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Orthotopic liver transplantation in two patients with hypertrophic obstructive cardiomyopathy
1Department of Anaesthesia and Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia.
Insights
Orthotopic liver transplantation (OLT) in patients with hypertrophic obstructive cardiomyopathy (HOCM) requires careful anesthetic management. Avoiding certain drugs and using echocardiography helped manage left ventricular outflow tract obstruction during OLT for HOCM patients.
Area of Science:
- Cardiology
- Anesthesiology
- Transplantation Surgery
Background:
- Orthotopic liver transplantation (OLT) is complex in end-stage liver disease patients due to high cardiac output and low systemic vascular resistance (SVR).
- Hypertrophic obstructive cardiomyopathy (HOCM) presents challenges, including left ventricular outflow tract (LVOT) obstruction, exacerbated by conditions common in OLT patients.
Observation:
- This report details two cases of OLT in patients diagnosed with HOCM.
- Intraoperative transesophageal echocardiography revealed that filling pressures did not accurately reflect end-diastolic volumes.
Findings:
- An anesthetic technique using halothane and vecuronium, while avoiding positive inotropic and chronotropic agents, was employed.
- Managing LVOT obstruction involved volume administration, vasoconstrictors, and avoiding inotropes/chronotropes, especially during the critical reperfusion phase.
Implications:
- This approach highlights the importance of tailored anesthetic strategies for OLT in HOCM patients.
- Careful hemodynamic management is crucial to mitigate LVOT obstruction and ensure successful OLT outcomes in this high-risk population.
Abstract:
Orthotopic liver transplantation (OLT) in patients with end-stage liver disease is a procedure associated with high cardiac output, low systemic vascular resistance (SVR), coagulopathy and the potential for significant blood loss. A feature of hypertrophic obstructive cardiomyopathy (HOCM) is left ventricular outflow tract obstruction which may be exacerbated by reduced SVR, reduced filling pressures, tachycardia and positive inotropy. We report two cases of OLT in patients with HOCM. Our anaesthetic technique involved the use of halothane and vecuronium and avoidance of drugs causing tachycardia and positive inotropy. Management was aided by intraoperative transoesophageal echocardiography which showed that filling pressures poorly reflected end-diastolic volumes. Volume administration, vasoconstrictors and avoidance of inotropes and chronotropes reduced the outflow tract obstruction which was particularly severe in the reperfusion period.