Successful Extracorporeal Membrane Oxygenation Support for Acute Pulmonary Thromboembolism during Adult Liver Transplantation

Abstract

Most coagulation factors are synthesized in the liver. Hence, the levels of most coagulation factors are decreased in cases of chronic liver disease. Chronic liver disease was previously considered as an acquired bleeding disorder, and basic laboratory tests of anticoagulation, including prothrombin time and activated partialthromboplastin time (aPTT), were used to assess the risk of bleeding.[1] However, a new hypothesis states that the coagulation system is rebalanced in chronic liver disease, with a decrease in the levels of natural anticoagulant factors, such as protein C and anti-thrombin, and a decrease in the levels of most of the coagulation factors under physiologic conditions.[1] Moreover, patients with chronic liver disease are considered to be procoagulant in many reports.[2,3] This could be explained by the increased levels of factor VIII mediated by the von Willebrand factor.[4,5] Consequently, patients with chronic liver disease are more likely to be at increased risk of venous or arterial thrombosis.[6-8] Here, we report a case of acute pulmonary thromboembolism that developed during adult liver transplantation (LT), which was managed successfully with venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support. A 61-year-old woman with a 1-year history of hepatitis B liver cirrhosis (LC) was scheduled to undergo elective adult-to-adult living donor LT. In addition to LC, she was also diagnosed with diabetes mellitus. Preoperative transthoracic echocardiography indicated normal biventricular and valvular function, with a left ventricular ejection fraction (LVEF) of 71%. Abdominal and pelvic computed tomography showed a large amount of ascites and esophageal varix with a cirrhotic liver. The laboratory findings were not remarkable, except for the low platelet count (65,000/ dL), and slightly elevated aspartate transaminase levels (57 IU/L) and total bilirubin levels (2.5 mg/dL). A skin incision was made with the patient under general anesthesia with stable