Treatment of pulmonary hypertension with inhaled nitric oxide during orthotopic liver transplantation

Despite pre-transplant screening, patients with chronic liver disease may present with previously undiagnosed pulmonary hypertension (PH) at the time of liver transplantation. While severe portopulmonary hypertension (PoPH) at the time of surgery is considered a contraindication to transplantation, the current evidence guiding perioperative management of newly diagnosed PH is limited.

We present a case of a 65-year-old male with previously undiagnosed severe PH secondary to cirrhosis-related hyperdynamic circulation, successfully managed with intra- and postoperative inhaled nitric oxide (iNO) therapy during orthotopic liver transplantation. Rapid stabilization of elevated mean pulmonary pressures (mPAP) allowed an uncomplicated perioperative transplant course.

This case highlights the importance of recognizing and addressing newly diagnosed PH at the time of liver transplantation. Whereas severe PoPH presents significant perioperative risk, PH in cirrhosis is more commonly due to alternative etiologies of venous congestion or hyperdynamic circulation. Our case suggests that elevated mPAP of alternative etiologies may not immediately compromise postoperative transplant outcomes. Intraoperative vasodilator therapy, including iNO, may be a useful therapeutic and diagnostic tool in these cases. Further investigation into perioperative management of new PH in liver transplantation is warranted to refine surgical decision-making and improve patient outcomes.