• Jacopo Belfiore, Michele Checchi, Niccolò Castellani Nicolini, Pietro Bertini, Dmitri Bezinover, Lorenzo DE Marchi, and Giandomenico Biancofiore.
• Transplant Anesthesia and Critical Care, Pisa NHS and University Hospitals, Pisa, Italy.
• Minerva Anestesiol. 2025 Jan 23.

AbstractIntraoperative hemodynamic monitoring is crucial for managing patients with end-stage liver disease (ESLD) undergoing orthotopic liver transplantation (OLT) due to their complex cardiovascular and pulmonary abnormalities. Traditionally, pulmonary artery catheterization (PAC) has been the standard for hemodynamic monitoring during OLT. However, the use of transesophageal echocardiography (TEE) has increased due to its real-time visualization of cardiac and vascular structures, which aids in managing hemodynamic instability during the three surgical phases of OLT: pre-anhepatic, anhepatic, and neo-hepatic. TEE provides dynamic assessment of preload, afterload, and cardiac output and has been shown to detect complications such as right and left ventricular dysfunction, intracardiac thrombus, and pulmonary embolism. Although TEE in patients with ESLD poses risks, particularly in the presence of esophageal varices, studies show a low incidence of complications when performed by experienced operators. Focused TEE protocols have proven effective in detecting common causes of hemodynamic instability with fewer views. This review summarizes the applications and safety considerations of TEE during OLT.

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