Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for cardiovascular collapse during and after liver transplantation (LT). According to the most recent guidelines, patients with severe cardiomyopathy are excluded from LT because of high-mortality risk during surgery. Intraoperative ECMO support could give these patients the opportunity to undergo LT by reducing the risk of heart failure and reperfusion syndrome. In this case report, we present a case of veno-arterial ECMO (VA-ECMO) support started before LT surgery in a patient with severe pulmonary hypertension, mitral valve steno-insufficiency, and right heart dysfunction. The presence of severe heart disease would have contraindicated LT, but simultaneous liver cirrhosis contraindicated mitral valve surgery, leaving the patient locked in a "Catch-22" state. The best solution was to perform LT with VA-ECMO support before, during, and after the surgery to reduce cardiac load and possible heart failure. LT was performed with good hemodynamic stability and the patient was successfully weaned from ECMO a few hours after surgery. At the 6 month follow-up, normal liver and kidney functions were recorded as well as an overall improvement of heart function; the patient successfully underwent mitral valve replacement and tricuspid annuloplasty 10 months after transplant and is now in good condition.
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