• Won Kyu Choi, Junghan Kim, Ho Joong Choi, Sang Hyun Hong, and Min Suk Chae.
• Department of Anesthesiology and Pain Medicine, Uijeongbu St. Mary's Hospital.
• Medicine (Baltimore). 2021 Jan 15; 100 (2): e24298e24298.

RationaleWe present the case of a patient with autoimmune hepatitis who suffered fatal intracardiac and pulmonary arterial thromboembolic complications after ABO-incompatible living donor liver transplantation (ABOi LDLT) with splenectomy.Patient ConcernsA 46-year-old female (blood type B+) with autoimmune hepatitis and hepatitis B carrier status underwent elective ABOi LDLT. The donor liver was from a 51-year-old male living donor (blood type A+). A splenectomy was performed without bleeding complications. Intraoperatively, the patients hemodynamic condition was acceptable, with no evidence of thromboembolism on transesophageal echocardiography (TEE).DiagnosisPostoperatively, her platelet count increased from 15.0 to 263.0 (× 109/L) and thromboelastographic parameters indicated hypercoagulable state. She suffered acute circulatory collapse, respiratory distress and, eventually, a decline in mental status. The attending physicians in the intensive care unit (ICU) immediately performed resuscitation.InterventionsThe patient underwent emergency exploratory surgery. Intraoperatively, hypotension, bradycardia and arrhythmia developed, together with high central venous pressure. Assessment of cardiac structure and function using rescue TEE incidentally identified multiple, huge thromboembolic clots in the cardiac chambers; therefore, the patient underwent cardiac thromboembolectomy, including cardiopulmonary bypass with hypothermia therapy.OutcomesDue to severe cardiac and respiratory distress, the patient required venoarterial extracorporeal membrane oxygenation (VAECMO) in the operating room and ICU. Despite continuous resuscitation in the ICU and maintenance of VAECMO, she suffered severe hypotension and massive bleeding that eventually led to death.LessonsIn patients with autoimmune hepatitis, risk factors for thromboembolism should be rigorously controlled during the peak period of reactive thrombocytosis after ABOi LDLT with splenectomy.Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

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