Orthotopic liver transplantation in two patients with hypertrophic obstructive cardiomyopathy.

Orthotopic liver transplantation (OLT) in patients with end-stage liver disease is a procedure associated with high cardiac output, low systemic vascular resistance (SVR), coagulopathy and the potential for significant blood loss. A feature of hypertrophic obstructive cardiomyopathy (HOCM) is left ventricular outflow tract obstruction which may be exacerbated by reduced SVR, reduced filling pressures, tachycardia and positive inotropy. We report two cases of OLT in patients with HOCM. Our anaesthetic technique involved the use of halothane and vecuronium and avoidance of drugs causing tachycardia and positive inotropy. Management was aided by intraoperative transoesophageal echocardiography which showed that filling pressures poorly reflected end-diastolic volumes. Volume administration, vasoconstrictors and avoidance of inotropes and chronotropes reduced the outflow tract obstruction which was particularly severe in the reperfusion period.