Intraoperative Use of Extracorporeal Membrane Oxygenation (ECMO) During Liver Transplantation: A Case Report

Extracorporeal membrane oxygenation (ECMO) is increasingly used for cardiorespiratory support in hemodynamically unstable patients, yet standardized guidelines for its intraoperative use during liver transplantation are lacking. We present a retrospective review of two orthotopic liver transplant (OLT) recipients who required intraoperative veno-venous (VV) ECMO support.  The first patient, a 52-year-old female with alcohol-related cirrhosis, developed acute pulmonary edema, rising oxygen requirements, and oliguric kidney injury, necessitating emergent VV ECMO during OLT. The second patient, a 66-year-old male with nonalcoholic steatohepatitis-related cirrhosis and severe hepatopulmonary syndrome, underwent planned intraoperative VV ECMO to optimize oxygenation. Both patients tolerated ECMO well and recovered with stable postoperative liver function and respiratory status at follow-up.  These cases illustrate that intraoperative ECMO - whether emergent or planned - can be a valuable adjunct to manage severe cardiopulmonary instability during liver transplantation. Our findings support broader discussion and development of protocols guiding their use in this setting.