2024 FSA Podium and Poster Abstracts

P072: INTRAOPERATIVE MANAGEMENT OF VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION IN COMBINED LIVER-LUNG TRANSPLANT
Andrea Rivero, DO; Liang Hong, DO; Mayo Clinic

Combined liver-lung transplantation is a rare procedure reserved for patients facing end-stage lung disease coupled with liver cirrhosis, who are unlikely to survive with a single organ transplant. Currently, no established guidelines address the anesthetic or mechanical support management for such cases. In this report, we present the management of venoarterial extracorporeal membrane oxygenation (VA ECMO) during a combined double lung and liver transplant.  

Our patient, a 61-year-old male with end-stage lung disease secondary to idiopathic pulmonary fibrosis, severe hemophilia A, and hepatic cirrhosis, presented for a combined transplant after rapid deterioration of respiratory status. A multidisciplinary team, comprising a cardiac anesthesiologist, abdominal transplant anesthesiologist, cardiac surgeon, abdominal transplant surgeon, intensive care physician, hematologist, collaborated to formulate a comprehensive plan. After uneventful anesthesia induction, cardiac surgeon centrally cannulated the VA ECMO with a 20F arterial cannula in the ascending aorta and a 25F venous cannula from right common femoral vein advanced to the right atrium. VA ECMO flow at 2 liters/min was initiated without significant hemodynamic changes. Given the patient’s severe hemophilia A and end-stage liver disease, factor VIII infusion was administered before and during surgery to achieve a target factor VIII activity of 100%. ε-aminocaproic acid infusion was administered after initial bolus of heparin. The activated clotting time (ACT) was checked every 30 minutes, with intermittent heparin administration to maintain ACT > 180. Factor VIII activity was monitored hourly and adjusted accordingly, aiming to maintain levels between 80-120%. The Abdominal surgeon utilized the piggyback technique, side clamping the inferior vena cava to implant the liver graft without interfering with ECMO flow. Transesophageal echocardiography guided ECMO flow during liver reperfusion with focus on right ventricular volume balance. The abdomen was left open to proceed with the double lung transplant. ECMO flow was adjusted to 4L/min during dissection phase of lung transplant. After left lung graft was implanted, ECMO flow was adjusted to 70% - 80% of the full flow with goal of maintaining pulmonary arterial pulsatility. Following the right lung graft implantation, the patient developed significant metabolic acidosis with lactate level of 15 mmol/L. He was transitioned from VA ECMO to VV ECMO and transferred to ICU with open chest. On POD#2, chest was closed, and VV ECMO was decannulated. He was discharged home on POD#39 in stable condition.  

The management of combined lung/liver transplantation poses significant challenges due to anatomic and physiologic considerations, the delicate balance of volume status, coagulopathy associated with liver disease, and poor lung reserve. This case underscores the importance of a multidisciplinary approach for the successful management of these complex patients.