Canabal, Juan

Extracorporeal membrane oxygenation (ECMO) use during liver transplantation is a complex and evolving aspect of critical care. This retrospective analysis presents the largest North American case series to date, offering a detailed comparison of survival outcomes in liver transplant (LT) patients supported by ECMO. A total of 15 patients were supported with ECMO, eight were supported on venoarterial (VA) ECMO and the remaining seven on venovenous (VV) ECMO. The median duration of ECMO support was 10 days. Mean intensive care unit (ICU) and hospital stays were 34.8 (interquartile range [IQR]: 1–158) and 49.2 days (IQR: 1–121), respectively. Overall survival was 33.3%, comparable to published rates (20–30%). Survival was based on ECMO initiation timing: preoperative 33.3% (1/3); intraoperative 50% (3/6); postoperative, 16.6% (1/6). All the patients (five) discharged from hospital were alive at 1 year follow-up. Significant ECMO-related complications included acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) (40%, n = 6/15), neurological complications (40%, n = 6/15), and bleeding requiring transfusion (26.6%, n = 4/15). Literature review suggests better outcomes with intraoperative or postoperative ECMO. While ECMO use is increasing in LT, outcomes remain poor. Improved survival may depend on careful patient selection, optimal timing of initiation, and distinguishing reversible pathology from irreversible one.

Background: Portopulmonary hypertension (POPH) is defined as pulmonary arterial hypertension (PAH) in the context of portal hypertension. Severe POPH has been considered an absolute contraindication of orthotopic liver transplantation (OLT).Objective: Since there are no definitive guidelines for the immediate preoperative, intraoperative, and postoperative evaluation and treatment of POPH patients, we have used published literature along with our experience to review current knowledge in this area.Summary: Moderate-to-severe POPH has important consequences in the perioperative management of candidates for OLT. Adequate right ventricular function is critical to survive the hemodynamic burden of OLT. Immediate preoperative assessment of hemodynamics; careful intraoperative monitoring and management of volume status, pressure changes, and ventricular function; and postoperative transitions of PAH-specific therapy are key components to successful OLT. We emphasize the advantages of the echocardiogram during all of these phases and stress the importance of a team approach to plan care and respond to the multiple challenges of OLT in POPH.