(247) Extracorporeal Cardiopulmonary Resuscitation in a Post-Liver Transplantation due to Air Embolism

Introduction: Vascular air embolism (VAE) has been reported during orthotopic liver transplantation. We report a unique case of air embolism in a liver transplant patient postoperatively leading to ST-elevation myocardial infarction (STEMI) and cardiac arrest who was successfully resuscitated with ECPR (extracorporeal membrane oxygenation during cardiopulmonary resuscitation).

Description: A 68 year old female with end stage liver disease secondary to non-alcohol steatohepatitis and autoimmune hepatitis with a MELD-Na of 25 received orthotopic liver transplantation from a DCD ( Donation after Cardiac Death) donor with a warm ischemia time of 26 mins, cold ischemia time of 18 hrs 57 mins with 15 hrs 49 mins on the Transmedics OCS pump. Intra-op course was uncomplicated with caval reconstruction using piggback technique, choledocho-choledochostomy and end-end portal vein reconstruction. She was extubated with hemodynamic stability in the intensive care unit. Six hours postoperatively, patient became hypotensive, and was noted to have acute development of STEMI in the inferior leads on telemetry. Patient developed pulseless electric activity and ACLS measures were initiated. She was emergently placed on VA-ECMO at the bedside. Due to notable bleeding in the drains and abdominal distention, patient was taken to the OR for hemorrhage control from vena cava bleeding before angiography. TEE performed in the OR showed air present in the left ventricle and aortic root confirming right to left shunt and pericardial effusion. Subsequent coronary angiography showed no sign of obstructive disease. Patient was weaned off VA-ECMO in 48 hours and her ICU course was complicated by need for dialysis, tracheostomy and encephalopathy. She was discharged to acute rehabilitation after thirty days with full neurocognitive recovery and off hemodialysis.

Discussion: VAE in this case could have occurred due to air remnant in the venous circulation at the anastomotic site or from entrainment from infusion pumps. VAE leading to STEMI is rare. ECPR post air embolism has been reported in neonates and not adults. In conclusion, this case highlights a rare, but fatal complication of VAE successfully resuscitated using ECPR which should be considered in reversible perioperative causes.