was managed with amiodarone. The patient received immunosuppressive drugs (Neoral->150mg/day and azathioprine->50mg/day).

On postoperative day 1, Creatinine 3,2mg/dl(before surgery Crea ,5mg/dl), SGOT/SGPT 226/45 and serum total bilirubin 2,0 mg/dl (direct 1,29mg/dl).

On postoperative day (POD) 2, the patient was weaned from mechanical ventilation and chest-drains were removed , Crea-> 4,2mg/dl, SGOT/SGPT 175/47, total bilirubin 2,3 (direct 1,49). The patient was afebrile, BP 110-70mmHg, PR 100/min. The IABC was removed On POD 5, Crea->4,0mg/dl, SGOT/SGPT 63/47, CPK 1655,total bilirubin 2,8 (direct 2,4). On POD 6, acute thrombosis of the left common femoral artery, where the IABC was placed, was diagnosed and an embolectomy with a Fogarty catheter took place. On POD 9 he was transferred to the ward.

On POD14, his appearance was ill, he had severe dyspnea at rest ,low pressure (systolic 85mmHg), the auscultation revealed pulmonary rales, rhonchi, arterial hypoxemia, severe metabolic acidosis and a chest X-ray showed interstitial and alveolar edema so he was transferred urgently in the ICU. An IABC was installed again, inotropic agents were given including dopamine with furosemide for diuresis. On POD 15, amrinone was administered and he gradually stabilized. His urine output was satisfactory, BP 120-70mmHg, PR 80-90/min. On POD 20, the IABC was removed, Crea->2,0mg/dl, his general condition was good and on POD 21, amrinone was stopped and fosinopril started. On POD 22, he was transferred to the ward and on POD 28 he was discharged in a good general condition.

Discussion

This patient is presented not so much for his diseased heart and liver but for the astonishing multiplicity, variety and severity of complications he had to overcome.

The combination of surgical myocardial revascularization and major organ transplantation was first reported 26 years ago. In recent years, a great progress has been made in cardiac and transplantation surgery. The high success rate in transplantation surgery has resulted to a growing number of patients who suffer from symptomatic coronary artery disease that requires surgical intervention.

A great number of questions emerge about these patients: the capacity of the transplanted liver to cope with the surgical trauma and the physiologic changes that take place during the cardiopulmonary bypass. Another interesting matter is about the blood levels of the immunosuppressive drugs. Would they fluctuate during the surgical procedure and provoke acute rejection of the organ? Would these drugs be responsible for an increased rate of infections and impairment of wound healing?

In the care of our patient, conforming with the available literature on these procedures, it was established that the liver can overcome the stress of the operation with only moderate and reversible deterioration in liver function tests. There were no abnormalities of the coagulation mechanism during and after surgery. It was not necessary to administer large amounts of fresh frozen plasma, plateles or other blood products.

Immunosuppressive drugs and their relationship with infections is of great concern. A cardiac operation creates a lot of problems originating from multiple, long incisions, major tissue trauma and physiologic changes with the mechanical circulatory assist system. All these factors can contribute to infections. Again our patient presented with no problem, concerning either infection or enhanced wound healing.

As we know cyclosporine is a nephrotoxic drug and our patient had mild chronic renal dysfunction, which was managed successfully. Immunosuppressive therapy did not create any problem and their levels were titrated with their blood levels.

Conclusion

In summary, cardiac operation can be safely undertaken in the liver transplant recipient with minimal morbidity. Liver dysfunction is a reversible phenomenon and renal failure is another significant problem that can be treated conservatively. The benefits for the patients seem to be satisfactory.

Correspondence to

Tourmousoglou Christos, 29 Bournazou St, 11521 Athens,Greece Tel.003 210 6468674 Fax.003 210 7482157 (for Christos Tourmousoglou) E-mail: tchris2@otenet.gr