P135 | Hepatopulmonary Syndrome: When the indication for liver transplantation becomes challenging

A. Scozzafava¹, R.E. Rullo¹, G. Potenza¹, K. Barbara¹, B. Caroleo² | ¹Università Magna Graecia di Catanzaro, ²Ospedale Civile di Soverato (CZ), Italy

Premises: In hepatopulmonary syndrome (HPS), an unfavorable complication of liver cirrhosis, hypoxemia worsens due to pulmonary vasodilation. They benefit significantly from liver transplantation (OLT).
Case report: A 60-year-old male smoker was suffering from HBV-related liver cirrhosis with portal hypertension. It was accompanied by pulmonary fibrosis (PF) with the following typical blood gas pattern (pH 7.41; SO2 93%; pO2 61mmHg; pCO2 33mmHg). The visit reported recent arterial hypotension and the onset of unusual dyspnea; During the 6MWT, SO2 was reduced to 85%; platypnea-orthodeoxia appeared. The HR-TC confirmed a framework for FP; On echocardiography, the PAPs was 50 mmHg. The rapid onset of dyspnea favored EPS rather than an exacerbation of FP. The patient underwent a cardiac bubble test, which showed late microbubbles in the left ventricle, confirming a right-to-left shunt, characteristic of EPS. The instrumental confirmation of the clinical hypothesis, despite a MELD score of 12, led to the patient being sent to the Transplant Center. Here, the diagnosis was confirmed, and he underwent OLT. Respiratory improvement was gradual; with an ever-decreasing need for oxygen therapy until it is completely discontinued. The spider nevi covering the entire body surface had disappeared a month after the transplant.
Conclusions: OLT is confirmed as a definitive option in EPS, even in the described case; DD is crucial if respiratory comorbidities are present, which could contraindicate liver transplantation. A timely diagnosis guided by clinical reasoning is fundamental to quickly activate the appropriate pathway.