Intraoperative Right Ventricular Systolic Function in Liver Transplantation Recipients: A Prospective Observational Study Using Transesophageal Echocardiography During Living-Donor Liver Transplantation.

OBJECTIVES: This study evaluated dynamic changes in right ventricular (RV) systolic function using transesophageal echocardiography (TEE) during living-donor liver transplantation (LDLT). DESIGN: Physiological echocardiographic observational study. SETTING: Single tertiary transplant center. PARTICIPANTS: Fifty adult patients undergoing LDLT surgery between April 29 and November 14, 2025, were analyzed prospectively. INTERVENTIONS: Intraoperative TEE was performed at 5 predefined surgical phases to assess RV systolic function using tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RVFAC), and tissue Doppler-derived systolic (S') velocity. Left ventricular ejection fraction and standard hemodynamic variables were recorded concurrently. The primary outcome was time-dependent change in RV systolic indices. MEASUREMENTS AND MAIN RESULTS: The median Model for End-Stage Liver Disease score was 16 (interquartile range, 9), and 38 patients (76%) were men. RV systolic indices demonstrated significant time-dependent variation. TAPSE decreased from 2.15 ± 0.31 cm at baseline to 1.79 ± 0.45 cm during inferior vena cava clamping, with partial recovery to 2.08 ± 0.30 cm by the end of surgery (p < 0.001). Tissue Doppler S' velocity showed a similar pattern (10.58 ± 2.87 to 9.60 ± 2.89 to 11.72 ± 2.56 cm/s, p < 0.001). RVFAC remained relatively preserved but varied significantly across time points (p = 0.014). Left ventricular ejection fraction remained stable (p = 0.224). Hemodynamic changes paralleled RV alterations and responded to vasoactive support. CONCLUSIONS: Transient reductions in RV systolic indices occurred predominantly during inferior vena cava clamping and improved following reperfusion. Intraoperative TEE allowed serial assessment of these phase-specific RV changes during LDLT.