Portopulmonary hypertension and atrial fibrillation in liver transplantation
Davis H, Galusca D, Nanamori M, Morita Y. Portopulmonary hypertension and atrial fibrillation in liver transplantation. Anesthesia and Analgesia 2017; 124(S5):439-439.
Anesthesia and Analgesia
Introduction: Atrial fibrillation with rapid ventricular response and portopulmonary hypertension can pose perioperative anesthetic challenges individually for liver transplantation. This case report describes both comorbidities managed successfully intraoperatively.
Methods: Patient is a 63yo male with portopulmonary hypertension secondary to alcoholic cirrhosis status post transjugular intrahepatic portosystemic shunt. Past medical history is also significant for paroxysmal atrial fibrillation, type 2 DM, HTN, chronic kidney disease, GERD, esophageal, and aortic stenosis status post transcatheter aortic valve replacement. His preoperative transesophageal echocardiography (TEE) showed right ventricular systolic pressure 23 mmHg. Prior to induction, patient was in atrial fibrillation with an irregular rate of 130-140 bpm. After uneventful induction with general anesthesia, TEE showed high pulmonary artery pressure (right ventricular systolic pressure 50 mmHg), confirmed with pulmonary artery catheterization. Intraoperatively, patient was administered sildenafil via orogastric tube and started on amiodarone infusion. Patient remained in atrial fibrillation with rate 130-140s throughout the case. The case was complicated with post-reperfusion coagulopathy requiring massive transfusion. The patient was transferred to SICU on amiodarone, norepinephrine, vasopressin, milrinone IV infusions. Postoperatively, low efficiency dialysis was initiated, vasopressors and milrinone weaned off, and patient was extubated on POD 3. On POD 7, patient found to have pleural effusion, which was negative for cultures. Lactic acid steadily decreased and coagulation studies trending toward normal. However, the patient gradually became delirious requiring multiple pharmacologic interventions. On POD 11, the patient passed away after sudden bradycardia followed by asystole despite aggressive resuscitation.
Conclusion: Combination of atrial fibrillation and portopulmonary hypertension may pose several challenges in liver transplantation due to large fluid shifts and electrolyte imbalance. Pre-induction atrial fibrillation with right ventricular response was likely due previously unidentified infectious etiology. Team decision was made to proceed with transplantation due to stable blood pressure and low likelihood to improve pre-existing conditions without transplantation. Patient tolerated the procedure and postoperative graft function was adequate. Sudden hemodynamic collapse may be explained by excessive antipsychotic dose, which possibly led to hypoventilation, worsening pulmonary hypertension and eventually RV dysfunction.
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