Balloon flotation pacing for severe post-reperfusion syndrome in adult liver transplantation: a four-patient case series

Post-reperfusion syndrome (PRS) is a common but potentially fatal complication during liver transplantation (LT), characterized by hypotension that may be accompanied by bradyarrhythmias and metabolic disturbances. Conventional management includes catecholamine administration, although high doses may have adverse cardiovascular effects. Clinical evidence regarding the placement of balloon flotation pacing catheters as a treating strategy during LT remains limited. This case series describes our experience with balloon flotation pacing for the management of severe PRS-related cardiovascular collapse in adult LT. We retrospectively reviewed data from adult patients who underwent piggyback orthotopic LT and had balloon flotation pacing catheters placed at our institution between October 2022 and December 2025. Four patients met the inclusion criteria for severe PRS and were included in the final analysis. Intraoperative data on catheter placement, pacing management, and hemodynamic changes were collected and analyzed. In all cases, the transvenous pacing catheter was placed before reperfusion; however, pacing was initiated only as a rescue therapy following the onset of cardiovascular collapse. Pacing was activated in all four patients following PRS-associated bradyarrhythmia and hypotension. Pacing was maintained at 70–83 beats/min for 5–9 min, after which sinus rhythm was restored and hemodynamic stability was achieved with additional catecholamine support. One patient died 10 days after transplantation because of graft failure and sepsis; the remaining three patients survived and were followed up for 6–12 months, with no additional cardiac events reported. This case series suggests that balloon flotation pacing may be a feasible and effective strategy for managing severe PRS-related cardiovascular collapse during LT. However, given the retrospective design and limited sample size, its clinical effectiveness and safety should be evaluated in larger prospective studies.