Perioperative management of liver transplantation with concurrent coronary artery disease: Report of two cases
A 55-year-old man (167 cm, 93 kg), scheduled to undergo LRLT for hepatitis B associated ESLD (Child-Turcotte-Pugh score 9, MELD 15), was decompensated with ascites and oesophageal variceal bleed. CAD was diagnosed when he had an episode of myocardial infarction 7 months ago. Subsequently, he underwent percutaneous intervention (PCI). Drug eluting stent was placed in LAD and bare metal stents were placed in D1 and D2 artery. He was on aspirin and clopidogrel (75 mg each). He remained asymptomatic subsequently. He also had hypertension and diabetes mellitus. Aspirin was stopped 2 months later in the view of repeated malaena. Preoperative echocardiogram showed EF of 42% with no pulmonary hypertension. During exercise stress echocardiogram, he achieved 90% of target HR but EF reduced from 42% to 35% and the mid-anterior septum and distal-inferior wall became akinetic. He became breathless 6 minutes after exercise and his functional capacity was rated good (METs-7, NYHA class II). Preoperative angiography revealed patent stent in LAD, blocked stent in D1 and D2 artery. Left circumflex artery was 10% blocked, while right coronary artery was 40% blocked. No further intervention was deemed necessary by cardiologist. The patient was on bisoprolol, torsemide, atorvastatin, clopidogrel and insulin. Clopidogrel was stopped 1 week prior to surgery and enoxaparin 60 mg OD was started. Airway examination was normal. Preoperative laboratory reports are summarized in .\nEnoxaparin was stopped 12 hours prior to surgery and bisoprolol was continued. Anaesthesia was induced with fentanyl 300 mcg, thiopentone 175 mg and intubation of trachea was facilitated with rocuronium 100 mg. Anaesthesia was maintained with 1-1.5% isoflurane in air/oxygen and fentanyl at 3 mcg/kg/h. Intraoperative monitoring and goals were same as in case 1. In addition, defibrillator pads were applied on chest. A 6 Fr sheath introducer was placed into left femoral artery for emergent establishment of intra-aortic balloon pump; however, the requirement did not arise.\nIntraoperative haemodynamic variables are summarized in . During the later part of the dissection phase, despite high dose of noradrenalin infusion, terlipressin infusion was started to maintain MAP and SVR. IVC was partially clamped during hepatic vein reconstruction. Before reperfusion, portal flush was used to avoid post-reperfusion syndrome (PRPS). A transient fall of MAP was treated with boluses of noradrenaline, phenylephrine and soda-bicarbonate. No intraoperative ST-segment changes were detected. Total blood loss was approximately 1200 ml. The patient was shifted to liver transplant ICU and extubated 6 hours later. Antiplatelet therapy and bisoprolol were restarted 1 day after the surgery. His postoperative recovery was uneventful. Postoperative monitoring was similar to the first patient. The patient was shifted from ICU on the 8th day and discharged on the 16th postoperative day.