Hepatopulmonary syndrome (HPS) is characterized by pulmonary vasodilation and subsequent hypoxemia in the setting of hepatic dysfunction. There is currently no pharmacologic intervention that has been shown to significantly affect outcomes and liver transplantation remains the mainstay of therapy. Unfortunately, patients undergoing liver transplantation are at high risk of significant hypoxemia and mortality in the early postoperative period. In the following case series, we present two cases of patients with severe HPS who underwent liver transplantation and experienced marked hypoxemia in the early postoperative period. In both cases, we successfully treated the patients with inhaled nitric oxide for their severe refractory life-threatening hypoxemia which led to immediate and dramatic improvements in their oxygenation. Although the use of inhaled nitric oxide in patients with HPS has been sporadically reported in pediatric literature and in animal studies, to our knowledge, our cases are the first recorded in adult patients.

Introduction Observational studies differ on the impact of performing tricuspid repair on surgical mortality. Some studies demonstrate increased surgical mortality related to right ventricular failure and circulatory shock, while there are other studies that evidence improvement in quality of life and signs of right heart failure in the long time. Objective To evaluate the impact on surgical mortality of concomitant tricuspid annuloplasty in patients undergoing cardiac surgery for rheumatic mitral valve disease, who have moderate to severe tricuspid regurgitation. Methods This is a prospective cohort from January 1, 2017 to December 30, 2020. All patients over 18 years of age who underwent cardiac surgery to correct rheumatic mitral valve disease with moderate to significant tricuspid regurgitation were included. The primary outcome was 30-days mortality. Results 165 patients were included, 98 (59.4%) underwent tricuspid valve annuloplasty. The mean age was 46, 5 (±12) years, the median of Euroscore II was 2,33%. The 30-days mortality was 17 (10.3%) and there was no difference between the groups submitted or not to tricuspid repair: 12 (12.2%) versus 5 (7.5%); p=0.44, respectively. In the multivariate analysis involving seven variables with a potential prediction of death in 30 days, tricuspid repair had no association with death, RR 2,4 (0,5 – 8,3); p=0.27. Conclusion In patients with rheumatic heart disease undergoing cardiac surgery for rheumatic mitral valve disease, perform tricuspid annuloplasty in individuals who had moderate to severe tricuspid insufficiency was not associated with increased surgical mortality. FUNDunding Acknowledgement Type of funding sources: None.