Liver Transplantation: Perioperative Care and Update on Intraoperative Management

Abstract

We will present some relevant concepts on the preoperative evaluation of patients with end-stage liver disease and describe some new intraoperative management strategies for liver transplantation. This review is limited to three topics: cardiac issues, pulmonary issues, and coagulation issues. While dobutamine stress echocardiography and myocardial perfusion scintigraphy are the most common screening methods for coronary artery disease, computed tomography techniques are gaining popularity although their value is still unclear. Positive screening tests should be followed by coronary angiography and revascularization. Severe valvular heart disease has to be corrected before transplantation is attempted; percutaneous techniques virtually eliminate the risk of acute hepatic failure frequently associated with cardiopulmonary bypass in patients with severe liver disease. Extracorporeal membrane oxygenation is a viable treatment option when severe pulmonary and cardiac complications develop. Patients with severe hepatopulmonary syndrome can undergo successful liver transplantation, but portopulmonary hypertension remains challenging. Perioperative coagulation management will likely evolve with the availability of prothrombin complex concentrate and fibrinogen concentrate. Rather than trying to provide a complete discussion, we emphasize new and interesting findings with significant clinical significance.