Description
Dr. Anil Singh is the Director of Liver Transplant Anaesthesiology & Critical Care at Nanavati Max Hospital, Mumbai. With over 15 years of experience, he specializes in liver transplant anaesthesia, critical care, and management of complex liver failure cases. He has led transplant programs at several top hospitals and is a founding member of the Liver Transplant Society of India. Dr. Singh is also internationally trained and recognized for his contributions to education and clinical excellence in liver transplantation.
Summary Listen
- Liver transplantation is the only definitive treatment for end-stage liver disease. Medical treatments often fail to improve survival in the face of life-threatening complications. The outcome of a liver transplant depends on careful pre-transplant evaluation, graft quality, surgical techniques, anesthesia techniques, and post-operative care/immunosuppression. Transesophageal echocardiography (TEE) plays a significant role in evaluating the heart pre-transplant and assessing graft quality intraoperatively.
- The liver transplant procedure is divided into three phases: pre-anhepatic (dissection), anhepatic (clamp), and neohepatic (re-perfusion). Bleeding and hemodynamic instability are common during the dissection phase. During the anhepatic phase, portal flow and potentially IVC flow are interrupted. The neohepatic phase begins with the re-establishment of blood flow to the new liver.
- While the American Society of Echocardiography recommends numerous TEE views, focusing on seven mid-esophageal views is sufficient for liver transplantation. These views include four-chamber, two-chamber, long-axis, aortic valve short-axis, bi-caval, modified bi-caval, and aortic valve long-axis. Each view allows for the assessment of specific cardiac structures and potential pathologies. The insertion is a very important thing which should be done, and that will come with slow practice.
- During the dissection phase, TEE is used to assess chamber sizes, ventricular function, valve function, and pulmonary artery pressure (PAP). It can also rule out pulmonary hypertension, assess the risk of paradoxical embolism, and detect cardiac shunts. Moreover, TEE aids in verifying the placement of central lines, Swan-Ganz catheters, and ECMO cannulas, as well as identifying pleural or pericardial effusions.
- The anhepatic phase poses unique hemodynamic challenges as standard fluid assessment parameters become unreliable. TEE allows for direct visualization of left ventricular volume and function. Crucially, it aids in the diagnosis and management of left ventricular outflow tract obstruction (LVOTO), a condition with a potentially fatal outcome if misdiagnosed.
- During the neohepatic phase, TEE is crucial for reassessing bi-ventricular function, especially the right ventricle, which impacts graft perfusion. TEE can rule out emboli resulting from reperfusion and assess the patency of the inferior vena cava and hepatic veins. Regular continuous TEE monitoring of the heart throughout all three phases is necessary for managing and adjusting the patients.
Sample Certificate
About the Speakers
Dr. Anil Singh
Director - Liver Transplant Anaesthology & Critical Care, Mumbai, Maharashtra
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