Intraoperative epoprostenol and nitric oxide for severe pulmonary hypertension during orthotopic liver transplantation: a case report and review of the literature.
BACKGROUND
The presence of pulmonary hypertension in patients scheduled for liver transplantation requires a comprehensive perioperative heart evaluation and treatment with epoprostenol (prostacycline) infusion until a liver donor becomes available. We contended that intraoperative attenuation of severe pulmonary hypertension could be achieved by epoprostenol infusion combined with nitric oxide inhalation.


METHODS
A 49 years old man with end stage liver disease secondary to hepatitis C and ethanol abuse presented for orthotopic liver transplantation. The case was complicated by severe pulmonary hypertension. Preoperative epoprostenol, at doses ranging from 6 to 26 ng.kg(-1).min(-1), was infused during the induction of anesthesia. Although lower than before (>70 mmHg), post-induction pulmonary pressure (by Swan-Ganz catheter) was 62/30 mmHg. Prior to surgical incision nitric oxide (NO) by inhalation was commenced, increasing the concentration from 10 to 40 ppm; pulmonary artery pressure (PAP) then declined to 55/25 mmHg. Before starting reperfusion of the transplanted liver, NO concentration was increased to 80 ppm: this allowed completion of the procedure with PAP at 32/16 mmHg. Real time transesophageal echocardiography indicated improvement in right heart function due to NO. Following surgery, NO was continued for 10 hs at a concentration of 40 ppm and the patient was then extubated. Epoprostenol infusion was continued for 2 months after the patient was discharged home; last PAP was measured 32/10 mmHg.


CONCLUSIONS
Severe intraoperative pulmonary hypertension during liver transplantation was successfully treated using the combination of IV epoprostenol infusion and NO inhalation in medium and high concentrations.
Vater
Youri
Y
Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA, USA.
Martay
Kenneth
K
Dembo
Greg
G
Bowdle
T Andrew
TA
Weinbroum
Avi A
AA
D000280:Administration, Inhalation; D011464:Epoprostenol / Q000008:administration & dosage*; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D007262:Infusions, Intravenous; D007432:Intraoperative Period; D017093:Liver Failure / Q000150:complications / Q000601:surgery; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009569:Nitric Oxide / Q000008:administration & dosage*
D009569:Nitric Oxide; D011464:Epoprostenol