Introduction:Pulmonary hypertension (PH) is defined as an elevated mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest. The perioperative management can be complicated by hemodynamic instability resulting in severe hypoxemia, acute right heart failure/circulatory collapse and death. Portal hypertension is a curable cause for PH. However, Krowka et al reported that mPAP of 50 mmHg or greater was associated with 100% cardiopulmonary mortality in liver transplantation (LT) setting.
Materials and Methods: A 45 years old male patient underwent LDLT for HBV + alcoholic cirrhosis and HCC. MELD score was 28. Echocardiography performed 2 months before the operation showed right ventricular systolic pressure (RVSP) 62 mmHg and maximum tricuspid regurgitant jet velocity (TRVmax) 3.8m/sec, suggesting moderate resting PH. During anesthetic induction, pulmonary vascular resistance (PVR) was measured as 246 dynes/sec/cm-5 and mPAP as 52mmHg. One hour later, they were 217 and 40, respectively, with infusion of Isosorbide 1mcg/Kg/min. Vital signs were stable and PaO2 level was 223 mmHg. So we decided to proceed with surgery despite of moderate PH.
Results: Graft weighed 550g and GRWR was 0.74. The living donor LT procedure was done with modified right lobe graft. Additionally portal vein endthrombectomy, direct ligation of a large splenorenal shunt and splenic artery ligation was done. The operation took 850 minutes and 24 pints of RBC, 16 pints of FFP, 8 pints of PC and 10 pints of cryoprecipitate. PVR and mPAP were in the range of 217~149 and 46~31, respectively. Alprostadil 7mcg/hr was started just after finishing arterial anastomosis and was infused for 7 days thereafter. Extubation was done 9 hours after the operation and liquid diet was begun 2 days after the operation. The day after LT, RVSP was 96 mmHg and TRVmax 4.9m/sec. And 5 days after LT, he complained of dyspnea and Beraprost (prostacyclin pathway agonist) was given orally. Even with mild dyspnea, the patient was discharged on foot 19 days after LT. 6 weeks after LT RVSP was measured as 84 mmHg and TRVmax 4.0m/sec. mPAP was 63 mmHg on right heart catheterization. On CT scan, there was marked hepatic congestion resulting from pulmonary hypertension. Endothelin receptor antagonist Ambrisentan was given orally. The patient's breathing difficulty almost disappeared soon. Now, 3 months after the operation, he returned to work.
Conclusion:The authors conducted LDLT in a case of severe pulmonary hypertension with mean PAP 50 mmHg successfully by careful intraoperative monitoring and postoperative management. When encountered a case of moderate to severe pulmonary hypertension during LT, initial response to anesthetic management might dictate whether to proceed with LT or not.