Refractory Hypotension after Liver Allograft Reperfusion: A Case of Dynamic Left Ventricular Outflow Tract Obstruction

Abstract

Hypotension after reperfusion is a common occurrence during liver transplantation following the systemic release of cold, hyperkalemic, and acidic contents of the liver allograft. Moreover, the release of vasoactive metabolites such as inflammatory cytokines and free radicals from the liver and mesentery, compounded by the hepatic uptake of blood, may also cause a decrement in systemic perfusion pressures. Thus, the postreperfusion syndrome (PRS) can materialize if hypotension and fibrinolysis occur concomitantly within 5 min of reperfusion. Treatment of the PRS may require the administration of inotropes, vasopressors, and intravenous fluids to maintain hemodynamic stability. However, the occurrence of the PRS and its treatment with inotropes and calcium chloride may lead to dynamic left ventricular outflow tract obstruction (DLVOTO) precipitating refractory hypotension. Expedient diagnosis of DLVOTO with transesophageal echocardiography is extremely vital in order to avoid potential cardiovascular collapse during this critical period.

Transesophageal ultrasonography during orthotopic liver transplantation: Show me more

“…The most common abnormal intra‐operative TEE findings during OLT are right‐sided microemboli, right ventricular dysfunction, and patent foramen ovale (PFO) with a left‐to‐right shunt . However, left ventricular outflow tract obstruction is more difficult to diagnose, and very few reports describe this dynamic problem . The same may be true for the diagnosis of left ventricular ballooning syndrome following reperfusion …”

“…76 However, left ventricular outflow tract obstruction is more difficult to diagnose, and very few reports describe this dynamic problem. 8,72 The same may be true for the diagnosis of left ventricular ballooning syndrome following reperfusion. 8,75 Since its introduction in 1976, TEE has progressively expanded its role outside the cardiac surgery setting.…”

“…If the patient has left ventricular hypertrophy and long anterior mitral leaflet, left ventricular outflow tract obstruction (LVOTO) may occur (see Movies ,). In LVOTO, the anterior leaflet of the mitral valve can occlude left ventricle outflow, causing severe posterolateral mitral regurgitation flow . A retrospective review of 106 transplant recipients found inducible LVOTO on preoperative dobutamine stress echocardiography (DSE) in 40% of patients .…”

“…In LVOTO, the anterior leaflet of the mitral valve can occlude left ventricle outflow, causing severe posterolateral mitral regurgitation flow. 8,72 A retrospective review of 106 transplant recipients found inducible LVOTO on preoperative dobutamine stress echocardiography (DSE) in 40% of patients. 73 In this study, an outflow gradient equal to or greater than 36 mm Hg was significantly associated with intra-operative hypotension.…”

Systolic Anterior Motion of the Mitral Valve Causing Dynamic Left Ventricular Outflow Tract Obstruction: An Underappreciated Complication During Lung Transplantation

“…We have experienced SAM after allograft reperfusion in lung transplantation (unpublished case) and a liver transplantation (published case) at our institution. 2 The liver transplant recipient developed hypotension that worsened with inotropic therapy. TEE helped with the diagnosis of SAM, and a change in hemodynamic management to beta blockade and vasopressors improved the hemodynamics.…”