Risk Factors Associated With Acute Heart Failure During Liver Transplant Surgery: A Case Control Study M. Susan Mandell, 1 Tamas Seres, 1 JoAnn Lindenfeld, 2 Scott W. Biggins, 3 David Chascsa, 3 Brian Ahlgren, 1 Michael Wachs, 4 and Kiran M. Bambha 3 Background. Acute intraoperative heart failure (HF) is a rare but often fatal complication of liver transplant surgery. Little is known about the clinical course or predictive variables. Our aims were to provide a detailed clinical description and conduct a systematic search for characteristics associated with intraoperative HF. Methods. A matched case-control study of adults undergoing pri- mary liver transplant from 2009 to 2011 was conducted. Cases showed new onset HF with an ejection fraction less than 50% during liver transplant surgery. Controls were recipients without signs or symptoms of HF. Matching was based on: age, sex, model for end-stage liver disease at the time of transplant, type 2 diabetes, and β-blocker use. Conditional logistic regression anal- yses were conducted. Results. From 2009 to 2011, seven (3%) of 256 recipients developed intraoperative HF with one resulting death. All survivors regained normal systolic function within 6 months of surgery. Decreasing preoperative serum sodium (odds ratio, 1.41; 95% confidence interval, 1.02-1.94; P = 0.039) and increasing number of units of packed red blood cells transfused intraoperatively (odds ratio=1.2, 95% confidence interval, 1.001-1.467, P = 0.048) were associated with HF. Conclusion. No preoperative echocardiographic parameter predicted HF in affected patients. Two possible explanations are: our patients suffered from stress cardiomyopathy and therefore had no evidence of impaired contraction before the event or echocardiographic predic- tors of HF were masked by circulatory changes in patients with cirrhosis. Lower serum sodium and more red blood cell transfu- sions were associated with intraoperative HF. Lower mortality of our intraoperative cases compared to others may be influenced by earlier diagnosis and intervention. (Transplantation 2015;99: 873–878) A cute heart failure (HF) is a group of conditions with di- verse presentations and origins that share the feature of abrupt cardiac dysfunction. 1 Heart failure is diagnosed when there are signs of congestion; extravascular fluid accumulation and hypoperfusion caused by cardiac dysfunction. 2 Heart failure with an ejection fraction (EF) less than 50% is termed HF with reduced EF (HFrEF) and termed HF with preserved EF when the ejction fraction is greater than 50%. Heart failure with preserved EF is usually associated with diastolic dysfunction. 3 Although all patients with systolic dysfunction have some degree of diastolic dysfunction, the converse is not true. 4 Perioperative HF is rare in patients with cirrhosis but HFrEF occurs in 1% to 7% of liver transplant recipients. 5-7 Presentation is abrupt and characterized by reduced systolic contraction and a high mortality rate. In a recent report, death occured 2 to 9 days after surgery because of refractory HFrEF and multiple end organ failure. 6 The description of HFrEF during liver transplant surgery shares some charac- teristics with stress cardiomyopathy; abrupt and portentially reversible myocardial depression. Takotsubo is a well- recognized variant of stress cardiomyopathy and has been described in a case report during transplant surgery. 8 Recent evidence shows that stress cardiomyopathy has multiple variants and that critically ill or septic patients expe- rience global hypokinesis and higher mortality rates than other patients. 9 The common factor that links the variants of stress cardiomyopathy is an excess of catecholamines in phenotypically suseptible individuals. 10 We therefore questioned if acute HFrEF during liver transplanation is a var- iant of stress cardiomyopathy similar to cases described in the Received 28 December 2013. Revision requested 31 January 2014. Accepted 1 July 2014. 1 Department of Anesthesiology, University of Colorado, Aurora, CO. 2 Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO. 3 Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO. 4 Division of Transplant Surgery, University of Colorado, Aurora, CO. The authors declare no funding or conflicts of interest. M.S.M. designed the study, participated in the performance of the research, and helped write the article. T.S. performed echocardiographic analysis, participated in the performance of the research, and helped write the article. J.L. reviewed the echocardiographic analysis, interpreted the findings, and wrote the article. S.B. analyzed and interpreted the data and helped write the article. D.C. col- lected the data and helped with the statistical analysis. B.A. helped with the echocardiographic interpretation. M.W. participated in performance of the re- search and helped interpret the data. K.B. helped with the design, data analysis, and interpretation and helped write the article. Correspondence: M. Susan Mandell, M.D., Ph.D., Department of Anesthe- siology and Critical Care, 12631 E. 17th Avenue, Aurora, CO 80045. (Susan.Mandell@UCDenver.edu). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0041-1337/15/9904-873 DOI: 10.1097/TP.0000000000000387 Original Clinical Science Transplantation ■ April 2015 ■ Volume 99 ■ Number 4 www.transplantjournal.com 873 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.