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Is Transesophageal Echocardiography Really Safe During Liver Transplant Surgery in Patients With High‐Risk Varices?

We read with interest the recent position paper from SATA concerning transesophageal echocardiography (TEE) in liver transplant surgery and congratulate authors on the robustness of their systematic review1 . However, we would challenge their summary finding that TEE is safe in liver transplant surgery, following a case from our own institution. The case involved a 67-year-old Caucasian male transplanted for hepatitis C related cirrhosis and hepatocellular carcinoma. At the time of transplant his MELD score was 9. His most recent endoscopy, 3 years prior to transplant surgery, had identified large (> 5mm), high risk varices with red wale signs. The patient had been appropriately placed on primary prophylaxis with propranolol, with no episodes of variceal bleeding. During transplant surgery a TEE was used for cardiac monitoring due to a history of treated portopulmonary hypertension. Significant bleeding from the mouth developed during surgery and TEE was removed and a Sengstaken tube inserted. Cardiac arrest occurred during subsequent reperfusion that required internal cardiac massage, ECMO and ongoing intensive care treatment involving mechanical ventilation, haemodialysis, vasopressors and transfusion. The patient subsequently died from multi-organ failure 48 hours following transplant surgery.