P018: MULTIVISCERAL TRANSPLANT IN A PATIENT WITH PORTO-PULMONARY HYPERTENSION A CASE REPORT
Massud Turbey, MD; Joshua Livingstone, MD; Vadim Shatz; Ahmed Zaghw; Yehuda Raveh; Fouad Souki; Ramona Nicolau-Raducu; Jackson Memorial Hospital
Introduction: Multivisceral transplant (MVTx) is the grafting of a visceral organs’ block that commonly includes the stomach, pancreas, intestine, and the liver. Stage I of visceral exenteration is most challenging as it involves extensive visceral dissection on basis of diffuse & large-caliber visceral portosystemic shunts, extensive scarring secondary to previous abdominal surgeries (“hostile abdomen”), and precarious hemostatic imbalance of ESLD.
Case presentation: 29-year-old Caucasian female, status post liver transplant at infancy due to biliary atresia. Later on, she developed extensive portal vein thrombosis and portopulmonary hypertension and underwent multivisceral transplant. Preoperative mean pulmonary artery pressure was <30 mmHg with a pulmonary vascular resistance of <300 dynes.s/cm5 on oral sildenafil and intravenous epoprostenol.
The donor was an 18-year-old Hispanic who died of intracranial hemorrhage. The anesthesia placed central venous and arterial accesses, and initiated intraoperative RRT, continuous TEE, and serial TEG monitoring. Immediately prior to laparotomy the superior mesenteric artery territory was embolized with gelfoam to facilitated visceral exenteration.
Intraoperatively, intravenous epoprostenol, sildenafil, milrinone and inhaled nitric oxide were utilized to reduce elevated mean pulmonary artery pressure and right ventricular strain associated with vascular clamping, reperfusion, and massive fluid shifts (Figure 1 A). Inotropes to maintain systemic pressure above pulmonary pressure with a goal MAP>65 mmHg (Figure 1 B, Coagulation management required comprehensive transfusion with careful balance between correcting blood loss and preventing thrombosis (Heparin 1000 units/hours initiated at surgical incision up until graft reperfusion while antifibrinolytic, EACA, was administered post reperfusion) (Figure 1 D, E). In stage III, despite the correction of coagulation, nitric oxide and epoprostenol used unleashed anti-platelet effects on a patient already susceptible to coagulopathy, which corrected with DDAVP (Figure D, E). Severe RV failure continued on POD 1-14 and gradually improved POD 15-28. The patient was subsequently decannulated and discharged home on POD 90.
Discussion: MVTx indication was extensive porto-mesenteric vein thrombosis with subsequent thrombosis of splenorenal/mesocaval shunt following LT. It has been suggested that PPHTN should be treated for a minimum of 12 weeks and have satisfactory RV function with mPAP < 35 mmHg prior to transplant. Both objectives were achieved prior to listing this patient. Our patient’s precarious perioperative course suggests that in patients with PPHTN, the listing criteria for MVTx ought to be much more restrictive than for LT, due to MVTx tremendous complexity. Multidisciplinary team of ECMO and pulmonologist joined and were advised.
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