Background <p>Hepatopulmonary syndrome (HPS) with pulmonary arteriovenous malformations (PAVMs) creates high risks of hemodynamic instability and gas embolism during pediatric liver transplantation. Transesophageal echocardiography is relatively contraindicated due to esophageal varices, while intermittent transthoracic echocardiography lacks the temporal resolution to capture transient events. This is the first report of continuous wearable echocardiography for real-time perioperative monitoring in a pediatric liver transplant recipient with HPS and PAVMs.</p> Case presentation <p>A 3-year-old girl with biliary atresia and decompensated cirrhosis underwent deceased donor liver transplantation. Preoperative evaluation confirmed severe HPS with PAVMs. During surgery, fluid management was guided by continuous monitoring using wearable echocardiography to maintain hemodynamic stability. In particular, within 10&#xa0;s after graft reperfusion, wearable echocardiography revealed numerous bright echogenic foci in all visualized cardiac chambers. This real-time finding provided immediate visual confirmation of gas embolism, which was associated with targeted multidisciplinary intervention. The surgery was successfully completed, and the patient was discharged on postoperative day 24.</p> Conclusions <p>This is the first detailed report demonstrating the utility of wearable echocardiography for continuous, real-time cardiac monitoring in a pediatric liver transplant recipient with severe HPS and PAVMs. This technology may facilitate individualized fluid management and enable early warning of catastrophic complications in pediatric liver transplantation when standard echocardiographic modalities are contraindicated or insufficient.</p>