Air Embolism Due to Intrapulmonary Shunt Responsible of Multiorgan Ischemia in a HIV/HCV Co-Infected Liver Transplant Recipient

Hepatopulmonary Syndrome (HPS) is characterized by an intrapulmonary vascular dilatation that occurs as a consequence of chronic liver disease in the absence of intrinsic cardiopulmonary disease. This produce arterial hypoxemia and the pulmonary symptoms of HPS are the result of oxygenation defects. We present a case of liver transplantation in patient affected by end-stage liver disease due to HCV co-infection, became hemiplegic on the left side on post operation day IV during the position of a central venous catheter in the right jugular vein. We investigate the presence of an Intrapulmonary Shunt (IPS) as a possible cause of peripheral air embolism according to several reports in the literature showing that IPS is a potential facilitator of Cerebrovascular Accident (CVA) or TIA. We might conclude suggesting that the diagnosis of HPS should be considered and a contrast-enhanced echocardiography with bubble study should be performed in every patient during the pre-liver transplant workup especially in case of advanced end-stage liver disease (Child-Pugh C or elevated MELD score), when the prevalence of IPS is more frequent, moderate arterial hypoxemia also in the absence of significant dyspnea and evidence of severe left atrial dilatation.