Abstract
IntroductionCombined with massive lung aeration loss resulting from acute respiratory distress syndrome, hepatopulmonary syndrome, a liver-induced vascular lung disorder characterized by diffuse or localized dilated pulmonary capillaries, may induce hypoxaemia and death in patients with end-stage liver disease.MethodsThe case of such a patient presenting with both disorders and in whom an extracorporeal membrane oxygenation was used is described.ResultsA 51-year-old man with a five-year history of alcoholic cirrhosis was admitted for acute respiratory failure, platypnoea and severe hypoxaemia requiring emergency tracheal intubation. Following mechanical ventilation, hypoxaemia remained refractory to positive end-expiratory pressure, 100% of inspired oxygen and inhaled nitric oxide. Two-dimensional contrast-enhanced (agitated saline) transthoracic echocardiography disclosed a massive right-to-left extracardiac shunt, without patent foramen ovale. Contrast computed tomography (CT) of the thorax using quantitative analysis and colour encoding system established the diagnosis of acute respiratory distress syndrome aggravated by hepatopulmonary syndrome. According to the severity of the respiratory condition, a veno-venous extracorporeal membrane oxygenation was implemented and the patient was listed for emergency liver transplantation. Orthotopic liver transplantation was performed at Day 13. At the end of the surgical procedure, the improvement in oxygenation allowed removal of extracorporeal membrane oxygenation (Day 5). The patient was discharged from hospital at Day 48. Three months after hospital discharge, the patient recovered a correct physical autonomy status without supplemental O2.ConclusionsIn a cirrhotic patient, acute respiratory distress syndrome was aggravated by hepatopulmonary syndrome causing life-threatening hypoxaemia not controlled by standard supportive measures. The use of extracorporeal membrane oxygenation, by controlling gas exchange, allowed the performing of a successful liver transplantation and final recovery.
Highlights
Combined with massive lung aeration loss resulting from acute respiratory distress syndrome, hepatopulmonary syndrome, a liver-induced vascular lung disorder characterized by diffuse or localized dilated pulmonary capillaries, may induce hypoxaemia and death in patients with end-stage liver disease
Materials and methods We here report the use of Extracorporeal membrane oxygenation (ECMO) as a bridge to orthotopic liver transplantation (OLT) in a patient with refractory hypoxaemia resulting from combined acute respiratory distress syndrome (ARDS) and hepatopulmonary syndrome (HPS)
This is the first case report describing the use of ECMO as a bridge to liver transplantation in a cirrhotic patient with life-threatening hypoxaemia resulting from combined ARDS and HPS
Summary
Combined with massive lung aeration loss resulting from acute respiratory distress syndrome, hepatopulmonary syndrome, a liver-induced vascular lung disorder characterized by diffuse or localized dilated pulmonary capillaries, may induce hypoxaemia and death in patients with end-stage liver disease. ECMO has been tested in acute respiratory distress syndrome (ARDS) [1,2] and before and after lung transplantation [3] Another potential use of ECMO could be the management of life-threatening hypoxaemia in patients with hepatopulmonary syndrome (HPS), selected for orthotopic liver transplantation (OLT). HPS, a liver-induced vascular lung disorder, is characterized by diffuse or localized dilated pulmonary capillaries and, less commonly, pleural and pulmonary arteriovenous communications coexisting with normal alveolar ventilation [4]. One case of successful use of ECMO in the management of life-threatening hypoxaemia following OLT for HPS has been reported [8] but there are no data concerning its use in the pre-operative management
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