Intraoperative anesthetic management of the liver transplant recipient with portopulmonary hypertension

Abstract

Purpose of reviewLiver transplantation in patients with portopulmonary hypertension (POPH) is associated with increased perioperative risk. Important recent advances in the management of liver transplantation recipients with POPH are discussed. Recent findingsThe presence of POPH at the time of liver transplantation should not be a contraindication for liver transplantation, as POPH is common and may be related to volume overload and/or high cardiac output (CO). Available data suggest that patients with mild POPH (25-35 mmHg) can safely undergo liver transplantation surgery. In more severe cases, treatment of POPH with a combination of vasoactive drugs may lead to successful liver transplantation with normalization of POPH. The key to successful intraoperative anesthetic management is maintaining the right ventricular preload and avoiding right ventricular dysfunction. Techniques include diuresis, intraoperative hemodialysis, venovenous bypass, or extracorporeal membrane oxygenation. Apart from the surgical and anesthetic techniques used, factors that contribute to increased pulmonary vascular resistance have to be avoided and the continuation of the vasodilators into the intraoperative and postoperative periods is crucial.

Role of extracorporeal membrane oxygenation as a salvage therapy for liver transplantation recipients in a high‐volume transplant center

“…POPH, present in approximately 5%-10% of LT candidates, [27] is known to increase the perioperative risk as it is associated with intraoperative acute right heart failure. [28] In this study, the proportion of patients who received ECMO treatment for POPH was 5.5% (6/ 109), which was smaller than expected. This finding might be related to the setting of our OLT program, where LDLT is dominant, and our institution's preoperative POPH screening protocol and appropriate perioperative management of these patients.…”

“…POPH, present in approximately 5%–10% of LT candidates,27 is known to increase the perioperative risk as it is associated with intraoperative acute right heart failure 28. In this study, the proportion of patients who received ECMO treatment for POPH was 5.5% (6/109), which was smaller than expected.…”

A novel escalation from veno-venous bypass to veno-venous ECMO during orthotopic liver transplantation. A case report

“…Potential indications for VA and VV ECMO during LT include right ventricular failure with portopulmonary hypertension 2 or respiratory failure with hypoxemia and hypoventilation in the setting of hepatopulmonary syndrome or acute respiratory distress syndrome. 3,4 However ECMO support remains uncommon and perhaps underutilized in the setting of LT.…”

Hemodynamic monitoring in liver transplantation ‘the hemodynamic system’

“…PoPH occurs in about 5–10% of liver transplantation recipients and is associated with poor prognosis [6,17,42,45,77]. A mean PAP of more than 50 mmHg before skin incision is an indication for case cancellation [1 ▪▪ ,42,45]. The incidental intraoperative finding of mild to moderate pulmonary hypertension in patients who had negative workup for PoPH is very common (67.7%) and is usually not associated with increased perioperative risk and is a result of the high CO and the volume overload that are prevalent among liver transplantation patients [17,43].…”

“…The PAC can differentiate portopulmonary hypertension (PoPH) from other causes of pulmonary hypertension [8 ▪ ,13]. PoPH occurs in about 5–10% of liver transplantation recipients and is associated with poor prognosis [6,17,42,45,77]. A mean PAP of more than 50 mmHg before skin incision is an indication for case cancellation [1 ▪▪ ,42,45].…”