Aggravation of Mitral Regurgitation by Calcium Administration in a Patient With Hypertrophic Cardiomyopathy During Liver Transplantation: A Case Report J.H. Chin, Y.K. Kim, D.K. Choi, W.J. Shin, and G.S. Hwang ABSTRACT Aggravation of mitral regurgitation (MR) due to left ventricular outflow tract obstruction (LVOTO) is likely to occur during liver transplantation in cirrhotic patients with hypertrophic cardiomyopathy (HCMP). Moreover, calcium administration following se- vere hypocalcemia due to inadequate citrate metabolism and massive transfusion may induce MR aggravation with LVOTO in such patients. Herein we have described a cirrhotic patient with HCMP in whom MR was aggravated due to LVOTO resulting from inadvertent rapid administration of calcium during liver transplantation. T HE PRESENCE OF hypertrophic cardiomyopathy (HCMP) is reported to increase the risk of death and myocardial infarction during noncardiac surgery. 1 In partic- ular, liver transplantation in cirrhotic patients with HCMP may be more hazardous because such patients have char- acteristics that can provoke left ventricular outflow tract obstruction (LVOTO) and aggravate mitral regurgitation (MR). These characteristics include low systemic vascular resistance (SVR), unstable volume status caused by massive bleeding, and the need for calcium administration to cor- rect severe hypocalcemia caused by inadequate citrate metabolism and massive transfusion. Herein we have de- scribed a cirrhotic patient with HCMP who experienced MR aggravation due to the development of LVOTO result- ing from unintentionally rapid administration of calcium to treat severe hypocalcemia caused by a massive transfusion during liver transplantation. CASE REPORT A 58-year-old woman with liver cirrhosis (Child-Pugh grade C) presented for a living donor liver transplantation. Preoperative transthoracic echocardiography showed trivial MR with mild LVOTO caused by systolic anterior motion (SAM) of mitral leaflets. The induction of anesthesia using thiopental sodium, fentanyl, vecuronium, and isoflurane was uneventful. The initial hemoglobin (Hb) was 8.5 g/dL, hematocrit (Hct) 25%, and Ca 2+ 1.15 mmol/L. A transesophageal echocardiogram (TEE) showed trivial MR without LVOTO (Fig 1A,B). While dissecting the diseased liver, enormous bleeding occurred, requiring a massive transfusion using a rapid infusion system. Since simultaneous administration of phenylephrine caused no response, continuous infusion of norepinephrine was commenced under TEE monitoring with aggressive volume replacement. At that time, Hb was 7.5 g/dL, Hct 22%, and Ca 2+ 0.31 mmol/L (Table 1). Due to the low concentration of ionized calcium and unstable vital signs, we administered 600 mg supplemental calcium chloride over 5 minutes. Immediately afterward, TEE indicated MR aggravation and LVOTO development (Fig 1C,D). Also, we detected increased cardiac contractility after calcium administration. At that moment, the hemodynamic variables deteriorated slightly (Table 1). The MR aggravation and LVOTO were resolved 15 minutes after a 400 mL volume loading. Twenty minutes after resolution of MR and LVOTO, we again administered 600 mg calcium chloride within 5 minutes to correct the hypocalcemia under normovolemic status. Again, severe MR and LVOTO occurred, resolving after approxi- mately 13 minutes. During the anhepatic and neohepatic periods, we slowly read- ministered 600 mg calcium chloride over 30 minutes, observing no MR aggravation or LVOTO development on TEE. During the reperfusion and neohepatic period, the hemodynamic variables were maintained satisfactorily (Table 1) and TEE revealed no further adverse events. Severe MR and LVOTO were not the result of hypovolemic conditions (which occurred several times during surgery due to massive bleeding, vascular clamping, or surgical manipulation), but were the result of calcium administration. From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. Address reprint requests to Young Kug Kim, MD, PhD, De- partment of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea. E-mail: kyk@amc. seoul.kr © 2009 by Elsevier Inc. All rights reserved. 0041-1345/09/$–see front matter 360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2009.02.080 Transplantation Proceedings, 41, 1979 –1981 (2009) 1979