*Purpose: The presence of patent foramen ovale (PFO) can result in intra-cardiac shunting of atheromatous debris during liver transplantation (LT) given the acute hemodynamic changes that occur during the operation. The effect of PFO on post-LT outcomes is still unclear. We aim to assess the impact of PFO on the incidence of cerebrovascular accidents (CVAs) post-LT.

*Methods: This is a retrospective study at a single transplant center. Patients who underwent LT between January 2014, and September 2019, were reviewed. All patients had a standard cardiac evaluation performed, including a transthoracic or transesophageal echocardiogram. Patients who had a PFO closure prior to LT were excluded. The population was analyzed based on PFO presence: PFO and no PFO groups. Analyzed data included demographics, comorbidities, model for end-stage liver disease (MELD) at transplant, left ventricular ejection fraction (EF), PFO size, duration of intubation post-LT, the incidence of CVA within 30 days post-LT, and the in-hospital mortality rates.

*Results: Of the 567 patients reviewed, 2 underwent PFO closure prior to LT and did not have post-operative CVA. Mean age of the 565 included patients was 57.3 ±9.5 years, 61.9% were males, and 10 patients (1.8%) had a prior history of CVA or transient ischemic attack (TIA). Alcohol and viral related cirrhosis were the most common etiologies of liver disease. 45 patients (8%) had PFO diagnosed during their pre-operative cardiac workup with no closure performed. Of those, 34 (75.6%) patients had small-sized PFO, while 7 (15.6%) had moderate PFO, and 4 (8.9%) had large PFO. Patients in the PFO group were older compared to the no PFO group (p=0.01) and tended to have a history of coronary artery disease (p=0.014). There was no statistically significant difference between the 2 groups in regards to gender, race, etiology of liver disease, mean MELD at transplant, mean EF, or mean duration of intubation post-LT. However, there was a statistically significant difference in the incidence of CVA within the first 30 days post-LT between the PFO group and the no PFO group, 6.7% and 1.2%, respectively (p=0.005). The 2 groups had similar in-hospital mortality rates, 2.2% in the PFO group and 3.1% in the no PFO group (p=0.747). On subgroup analysis based on PFO size, there was no statistically significant association between the PFO size and the incidence of CVA within 30 days post-LT: small, moderate, and large sized PFO groups had CVA incidence of 2.9%, 14.3%, and 25%, respectively (p=0.168).

*Conclusions: The presence of PFO in patients undergoing LT was associated with an increased incidence of CVA post-operatively. Therefore, this study suggests that prophylactic closure of PFO prior to LT should be considered regardless of the size to reduce the risk of neurological complications post-LT.

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