Laparoscopic cholecystectomy in a cardiac transplant candidate with an ejection fraction of less than 15

BACKGROUND AND OBJECTIVES: Laparoscopic procedures are becoming increasingly popular, even in the severely ill patient. We present a case of a cardiac transplant candidate with an ejection fraction of less than 15% who underwent a laparoscopic cholecystectomy. This is the first case in which intraoperative hemodynamic measurements were recorded in a patient with cardiopulmonary disease this severe. METHODS: The patient underwent the procedure while measurements were made at crucial intervals (baseline, with incremental insufflation, reverse Trendelenberg, at desufflation) using a pulmonary artery catheter, transesophageal echocardiography with fractional area measurements, radial arterial line, as well as standard monitoring. RESULTS: This patient showed hemodynamic changes consistent with a person without severe heart disease. There was a rise in mean arterial and systemic vascular resistance with insufflation to 10 mm Hg, which was further exaggerated by reverse Trendelenberg. Heart rate and pulmonary artery wedge pressure increased slightly. The cardiac output and fractional area change declined minimally. CONCLUSIONS: We conclude that if a patient with congestive heart failure is medically optimized, and intra-abdominal pressures and surgical times are minimized, laparoscopic cholecystectomy may be performed with minimal risk to the patient.