Low‐dose tissue plasminogen activator is safe and effective in treating major intracardiac thrombosis in liver transplant recipients

BACKGROUND: Major intracardiac thrombosis is an uncommon event during liver transplantation and has a high mortality rate. Given concerns for hemorrhage in liver transplantation with higher doses, low-dose tissue plasminogen activator has been proposed as a treatment that rapidly leads to localized clot lysis and resolution of right ventricular failure. METHODS: This is a retrospective study using a prospectively collected database at the University of California at Los Angeles of liver transplant recipients from 2004-2021. Adult patients who received tissue plasminogen activator for intracardiac thrombosis detected on transesophageal echocardiography were included. RESULTS: Out of 3236 liver transplants from 2016 to 2021, 11 liver transplant recipients were treated with intravenous low-dose tissue plasminogen activator for major intracardiac thrombosis. The TPA dose range was 1-2.5 mg with three patients receiving more than one dose. All patients had severe hemodynamic instability. 90.9% of patients had right ventricular failure and 63.6% had cardiac arrest. After administration of low-dose tissue plasminogen activator, 100% of patients had clinical improvement, clot resolution, and intraoperative survival, with 91% survival at 6 months post-transplant. Adverse events included two patients with abdominal bleeding requiring re-exploration and three patients having new intracranial hemorrhage which self-resolved. CONCLUSIONS: Low dose tissue plasminogen activator was effective in treating major intracardiac thrombosis in our group of patients. Major complications included a limited number of hemorrhagic events.