The Intraoperative Finding of a Large Atrial Septum Defect Pre-Liver Transplantation: A Case Report

The case report discusses a significant discrepancy between the pre-transplant cardiac evaluation and post-induction transesophageal echocardiography, leading to aborting the surgical procedure. The transthoracic echocardiography [TTE] pre-liver transplant indicated only a minor intracardiac shunt, while the post-induction transesophageal echocardiography [TEE] showed a large atrial septal defect with a more significant left to right shunt. The attempt to close the defect with a transcatheter closure device failed and the perioperative care team decided not to proceed with the liver transplantation. Later cardiac evaluation with cardiac magnetic resonance imaging demonstrated a secundum atrial septum defect in the inferior border of the interatrial septum with 43 ml flow difference between systemic and pulmonary circulation. The failure to identify a large atrial septal defect/inferior venosus defect in the preoperative screening process for liver transplantation resulted in failing to optimize the patient pre transplant. Although complications related to large atrial septal defects are rare during liver transplant (paradoxical embolisms, malignant arrhythmias, myocardial infarctions or cerebrovascular complications), they can be potentially fatal. The preoperative cardiac assessment should have included optimization of this congenital defect. The case report discusses implications of atrial septal defects for liver transplant and why the screening process may have missed the defect. The findings of a positive bubble study during the transthoracic echocardiography should not be trivialized and may require further workup.