Low-dose tissue plasminogen activator is safe and effective in treating major intracardiac thrombosis in liver transplant recipients.

BACKGROUND

Major intracardiac thrombosis is an uncommon event during liver transplantation and has a high mortality rate. Given concerns for hemorrhage in liver transplantation with higher doses, low-dose tissue plasminogen activator has been proposed as a treatment that rapidly leads to localized clot lysis and resolution of right ventricular failure.

METHODS

This is a retrospective study using a prospectively collected database at the University of California at Los Angeles of liver transplant recipients from 2004-2021. Adult patients who received tissue plasminogen activator for intracardiac thrombosis detected on transesophageal echocardiography were included.

RESULTS

Out of 3236 liver transplants from 2016 to 2021, 11 liver transplant recipients were treated with intravenous low-dose tissue plasminogen activator for major intracardiac thrombosis. The TPA dose range was 1-2.5 mg with three patients receiving more than one dose. All patients had severe hemodynamic instability. 90.9% of patients had right ventricular failure and 63.6% had cardiac arrest. After administration of low-dose tissue plasminogen activator, 100% of patients had clinical improvement, clot resolution, and intraoperative survival, with 91% survival at 6 months post-transplant. Adverse events included two patients with abdominal bleeding requiring re-exploration and three patients having new intracranial hemorrhage which self-resolved.

CONCLUSIONS

Low dose tissue plasminogen activator was effective in treating major intracardiac thrombosis in our group of patients. Major complications included a limited number of hemorrhagic events.