Perioperative management of liver transplantation with concurrent coronary artery disease: Report of two cases
A 62-year-old man (156 cm, 48 kg), scheduled to undergo LRLT for cryptogenic ESLD (Child-Turcotte-Pugh score 9, MELD 12), was decompensated with hepatic encephalopathy, ascites and hepatorenal syndrome. He also had hypertension and diabetes mellitus. He suffered cardiac arrest lasting approximately 30 seconds during large volume paracentesis 8 months ago. A quicker decompression probably induced asystole. Post-cardiac arrest, there was no neurological deficit. He had effort tolerance of NYHA class II. Preoperative echocardiogram showed ejection fraction (EF) of 55% with no pulmonary hypertension. Dobutamine stress echocardiogram was negative for inducible ischemia. Preoperative angiography revealed 30% block in proximal left-anterior descending artery (LAD), 100% block in posterior descending artery with good collateralization. The patient was on metoprolol, terlipressin, aspirin and insulin. Airway examination was normal. Preoperative laboratory values are summarized in . Aspirin was discontinued 7 days before surgery while metoprolol was continued.\nAnaesthesia was induced with fentanyl 200 mcg, propofol 70 mg and intubation was facilitated with rocuronium 50 mg. Anaesthesia was maintained with 1-1.5% isoflurane in air/oxygen and fentanyl at 2 mcg/kg/h. Intraoperative monitoring included a five-lead electrocardiogram (ECG) with ST trends, invasive arterial blood pressure; EV1000® (version-1.2)/flotrac® (Edward life sciences, USA) for CO, SVR, systolic volume variation (SVV) and central venous pressure (CVP) and pulmonary artery catheter (PAC) for mean pulmonary artery pressure (MPAP) and pulmonary capillary wedge pressure (PCWP). Thromboelastograhy, PT/INR, haemoglobin, platelet count and ABG were monitored at regular intervals.\nThe intraoperative goals for mean arterial pressure (MAP), heart rate (HR), MPAP, CO, SVR and urine output were 65-75 mmHg, 60-90 beats/min, 15-20 mmHg, 6-10 l/min, 500-800 dyne.s/cm5 and 0.5 ml/kg/h, respectively. They were maintained with intravenous fluids along with noradrenaline and terlipressin infusions.\nInferior vena cava (IVC) was partially clamped during hepatic vein reconstruction. Transient fall in MAP at reperfusion was managed with boluses of noradrenaline and phenylephrine. No intraoperative ST-segment changes were detected.\nIntraoperative haemodynamic variables are summarized in . Total blood loss was approximately 1500 ml. The patient was shifted to liver transplant ICU and extubated 12 hours later. Antiplatelet therapy and metoprolol were restarted 48 hours after the surgery. Twelve-lead ECG 12 hourly and Troponin-I level 24 hourly were monitored for the first 5 days. The patient was shifted from ICU on the 10th day and discharged on the 16th postoperative day.