Planned Venovenous-Extracorporeal Membrane Oxygenation as a Bridge to Orthotopic Liver Transplant Performed for Very Severe Hepatopulmonary Syndrome: A Case Report

Concerns related to poor oxygenation in patients with severe hepatopulmonary syndrome (HPS) may be prohibitive when considering their candidacy for liver transplantation. Extracorporeal membrane oxygenation (ECMO) has been utilized in only a few case reports as a bridge to liver transplant in patients with severe respiratory failure. We report a case of a 66-year-old man with cirrhosis and very severe (arterial oxygen pressure (PaO2) < 50 mmHg) hepatopulmonary syndrome who underwent an orthotopic liver transplant with the planned use of venovenous-ECMO. Pre-transplant echocardiography demonstrated a small-trivial patent foramen ovale (PFO) but following the resolution of hepatopulmonary shunting after liver transplantation, the PFO size enlarged and contributed to a thromboembolic stroke. We conclude that well-selected patients with HPS could benefit from the use of planned venovenous-ECMO and that a small-trivial PFO seen in a patient with HPS may warrant intervention prior to transplantation.