Conversion from veno-arterial to veno-pulmonary ECMO for refractory pulmonary hypertension and right ventricular failure after orthotopic liver transplantation

A female patient in mid-30s with a medical history of pulmonary arterial hypertension (PAH) and autoimmune hepatitis underwent an orthotopic liver transplant, after which she had exacerbated PAH and developed right ventricular (RV) dysfunction and shock, leading to veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) initiation. Despite fluid removal, pulmonary vasodilators, positive inotropic support and VA ECMO, her condition slowly worsened, and she could not be weaned from VA ECMO. Concurrent veno-pulmonary (VP) ECMO support was initiated, leading to optimisation of haemodynamics, decannulation from VA ECMO after 2 days, successful RV recovery and decannulation from VP ECMO support after 6 days. This case highlights the use of VP ECMO as a therapeutic option for PAH and refractory right ventricular failure despite maximum medical therapy and VA ECMO.