Background: The presence of pulmonary hypertension in patients scheduled for liver transplantation requires a comprehensive perioperative heart evaluation and treatment with epoprostenol (prostacycline) infusion until a liver donor becomes available. We contended that intraoperative attenuation of
severe pulmonary hypertension could be achieved by epoprostenol infusion combined with nitric oxide inhalation.
Case Report: A 49 years old man with end stage liver disease secondary to hepatitis C and ethanol abuse presented for orthotopic liver transplantation. The case was complicated by severe pulmonary hypertension.
Preoperative epoprostenol, at doses ranging from 6 to 26 ng·kg[sup]–1[/sup]·min[sup]–1[/sup], was infused during the induction of anesthesia. Although lower than before (>70 mmHg), post-induction pulmonary pressure (by Swan-Ganz catheter) was 62/30 mmHg. Prior to surgical incision nitric oxide (NO) by inhalation was commenced, increasing the concentration from 10 to 40 ppm; pulmonary artery
pressure (PAP) then declined to 55/25 mmHg. Before starting reperfusion of the transplanted liver, NO concentration was increased to 80 ppm: this allowed completion of the procedure with PAP at 32/16 mmHg. Real time transesophageal echocardiography indicated improvement in right heart function due to NO. Following surgery, NO was continued for 10 hs at a concentration of 40 ppm and the patient was then extubated. Epoprostenol infusion was continued for 2 months after the patient was discharged home; last PAP was measured 32/10 mmHg.
Conclusions: Severe intraoperative pulmonary hypertension during liver transplantation was successfully treated using the combination of IV epoprostenol infusion and NO inhalation in medium and high concentrations.

Keywords: Administration, Inhalation, Epoprostenol - administration & dosage, Hypertension, Pulmonary - physiopathology, Infusions, Intravenous, Intraoperative Period, Liver Failure - surgery, Liver Transplantation, Nitric Oxide - administration & dosage