3: VV ECMO supported liver transplant in a case of fulminant liver failure

Introduction: VV ECMO is used to support the emergent management of respiratory failure refractory to conventional treatment 1. Marked coagulopathy, very often, poses a challenge to incorporating ECMO in the management of liver failure. We report a case of fulminant liver failure, with severe preoperative hypoxic respiratory failure, who underwent a VV ECMO supported orthotopic liver transplant successfully. Case Report: A 21 year old female patient was transferred to our facility with fulminant liver failure due to autoimmune hepatitis. She was in acute progressive hypoxic respiratory failure due to diffuse alveolar hemorrhage secondary to severe coagulopathy. She had grade 2 metabolic encephalopathy without cerebral edema on head CT. The patient’s condition declined progressively despite high-volume plasma exchange and CRRT. Severe desaturation to less than 60% on transfer to operating room prompted institution of VV ECMO. The femoral cannula was inserted and placed below the renal veins (23Fr 38cm long access cannula), and right internal jugular return cannula (17 Fr 15cm long) was placed under fluoroscopy and TEE guidance. ECMO flow of 2.5-3.0 l/min was achieved with prompt improvement of gas exchange. After transplantation, the patient was transferred to ICU on VV ECMO. The patient was successfully weaned off VV ECMO on postoperative day 5. Conclusion: VV ECMO is being increasingly utilized for respiratory failure in post liver transplant patients, with improved outcomes 2. However, there are not many case reports of liver transplants being performed on VV ECMO support considering the challenges posed by the venous cannula traversing the surgical field. Our case demonstrates the successful use of VV ECMO in a fulminant liver failure patient with severe respiratory failure peri-operatively.