Transplanting Against the Gradient: Invasive Evaluation of Resting and Dynamic Left Ventricular Outflow Tract (LVOT) Obstruction in a Liver Transplant Candidate

Dynamic left ventricular outflow tract (LVOT) obstruction remains a clinically significant perioperative risk factor in candidates for liver transplantation (LT). Among patients with end-stage liver disease (ESLD), conventional resting echocardiography may inadequately characterize the hemodynamic burden of provoked LVOT obstruction, resulting in incomplete cardiovascular risk stratification before transplantation. This report details the use of an invasive preload-provocation fluid challenge to distinguish dynamic from fixed LVOT obstruction, thereby directly impacting anesthetic planning and transplant candidacy. A 69-year-old female patient with drug-induced ESLD displayed a resting transthoracic LVOT gradient of 84 mmHg while on beta-blocker therapy. Cardiac catheterization revealed a baseline intracavitary mid-cavity-to-LVOT gradient of 60 mmHg. Administration of a 500 mL 5% albumin preload over 10 minutes resulted in a reduction of the gradient to 16 mmHg, confirming a load-dependent dynamic obstruction consistent with ESLD physiology rather than fixed LVOT obstruction. Following reassessment, the patient successfully underwent LT utilizing advanced invasive hemodynamic monitoring. Anesthetic management prioritized afterload support and meticulously controlled volume administration, yielding intraoperative cardiovascular stability. Postoperatively, echocardiography demonstrated resolution of LVOT gradients and preserved graft function at six months. This proof-of-concept case underscores the utility of a standardized invasive preload challenge in distinguishing dynamic from fixed LVOT obstruction and guiding perioperative strategy. In the presence of preload-responsive gradients and careful afterload maintenance, LVOT obstruction should not be considered an absolute contraindication to LT. Integration of this diagnostic approach into pre-transplant assessment protocols may refine cardiovascular risk stratification and expand LT eligibility among patients presenting with this unique hemodynamic profile.