CASE REPORT Year : 2023  |  Volume : 9  |  Issue : 1  |  Page : 70-72

Postheart transplant prolonged hospital stay due to massive ascites

Manoj Kumar Sahu1, Azaria Jayaraj Premkumar1, Sarvesh Pal Singh1, Ummed Singh Dhatterwal1, Milind Padmakar Hote1, Sandeep Seth2
1 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India

Date of Submission16-Jan-2023Date of Decision09-Mar-2023Date of Acceptance29-Mar-2023Date of Web Publication04-May-2023

Correspondence Address:
Manoj Kumar Sahu
Department of Cardiothoracic and Vascular Surgery, CTVS Office, 7th Floor, CN Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jpcs.jpcs_4_23

Heart transplantation (HTx) is a gold standard for end-stage heart failure (ESHF). Cardiomyopathies form the majority of patients who undergo HTx. Grown-up congenital heart disease, with or without prior palliative surgery, progresses to ESHF requiring HTx. They constitute the least among all heart recipients. The immediate posttransplant management may become challenging due to severe right heart failure, massive ascites, pleural effusion, and cardiac cachexia. Scarce data are available on this subset of patients. We describe one such patient's post-HTx management. A 15-year-old male with Ebstein's anomaly, restrictive cardiomyopathy, severe right ventricular (RV) dysfunction, atrial flutter, left atrial clot, postradiofrequency ablation, New York Heart Association III, and early cardiac cirrhosis underwent HTx successfully. He had significant mediastinal hemorrhage postoperatively, and managed medically; echocardiography showed a good biventricular function with mild tricuspid regurgitation (TR), and he was extubated on the 1st postoperative day. However, progressive RV function deterioration was observed over the next 72 h (tricuspid annular plane systolic excursion of 7 mm with mild TR) with massive worsening ascites and pleural effusion. He was treated with milrinone and furosemide infusion and noninvasive ventilation, but response to optimal diuretic doses was poor, and the ascites did not decrease. Hence, intermittent paracentesis was done, and 10 L of ascitic fluid was removed over 10 days. Then, he responded to diuretics; his RV function improved. His respiratory support and inotropes were discontinued. His immunosuppressants consisted of tacrolimus and prednisolone. Mycophenolate mofetil was withheld due to leukopenia. At 6-month follow-up, his cardiac functions were normal, ascites completely resolved, appetite improved, and he gained weight.

Keywords: Ebstein's anomaly, grown-up congenital heart disease, heart transplant, massive ascites

How to cite this article:
Sahu MK, Premkumar AJ, Singh SP, Dhatterwal US, Hote MP, Seth S. Postheart transplant prolonged hospital stay due to massive ascites. J Pract Cardiovasc Sci 2023;9:70-2
How to cite this URL:
Sahu MK, Premkumar AJ, Singh SP, Dhatterwal US, Hote MP, Seth S. Postheart transplant prolonged hospital stay due to massive ascites. J Pract Cardiovasc Sci [serial online] 2023 [cited 2023 May 10];9:70-2. Available from: https://www.j-pcs.org/text.asp?2023/9/1/70/375810   Introduction 

Heart transplantation (HTx) is a gold standard for end-stage heart failure (ESHF). Cardiomyopathies constitute a maximum number of heart recipients.[1] Grown-up congenital heart (GUCH) disease, with or without prior palliatve surgeries, ends up in terminal heart failure causing death in 40%.[2] This subset of patients accounts for approximately 3% of the HTx (the International Society for Heart and Lung Transplantation 2019) done around the world. The immediate posttransplant management may become challenging due to bleeding, severe right heart failure (RHF), massive ascites, pleural effusion, cardiac cachexia, and hypoproteinemia. Scarce data are available on this subset of patients undergoing HTx. Ascites that cannot be mobilized by the maximal doses of diuretics is defined as refractory ascites and is a common clinical condition in RHF. For patients who are refractory to diuretic therapy, alternative interventions like paracentesis might be a solution. We present a patient with massive ascites due to RHF after cardiac transplantation.

  Case Report 

A 15-year-old male adolescent weighing 32 kg, body mass index (BMI) 13.33 kg/m2 with Ebstein's anomaly, restrictive cardiomyopathy, right ventricular (RV) endomyocardial fibrosis, severe RV dysfunction, large left atrial clot, atrial flutter, New York Heart Association III, and ascites on oral anticoagulant underwent a successful heart transplant with an adult donor heart. Higher mediastinal bleeding postoperatively was managed medically; echocardiography showed a good biventricular function with mild tricuspid regurgitation (RV systolic pressure = 24 + right atrial pressure), and he was extubated on the 1st postoperative day. Progressive RV dysfunction (tricuspid annular plane systolic excursion of 7 mm) occurred over the next 72 h complicating severe pleural effusion and worsening ascites. He was supported with a noninvasive pressure support ventilation and infusions of milrinone and furosemide.

Ascites increased despite the maximum doses of diuretics, and the patient became more dyspneic. He developed paralytic ileus, and his urine output dropped. Hence, paracentesis was planned. 10 L of ascitic fluid was drained in a staggered manner, alternate days over 10 days [Figure 1]. The removed ascitic fluid was replaced by 5% albumin at 1:1 ratio. After two sittings of paracentesis, his urine output improved >1 ml/kg/h with diuretics. His RV function and appetite improved. Respiratory support and inotropes were tapered and stopped. Blood flow in the inferior vena cava was increased due to decrease in the intra-abdominal pressure, which improved the cardiac output and blood pressure. There were no complications such as fluid leakage, hemodynamic instability, or infection from paracentesis. His maintenance immunosuppressants consisted of tacrolimus and prednisolone. Mycophenolate mofetil was withheld due to leukopenia. The patient was discharged on the 25th posttransplant day. On follow-up at 6 months, his cardiac functions were normal, ascites completely resolved, appetite improved, and he gained weight [Figure 2].

Figure 1: Postoperative day 15: Postparacentesis (five sittings), relieved of dyspnea, but still with ascitic fluid

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  Discussion 

Congenital heart disease survivors due to medical or surgical interventions, who are into their adolescence or adulthood, are labelled as GUCH patients. The International Society for Heart and Lung Transplantation (ISHLT) 2018 registry reported that GUCH patients accounted for only 3% of adult heart transplants performed worldwide between 2009 and 2017.[1] It is estimated that ESHF accounts for up to 40% of deaths in GUCH. GUCH patient population complicates the universal application of typical heart failure therapies and transplant models.[2] Those patients having severe RHF before transplantation are depleted of muscle mass, have low BMI, ascites, liver dysfunction, coagulation disturbances, hypoproteinemia, and renal dysfunction.

Staged palliative surgeries have improved the longevity of the GUCH patients, but ultimately they will require HTx. HTx in GUCH patients meets with multiple challenges due to various risk factors such as long-standing cardiac dysfunction, multiple prior surgeries, effects of cyanosis on other organs, and elevated pulmonary vascular resistance. Managing these patients postoperatively is a challenge. Bleeding, a major complication, increases the morbidity and mortality in the immediate postoperative period. Our patient drained 1.3 L in the first 24 h and was managed conservatively with red blood cells, plasma, cryoprecipitate, platelets, Vitamin K, and factor VIIa (NovoSeven® Abbott India Ltd, Mumbai, Maharashtra, India).

Ascites can be managed in 90% of patients through diuretic therapy. However, some of these patients become resistant to diuretics and develop respiratory distress due to large amount of ascitic fluid and pleural effusion, requiring long duration ventilatory support in the immediate postoperative period. It becomes difficult to mobilize them out of bed early leading to infections. Ascites may contribute to acute renal insufficiency and paralytic ileus interrupting enteral nutrition. The transplanted patients require paracentesis to decompress the abdomen, improving their respiratory and renal functions. Siqueira et al. reported alternative therapeutic options such as repeated large volume paracentesis, extracorporeal ultrafiltration of ascitic fluid with reinfusion, or surgical intervention to treat massive ascites.[3] Ginés et al. compared diuretic therapy and therapeutic paracentesis, followed by diuretics in 117 patients with cirrhosis and tense ascites in a randomized prospective trial.[4] The study showed that paracentesis was more effective in eliminating ascites, resulting in a fewer complications, and a shorter intensive care unit (ICU) and hospital stay. Albumin is probably the best choice of a plasma expander for use with large-volume paracentesis.[5] Persistent ascites aggravates unfavorable conditions in HTx patients in their early postoperative period. It may negatively affect the gastrointestinal, renal, and respiratory functions, inability to achieve the immunosuppressant levels, leading to complications such as allograft dysfunction, rejection, infection, renal failure, and longer convalescence. Thereby, the ventilation duration, inotrope course, ICU, and hospital stay get prolonged. Sezgin et al. presented a similar case as ours, where a patient with massive ascites due to RHF post-HTx was managed with large-volume paracentesis and convalesced.[6]

Our patient did not respond to the maximal dosage of diuretics. Moreover, posttransplantation pulmonary artery hypertension (PAH) aggravated RHF causing persistent accumulation of ascites. This situation caused a significant decrease in left heart preload and low cardiac output (LCO) in our patient requiring a longer inotropic support and ICU stay. Similar findings have been described in the literature.[7] Aggressive paracentesis was preferred to break the vicious cycle between ascites and decreased venous return, which kept the patient in LCO, ileus, and renal failure. We treated our patient with sildenafil, milrinone, diuretics, and staggered removal of ascitic fluid in the early postoperative period, which was effective in controlling PAH and RV failure. This helped the patient convalesce. His first endomyocardial biopsy showed no cellular or antibody-mediated rejection of the allograft (Grade 0R, ISHLT). Finally, the patient was discharged on day 25.

  Conclusion 

Intermittent paracentesis decreased ascitic fluid volume load and intra-abdominal pressure while treating severe RV dysfunction with inodilators, and diuretics improved our patient's cardiac function and LCO. His pulmonary and renal functions improved, bettering his nutrition and mobility, and he convalesced gradually. Hence, large-volume paracentesis is an alternate therapy in these patients, safe and effective to manage tense ascites resistant to diuretics.

Ethical clearance

We, the authors, confirm that this is an original case report, and this has not been submitted to any other journals for possible publication.

Informed consent

Informed consent was obtained from the patient regarding possible publication of this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Khush KK, Cherikh WS, Chambers DC, Harhay MO, Hayes D Jr., Hsich E, et al. The International thoracic organ transplant registry of the international society for heart and lung transplantation: Thirty-sixth adult heart transplantation report – 2019; Focus theme: Donor and recipient size match. J Heart Lung Transplant 2019;38:1056-66.  
    2.Fynn-Thompson F. Heart transplantation in adults with congenital heart disease. Methodist Debakey Cardiovasc J 2019;15:145-8.  
    3.Siqueira F, Kelly T, Saab S. Pathogenesis, Clinical Impact and Management. Gastroenterol Hepatol (N Y) 2009;5:647-56.  
    4.Ginés P, Arroyo V, Quintero E, Planas R, Bory F, Cabrera J, et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 1987;93:234-41.  
    5.Neong SF, Adebayo D, Wong F. An update on the pathogenesis and clinical management of cirrhosis with refractory ascites. Expert Rev Gastroenterol Hepatol 2019;13:293-305.  
    6.Sezgin A, Uguz E, Akay T, Aşlamaci S. Massive ascites due to right heart failure after cardiac transplantation and its treatment: A case report. Transplant Proc 2008;40:326-7.  
    7.Lin CH, Hsu RB, Wu MH, Wang JK, Wang SS, Chu SH. Orthotopic heart transplantation in a child with severe heart failure and chylous ascites. J Heart Lung Transplant 2003;22:826-7.  
    
  [Figure 1], [Figure 2]