*Purpose: Intracardiac thrombus (ICT) is an intraoperative complication during orthotopic liver transplantation (OLT) with high mortality. Patients with end stage liver disease have compromised coagulation pathways and when combined with stressors of surgery, thrombi can form. However, it is unknown which patients are most likely to develop ICT.

*Methods: Retrospective review of anesthesia records identified liver transplant recipients who developed ICT from 2010 to 2017. Presence of ICT was defined as the following: a) A note in the anesthesia record by the anesthesiologist or anesthesia resident stating presence of ICT on transesophageal echocardiography (TEE) or high suspicion for ICT based on clinical findings or b) Hemodynamic findings including sudden hypotension, increase in central venous pressure, increase in pulmonary artery pressure (if pulmonary artery catheter present) consistent with ICT with subsequently documented administration of heparin or tissue plasminogen activator. Potential risk factors were analyzed using Fisher’s exact tests or chi-squared tests for categorical data and independent t-tests for continuous data.

*Results: The incidence of ICT during OLT was 4.17% (22/528) with a 45.45% (10/22) mortality. Patients who developed ICT had higher physiologic MELD scores at the time of transplant (25.1 vs 32.4, p=0.004), received grafts from donors with higher BMIs (28.1 vs 32.2, p=0.007) and had longer intraoperative warm ischemia times (53.1 vs 67.5 mins, p=0.001). Administration of intravenous heparin prior to inferior vena cava (IVC) cross-clamping was associated with a lower risk of developing ICT (OR 0.25 (0.08-0.75)). Antifibrinolytic administration was not associated with ICT.

*Conclusions: The incidence of ICT at our institution is higher than previously reported though mortality is lower. This may be explained by our routine use of TEE. While many factors associated with ICT in this study are non-modifiable, administration of IV heparin prior to IVC cross-clamping is modifiable and was found to be protective. Future studies will be needed to determine dosing and timing of heparin administration.

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