Dynamic left ventricular outflow tract obstruction in an orthotopic liver transplant recipient

A 53 year-old man with Laennec's and hepatitis C-related cirrhosis was found to have dynamic left ventricular outflow tract obstruction during routine evaluation for orthotopic liver transplantation. The outflow tract obstruction gradient was quantified as being 155 to 189 mmHg maximally during dobutamine stress echocardiography. The patient subsequently underwent successful orthotopic liver transplantation at our institution. We discuss here the use of intraoperative transesophageal echocardiography to detect early signs of dynamic outflow tract obstruction and provide a rational guide for fluid and hemodynamic management. We conclude that the measured pressure across the left ventricular outflow tract during dobutamine stress testing does not necessarily predict either intraoperative hemodynamic perturbations such as obstruction or outcome in these patients.