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We present a case of severe refractory hypotension in a patient undergoing de-bulking liver resection for massive polycystic liver disease. Emergent trans-oesophageal echocardiography (TOE) revealed dynamic left ventricular outflow tract (LVOT) obstruction with systolic anterior motion (SAM) of the anterior mitral leaflet (AML). Notably, he had a structurally normal heart on pre-operative trans-thoracic echocardiography (TTE). Diagnosis of SAM by TOE, possible mechanisms and specific management of refractory hypotension in this context are discussed.

Unexpected refractory intra-operative hypotension during non-cardiac surgery: Diagnosis and management guided by trans-oesophageal echocardiography