Liver transplantation (LT) is an established therapy for patients with end-stage liver disease. Advances in surgical technique, anesthetic management, and standardization of perioperative care have significantly improved outcomes, making LT an increasingly safe and commonly-performed procedure.¹ Nevertheless, due to the profound physiologic derangements associated with advanced liver disease and the complexity of the operation itself, significant complications can occur at every stage of perioperative care.^2, 3 Hemodynamic instability, metabolic disturbances, coagulopathy, hemorrhage, and cardiac dysfunction can rapidly evolve and pose life-threatening challenges.

When conventional resuscitative strategies fail to restore adequate circulation or oxygenation, extracorporeal membrane oxygenation (ECMO) has emerged as a valuable modality for temporary cardiopulmonary support for many causes of life-threatening shock.⁴ The ability to modify cannulation strategies and circuit components in response to dynamic physiologic changes makes ECMO particularly well-suited to support complex intraoperative and postoperative scenarios.

In this case conference, we describe the management of a patient who developed recurrent cardiac arrests in the early postoperative period after a successful LT. The patient was supported with veno-arterial (VA)-ECMO, later converted to veno-arterial-venous (VAV)-ECMO, supplemented with an in-line hemoconcentrator to facilitate rapid metabolic and fluid optimization. This case illustrates flexible extracorporeal support strategies and coordinated multidisciplinary management in critically ill patients.