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Coelho DRA, da Luz RO, Basto ST, de Barros Wanderley Júnior MR, de Sousa CCT, de Carvalho ERF, de Sousa Martins Fernandes E, Brito-Azevedo A. Life-Threatening Electrical Storm Following Liver Transplantation: A Case Report. Am J Case Rep 2024; 25:e941932. [PMID: 38178564 PMCID: PMC10775133 DOI: 10.12659/ajcr.941932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 12/01/2023] [Accepted: 11/14/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Electrical storm is a rare but potentially life-threatening syndrome characterized by recurrent ventricular arrhythmias. Liver transplant recipients are at increased risk of developing electrical storms due to conditions that prolong QT intervals, such as cirrhotic cardiomyopathy. However, limited information exists on electrical storms in this specific population. This case report presents a patient who experienced 13 cardiac arrests during ventricular fibrillation following liver transplantation. CASE REPORT A 61-year-old woman with a medical history of diabetes, obesity, and cirrhosis due to non-alcoholic fatty liver disease underwent liver transplantation using a deceased donor's liver. Following the procedure, she developed a deterioration in her respiratory function, necessitating orotracheal intubation. Approximately 21 hours post-surgery, she experienced cardiac arrest during ventricular fibrillation, which was rapidly reversed with electrical defibrillation. However, the patient entered a state of electrical storm. Management involved antiarrhythmic medications and temporary transvenous cardiac pacing. She remained stable for 40 hours, but a dislodgment of the device triggered another episode of ventricular fibrillation, leading to her death. CONCLUSIONS This case report highlights the clinical presentation and challenges in managing electrical storms in liver transplant recipients. We hypothesize that cirrhotic cardiomyopathy could be the cause of her recurrent ventricular arrhythmias. Further studies are needed to better understand the underlying mechanisms and risk factors of this life-threatening syndrome in this population, which may enhance risk stratification and enable earlier intervention.
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Affiliation(s)
| | | | - Samanta Teixeira Basto
- Department of Gastrointestinal and Liver Transplant Surgery, Hospital Adventista Silvestre (HAS), Rio de Janeiro, RJ, Brazil
| | | | | | | | | | - Anderson Brito-Azevedo
- Department of Gastrointestinal and Liver Transplant Surgery, Hospital Adventista Silvestre (HAS), Rio de Janeiro, RJ, Brazil
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Coelho DRA, da Luz RO, Basto ST, de Sousa CCT, da Silva HP, de Sousa Martins Fernandes E, Brito-Azevedo A. Prolonged Anhepatic State as a Bridge to Retransplantation: A Challenging Case of a 35-Year-Old Male Liver Transplant Patient with a Temporary Portacaval Shunt. Am J Case Rep 2023; 24:e941933. [PMID: 38150414 PMCID: PMC10763644 DOI: 10.12659/ajcr.941933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/24/2023] [Accepted: 11/03/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Liver transplantation is a life-saving intervention for patients with a diagnosis of acute liver failure or end-stage liver disease. Despite advances in surgical techniques and immunosuppressive therapies, primary nonfunction remains a concern, often necessitating retransplantation. In these scenarios, the anhepatic state, achieved through total hepatectomy with a temporary portacaval shunt, serves as a bridge to retransplantation. However, the challenge lies in the uncertain survival period and several potential complications associated with this procedure. CASE REPORT We present a case of a 35-year-old male patient with autoimmune hepatitis who underwent liver transplantation from a deceased donor. Seven days later, he experienced acute liver failure, leading to an urgent listing for retransplantation. To prevent the intense systemic inflammatory response, the patient underwent a total hepatectomy with a temporary portacaval shunt while awaiting another graft and endured a 57-h anhepatic state. On day 17 following retransplantation, he had cerebral death due to a hemorrhagic stroke. CONCLUSIONS This case underscores one of the most prolonged periods of anhepatic state as a bridge to retransplantation, highlighting the complexities associated with this technique. The challenges include sepsis, hypotension, coagulopathy, metabolic acidosis, renal failure, electrolyte disturbances, hypoglycemia, and hypothermia. Vigilant monitoring and careful management are crucial to improve patient outcomes. Further research is needed to optimize the duration of the anhepatic state and minimize complications for liver transplantation recipients.
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Affiliation(s)
| | | | - Samanta Teixeira Basto
- Department of Gastrointestinal and Liver Transplant Surgery, Hospital Adventista Silvestre (HAS), Rio de Janeiro, RJ, Brazil
| | | | | | | | - Anderson Brito-Azevedo
- Department of Gastrointestinal and Liver Transplant Surgery, Hospital Adventista Silvestre (HAS), Rio de Janeiro, RJ, Brazil
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Brito-Azevedo A, Monte da Costa FC. COVID-19: Winter Is Coming. J Gen Intern Med 2021; 36:810. [PMID: 33443700 PMCID: PMC7808114 DOI: 10.1007/s11606-020-06362-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/24/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Anderson Brito-Azevedo
- Liver Transplant Unit, São Lucas Hospital, Rio de Janeiro, RJ, Brazil. .,Liver Transplant Unit, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil.
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Brito-Azevedo A. Hydroxychloroquine in COVID-19: Taking care of statistics to take care of patients. Int J Infect Dis 2020; 99:324. [PMID: 32768698 PMCID: PMC7406426 DOI: 10.1016/j.ijid.2020.07.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/23/2020] [Indexed: 11/05/2022] Open
Affiliation(s)
- Anderson Brito-Azevedo
- Liver Transplant Unit, São Lucas Hospital, Rio de Janeiro, RJ, Brazil; Liver Transplant Unit, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil.
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Brito-Azevedo A, Pinto EC, de Cata Preta Corrêa GA, Bouskela E. SARS-CoV-2 infection causes pulmonary shunt by vasodilatation. J Med Virol 2020; 93:573-575. [PMID: 32706407 PMCID: PMC7404894 DOI: 10.1002/jmv.26342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 11/24/2022]
Abstract
Patients with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) may present a significant hypoxemia. The exactly mechanism of such hypoxemia in patients with coronavirus disease 2019 (COVID‐19) is not well described. It has been suggested that microthrombosis contributes to this mechanism, increasing pulmonary dead space. However, dead spaces would not be sensible to oxygen supplementation, and also, enlargement of pulmonary vessels it has been evidenced. Shunt mechanism by vasodilatation, instead, could explain decubitus dependence in oxygenation by blood redistribution as observed in these patients, and moreover, would be more sensible to oxygen supplementation than dead spaces. We hypothesized that SARS‐CoV‐2 causes an intrapulmonary vascular dilatation (IPVD), determining a shunt mechanism by vasodilatation. We performed contrast‐enhanced transthoracic echocardiography to search IPVD shunt in patients with confirmed COVID‐19, hospitalized in an intensive care unit. Ten patients were recruited; one patient was excluded due to low quality of echocardiographic image, and nine patients were included. IPVD was found in seven (78%) patients, with different grades, including patient with normal compliance and the one without invasive ventilation. We demonstrated that shunt by IPVD is present among patients with COVID‐19, and this mechanism is probably implicated in significant hypoxemia observed. Our study brings to light a novel pathophysiological process about Covid‐19 disease. We demonstrated that SARS‐CoV‐2 infection cause a shunt mechanism by intrapulmonary vasodilatation, and this finding can be implicated in important hypoxemia observed in these patients. We hypothesize that bradykinin probably has a key role in this process.
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Affiliation(s)
- Anderson Brito-Azevedo
- Transplant Department, Liver and Pancreas Unit, São Lucas Hospital, Rio de Janeiro, Brazil.,Internal Medicine Department, Adventista Silvestre Hospital, Rio de Janeiro, Brazil.,Biomedical Department, Laboratory for Clinical and Experimental Research on Vascular Biology (BioVasc), State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eduardo Costa Pinto
- Transplant Department, Liver and Pancreas Unit, São Lucas Hospital, Rio de Janeiro, Brazil.,Intensive Care Department, Intensive Care Unit, Panamericano Hospital, Rio de Janeiro, Brazil
| | | | - Eliete Bouskela
- Biomedical Department, Laboratory for Clinical and Experimental Research on Vascular Biology (BioVasc), State University of Rio de Janeiro, Rio de Janeiro, Brazil
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Brito-Azevedo A. Diuretic window hypothesis in cirrhosis: Changing the point of view. World J Gastroenterol 2019; 25:3283-3290. [PMID: 31341355 PMCID: PMC6639551 DOI: 10.3748/wjg.v25.i26.3283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/09/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
Since the 1970s, non-selective beta-blockers (NSBB) have been used to prevent variceal upper bleeding in advanced cirrhotic patients. However, several recent studies have raised the doubt about the benefit of NSBB in end-stage cirrhotic patients. In fact, they suggested a detrimental effect in these patients that even reduced survival. All of these studies have been assembled to compose the “window therapy hypothesis”, in which NSBB would have traditional indication to be initiated to prevent variceal upper bleeding; however, treatment should be stopped (or not be initiated) in patients with end-stage cirrhosis. NSBB would reduce the cardiac reserve of these patients, worsening systemic perfusion and prognosis. However, it should be emphasized that these studies present important bias issues, and their results also suggested that diuretic treatment may also be behind the effects observed. In this opinion review, we changed the point of view from NSBB to diuretic treatment, based on a physiopathogenic approach of circulatory parameters of cirrhotic patients studied, and based on diuretic effect in blood pressure lowering and in other hypervolemic disease, as heart failure. We suggest a “diuretic window hypothesis”, composed by an open window in hypervolemic phase, an attention window when patient present in a normal plasma volume phase, and a closed window during the plasma hypovolemic phase.
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Affiliation(s)
- Anderson Brito-Azevedo
- Liver Transplant Unit, São Lucas Hospital, Rio de Janeiro 22061-080, Brazil
- Liver Transplant Unit, São Francisco na Providência de Deus Hospital, Rio de Janeiro 20520-053, Brazil
- Liver Transplant Unit, Adventist Silvestre Hospital, Rio de Janeiro 22241-280, Brazil
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7
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Fernandes EDSM, de Mello FPT, Andrade RO, Girao CL, Pimentel LS, Cesar C, Sousa CC, Brito-Azevedo A, Basto ST, Torres OJM. Living Donor Liver Transplant as Rescue Surgery for a Patient with Hepatocellular Carcinoma Who Underwent Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS). Am J Case Rep 2018; 19:1338-1341. [PMID: 30409960 PMCID: PMC6238545 DOI: 10.12659/ajcr.911694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is an important tool to induce fast liver hypertrophy. The degree of hepatic fibrosis/cirrhosis in patients with HCC negatively impacts their health, and the risk of liver failure is always present. In these cases, liver transplantation may be necessary as a rescue procedure. We present the case of a patient with HCC who underwent ALPPS and developed liver failure. A living donor liver transplant was performed as a rescue procedure. CASE REPORT A 49-year-old man with chronic hepatitis B without cirrhosis underwent computed tomography, which revealed an expansive lesion in the right lobe of his liver that was diagnosed as hepatocellular carcinoma. Liver resection was indicated and liver cirrhosis was observed with high portal pressure after transection. The treatment strategy was switched from right hepatectomy to ALPPS. The patient developed severe liver dysfunction and liver transplantation was indicated. His postoperative course was uneventful and 3 months after the procedure the patient was without complications. CONCLUSIONS Living donor liver transplantation may be necessary as a rescue procedure for patients who underwent ALPPS and develop liver dysfunction.
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Affiliation(s)
- Eduardo de Souza Martins Fernandes
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil.,Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Ronaldo Oliveira Andrade
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Camila Liberato Girao
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Leandro Savattone Pimentel
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Camilla Cesar
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Claudia Cristina Sousa
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Anderson Brito-Azevedo
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Samanta Teixeira Basto
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Orlando Jorge Martins Torres
- Department of Gastrointestinal and Liver Transplant Surgery, University Hospital, Federal University of Maranhão, São Luis, MA, Brazil
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Affiliation(s)
- Anderson Brito-Azevedo
- Division of Hepatology, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.,Liver Transplant Unit, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
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Affiliation(s)
- Anderson Brito-Azevedo
- Division of Hepatology, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil; Liver Transplant Unit, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil.
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Brito-Azevedo A, Perez RDM, Coelho HSM, Fernandes EDSM, Castiglione RC, Villela-Nogueira CA, Bouskela E. The anti-inflammatory role of propranolol in cirrhosis: Preventing the inflammatory exhaustion? J Hepatol 2017; 66:240-241. [PMID: 27542323 DOI: 10.1016/j.jhep.2016.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 07/25/2016] [Accepted: 08/10/2016] [Indexed: 02/03/2023]
Affiliation(s)
- Anderson Brito-Azevedo
- Division of Hepatology, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil; Liver Transplant Unit, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil.
| | - Renata de Mello Perez
- Division of Hepatology, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil; Department of Gastroenterology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil; D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
| | - Henrique Sérgio Moraes Coelho
- Division of Hepatology, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Eduardo de Souza Martins Fernandes
- Liver Transplant Unit, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil; Departament of Surgery, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Raquel Carvalho Castiglione
- Laboratory for Clinical and Experimental Research on Vascular Biology (BioVasc), State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Eliete Bouskela
- Laboratory for Clinical and Experimental Research on Vascular Biology (BioVasc), State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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11
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Brito-Azevedo A, Perez RDM, Coelho HSM, Fernandes EDSM, Castiglione RC, Villela-Nogueira CA, Bouskela E. Propranolol improves endothelial dysfunction in advanced cirrhosis: the 'endothelial exhaustion' hypothesis. Gut 2016; 65:1391-2. [PMID: 26984854 DOI: 10.1136/gutjnl-2016-311696] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 02/27/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Anderson Brito-Azevedo
- Division of Hepatology, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil Liver Transplant Unit, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Renata de Mello Perez
- Division of Hepatology, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil Department of Gastroenterology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Henrique Sérgio Moraes Coelho
- Division of Hepatology, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Eduardo de Souza Martins Fernandes
- Liver Transplant Unit, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil Departament of Surgery, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Raquel Carvalho Castiglione
- Laboratory for Clinical and Experimental Research on Vascular Biology (BioVasc), State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Eliete Bouskela
- Laboratory for Clinical and Experimental Research on Vascular Biology (BioVasc), State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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