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Case report: Fatal hepatic failure after aortic valve replacement and sevoflurane exposure

[Présentation de cas : Insuffisance hépatique fatale après un remplacement de la valve aortique et une exposition au sévoflurane]

Andreas Lehmann, MD^*, Michael Neher, MD, Arndt-Holger Kiessling, MD, Frank Isgro, MD, Anette Koloska and Joachim Boldt, MD^*

^* From the Departments of Anesthesiology and Intensive Care Medicine,
Cardiac Surgery, and
Pathology, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany.

Address correspondence to: Dr. Andreas Lehmann, Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Postfach 21 73 52, D-67073 Ludwigshafen, Germany. Phone: ++49–621–503–000; Fax: ++ 49–621–503–3024; E-mail: lehmanna{at}klilu.de

Purpose: To report a case of lethal hepatotoxicity possibly caused by sevoflurane.

Clinical features: A 76-yr-old woman with a history of four previous minor surgical procedures developed acute liver failure after general anesthesia with sevoflurane, sufentanil and propofol for aortic valve replacement. After an uneventful procedure the patient was extubated 4.5 hr after surgery. On the second postoperative day, serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) increased. On the third postoperative day liver failure occurred, ALT peaked at 10504 U·L^–1 and AST at 15516 U·L^–1, and coagulopathy with an international normalized ratio of 4.6 developed. Liver transplantation was considered but rejected as a therapeutic option. The patient died three days after the operation in multiple organ failure triggered by hepatic failure. Other possible causes for liver failure were excluded.

Conclusions: Sevoflurane hepatitis as a cause for liver failure may be implicated in this patient undergoing valve surgery. Unlike other halogenated anesthetic drugs, sevoflurane is not metabolized to hepatotoxic trifluroacetyl proteins. However, compound A may react with proteins and may be transformed into antigenic material. We suggest that all halogenated anesthetics may be implicated with acute liver injury.