Intraoperative Cardiac Arrest during Adult Liver Transplantation: Incidence and Risk Factor Analysis from 7 Academic Centers in the United States

Natalie K. Smith, Jeron Zerillo, Sang Jo Kim, Guy E. Efune, Cynthia Wang, Sher Lu Pai, Ryan Chadha, Todd M. Kor, David R. Wetzel, Michael A. Hall, Kristen K. Burton, Kyota Fukazawa, Bryan Hill, Mia Ashley Spad, David B. Wax, Hung Mo Lin, Xiaoyu Liu, Jaffer Odeh, Laurence Torsher, James D. KindscherM. Susan Mandell, Tetsuro Sakai, Samuel Demaria

Research output: Contribution to journalArticlepeer-review

20 Scopus citations


Background: Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS: Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS: ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P =.0386), BMI ≥40 (2.16 [1.12-4.19]; P =.022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P =.02; MELD ≥40: 2.73 [1.53-4.85], P =.001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P <.001), living donors (2.13 [1.16-3.89], P =.014), and reoperation (1.87 [1.13-3.11], P =.015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA. CONCLUSIONS: We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.

Original languageEnglish
Pages (from-to)130-139
Number of pages10
JournalAnesthesia and Analgesia
Issue number1
StatePublished - 1 Jan 2021


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