Viscoelastic Testing for Hemostatic Assessment in Liver Transplantation

Background/Objectives: End-stage liver disease leads to a unique coagulation profile. This rebalanced coagulation status is characterized by the propensity to bleed easily and form clots in blood vessels. Managing these patients requires close monitoring and an understanding of the underlying pathophysiology. Decreased production of coagulation factors by the liver and splenic sequestration of platelets lead to conditions favoring a hypocoagulable picture. Increased levels of factor VIII and von Willebrand factor along with decreased production of anticlotting factors lead to an environment favoring thrombosis. Viscoelastic testing allows clinicians to navigate this challenging coagulation scenario and preserve the delicate balance. Methods: We review recent technological advancements in coagulation monitoring during liver transplantation. Viscoelastic testing has been used and validated in liver transplantation initially using mechanical methods for assessing clot formation and strength, but newer viscoelastic testing platforms are transitioning toward resonance-based technologies and cartridge-based point-of-care devices that allow for faster assessment of coagulopathies. Development of faster point-of-care devices is beneficial for liver transplantation given acute coagulopathies that can occur throughout phases of the case. Results/Conclusions: This paper will discuss briefly transfusion thresholds; how the SEER-based Quantra, resonance-based TEG 6s, and automated cartridge-based ROTEM SIGMA work; gaps using conventional coagulation testing; and the integration of these systems into perioperative decision making to support goal-directed transfusion strategies.