1
|
Zhang IW, Lurje I, Lurje G, Knosalla C, Schoenrath F, Tacke F, Engelmann C. Combined Organ Transplantation in Patients with Advanced Liver Disease. Semin Liver Dis 2024. [PMID: 39053507 DOI: 10.1055/s-0044-1788674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Transplantation of the liver in combination with other organs is an increasingly performed procedure. Over the years, continuous improvement in survival could be realized through careful patient selection and refined organ preservation techniques, in spite of the challenges posed by aging recipients and donors, as well as the increased use of steatotic liver grafts. Herein, we revisit the epidemiology, allocation policies in different transplant zones, indications, and outcomes with regard to simultaneous organ transplants involving the liver, that is combined heart-liver, liver-lung, liver-kidney, and multivisceral transplantation. We address challenges surrounding combined organ transplantation such as equity, utility, and logistics of dual organ implantation, but also advantages that come along with combined transplantation, thereby focusing on molecular mechanisms underlying immunoprotection provided by the liver to the other allografts. In addition, the current standing and knowledge of machine perfusion in combined organ transplantation, mostly based on center experience, will be reviewed. Notwithstanding all the technical advances, shortage of organs, and the lack of universal eligibility criteria for certain multi-organ combinations are hurdles that need to be tackled in the future.
Collapse
Affiliation(s)
- Ingrid Wei Zhang
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin, Berlin, Germany
- European Foundation for the Study of Chronic Liver Failure (EF CLIF) and Grifols Chair, Barcelona, Spain
| | - Isabella Lurje
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Cornelius Engelmann
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin, Berlin, Germany
| |
Collapse
|
2
|
Heering G, Lebovics N, Agarwal R, Frishman WH, Lebovics E. Fontan-Associated Liver Disease: A Review. Cardiol Rev 2024:00045415-990000000-00231. [PMID: 38477576 DOI: 10.1097/crd.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Fontan-associated liver disease (FALD) is a chronic complication of the Fontan procedure, a palliative surgery for patients with congenital heart disease that results in a single-ventricle circulation. The success of the Fontan procedure has led to a growing population of post-Fontan patients living well into adulthood. For this population, FALD is a major cause of morbidity and mortality. It encompasses a spectrum of hepatic abnormalities, ranging from mild fibrosis to cirrhosis and hepatocellular carcinoma. The pathophysiology of FALD is multifactorial, involving hemodynamic and inflammatory factors. The diagnosis and monitoring of FALD present many challenges. Conventional noninvasive tests that use liver stiffness as a surrogate marker of fibrosis are unreliable in FALD, where liver stiffness is also a result of congestion due to the Fontan circulation. Even invasive tissue sampling is inconsistent due to the patchy distribution of fibrosis. FALD is also associated with both benign and malignant liver lesions, which may exhibit similar imaging features. There is therefore a need for validated diagnostic and surveillance protocols to address these challenges. The definitive treatment of end-stage FALD is also a subject of controversy. Both isolated heart transplantation and combined heart-liver transplantation have been employed, with the latter becoming increasingly preferred in the US. This article reviews the current literature on the epidemiology, pathophysiology, diagnosis, and management of FALD, and highlights knowledge gaps that require further research.
Collapse
Affiliation(s)
- Gabriel Heering
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Nachum Lebovics
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
- Albert Einstein College of Medicine, Bronx, NY
| | - Raksheeth Agarwal
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
- Internal Medicine at Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Edward Lebovics
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
| |
Collapse
|
3
|
Alsoufi B, Kozik D, Perrotta M, Wilkens S, Lambert AN, Deshpande S, Slaughter M, Trivedi J. Trends and outcomes of heart transplantation in adults with congenital heart disease. Eur J Cardiothorac Surg 2024; 65:ezae086. [PMID: 38447194 DOI: 10.1093/ejcts/ezae086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVES Heart transplantation for adult congenital heart disease is complicated and associated with challenging pretransplant support, long waiting and high early post-transplant mortality. We explored if surgical and medical advances and allocation system changes have affected outcomes. METHODS From United Network for Organ Sharing database, adults with congenital heart disease listed for heart transplantation were queried. To explore practice and outcome trends, patients were divided into 4 eras (eras 1-3: nearly 3 equal periods from 1992 to 2018, era 4: after 2018, corresponding with new allocation system). Univariate and multivariable analysis was performed to evaluate outcomes. RESULTS A total of 2737 patients were listed. There was gradual increase in listed and transplanted patients, along with significant increase in use of mechanical support, simultaneous kidney and liver transplantation. While proportion of transplanted remained constant, there was decrease in proportion delisted/died after listing (P = 0.01) and waiting list duration (P = 0.01), especially in era 4. Thirty-day post-transplant mortality remains high; however, it has significantly improved starting era 3 (P = 0.01). Current survival at 1-year and 5-years is 85% and 65%, with improvement mainly related to decreased early death. On multivariable analysis, factors associated with survival were lower glomerular filtration rate (hazard ratio = 0.99, P = 0.042), bilirubin (hazard ratio = 1.17, P<0.001) and mechanical ventilation (hazard ratio = 2.3, P=0.004). CONCLUSIONS Heart transplantation in adults with congenital heart disease is increasing, along with added complexity, higher usage of pretransplant mechanical support and simultaneous organ transplantation. Despite that, more complex patients do not experience worse outcomes. Early mortality improved but remains high. New donor allocation system allowed shorter waiting time and higher proportion transplanted without altering early mortality.
Collapse
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Deborah Kozik
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Melissa Perrotta
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Sarah Wilkens
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Andrea Nicole Lambert
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Shriprasad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - Mark Slaughter
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| |
Collapse
|
4
|
Shingina A, Bansal N, Cedars A, Chen S, Daugherty T, Emamaullee J, Ganger D, Ge J, Heller T, Hughes D, Kay J, Ortega Legaspi J, Menachem J, Montenovo M, Sack J, Reardon L, Schiano T, Simpson K, Teuteberg J, Tompkins R, Vodkin I, Wu F, Lui G, Zaidi AN, Kappus M, Hilscher M. Combined heart liver transplantation in the patients with advanced liver disease and/or hepatocellular carcinoma: Why cannot liver pull the heart? Am J Transplant 2024; 24:503-505. [PMID: 37839708 DOI: 10.1016/j.ajt.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Alexandra Shingina
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Neha Bansal
- Division of Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, New York, USA
| | - Ari Cedars
- Divisions of Pediatric and Adult Cardiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tami Daugherty
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Juliet Emamaullee
- Liver Transplant Center, Children's Hospital-Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Daniel Ganger
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA
| | - Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Theo Heller
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Dempsey Hughes
- Division of Gastroenterology and Hepatology, Division of Gastroenterology Veterans Affairs Medical Center, Michigan Medicine University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph Kay
- Colorado University School of Medicine, Denver, Colorado, USA
| | - Juan Ortega Legaspi
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jonathan Menachem
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Martin Montenovo
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jordan Sack
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Leigh Reardon
- Division of Adult Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California, USA
| | - Thomas Schiano
- Divisions of Hepatology (T.S.), Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kathleen Simpson
- University of Colorado Denver, Children's Hospital of Colorado, Aurora, CO, USA
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, California, USA
| | - Rose Tompkins
- The Guerin Family Congenital Heart Program, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Irine Vodkin
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Fred Wu
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, Boston, Massachusetts, USA
| | - George Lui
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA; Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ali N Zaidi
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Moira Hilscher
- Department of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Mayo Clinic, USA
| |
Collapse
|
5
|
Wu WK, Siegrist KK, Ziogas IA, Mishra KL, Matsuoka LK, Menachem JN, Izzy M, Shingina A, Do NL, Bacchetta M, Shah AS, Alexopoulos SP. Perioperative Characteristics and Outcomes of Fontan Versus Non-Fontan Patients Undergoing Combined Heart-Liver Transplantation: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:745-754. [PMID: 38172029 DOI: 10.1053/j.jvca.2023.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Combined heart-liver transplantation (CHLT) is becoming increasingly frequent as a maturing population of patients with Fontan-palliated congenital heart disease develop advanced liver fibrosis or cirrhosis. The authors present their experience with CHLT for congenital and noncongenital indications, and identify characteristics associated with poor outcomes that may guide intervention in high-risk patients. DESIGN This was a single-center retrospective cohort study. SETTING This study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee. PARTICIPANTS The study included 16 consecutive adult recipients of CHLT at the authors' institution between April 2017 and February 2022. INTERVENTIONS Eleven patients underwent transplantation for Fontan indications, and 5 were transplanted for non-Fontan indications. MEASUREMENTS AND MAIN RESULTS Compared with non-Fontan patients, Fontan recipients had longer cardiopulmonary bypass duration (199 v 119 minutes, p =m0.002), operative times (786 v 599 minutes, p = 0.01), and larger blood product transfusions (15.4 v 6.3 L, p = 0.18). Six of 16 patients required extracorporeal membrane oxygenation (ECMO), of whom 4 were Fontan patients who subsequently died. Patients who required ECMO had lower 5-hour lactate clearance (0.0 v 3.5 mmol/L, p = 0.001), higher number of vasoactive infusions, lower pulmonary artery pulsatility indices (0.58 v 1.77, p = 0.03), and higher peak inspiratory pressures (28.0 v 18.5 mmHg, p = 0.01) after liver reperfusion. CONCLUSIONS Combined heart-liver transplantation in patients with Fontan-associated end-organ disease is particularly challenging and associated with higher recipient morbidity compared with non-Fontan-related CHLT. Early hemodynamic intervention for signs of ventricular dysfunction may improve outcomes in this growing high-risk population.
Collapse
Affiliation(s)
- Wei Kelly Wu
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN; Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kara K Siegrist
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Kelly L Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Lea K Matsuoka
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN; Transplant Center, University of California Davis Medical Center, Sacramento, CA
| | - Jonathan N Menachem
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alexandra Shingina
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nhue L Do
- Division of Pediatric Cardiac Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN; Transplant Center, University of California Davis Medical Center, Sacramento, CA.
| |
Collapse
|
6
|
Iyengar A, Weingarten N, Herbst DA, Helmers MR, Kelly JJ, Meldrum D, Dominic J, Guevara-Plunkett S, Atluri P. Waitlist Trends in Heart-Liver Transplantation With Updated US Heart Allocation System. Ann Thorac Surg 2023; 116:1270-1275. [PMID: 35987345 DOI: 10.1016/j.athoracsur.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/10/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In October 2018, the United States implemented a change in the donor heart allocation policy from a three-tiered to a six-tiered status system. The purpose of the current study was to examine changes in waitlist patterns among patients listed for concomitant heart-liver transplantation with implementation of the new allocation system. METHODS Patients listed for heart-liver transplantation between January 1, 2012, and June 30, 2021, were identified from the United Network for Organ Sharing database. Patients were grouped by era according to initial list date before or after October 18, 2018. Competing risks regression for mortality, transplantation, removal from waitlist due to illness was performed according to the method of Fine and Gray. Waitlist data were censored at 3 years from initial listing. RESULTS Overall, 523 patients were identified, of whom 310 were listed before (era 1, 59%) and 213 after (era 2, 41%) allocation change. Patients in era 1 were older, had more restrictive cardiomyopathy, and more preoperative inotrope use (all P < .05). However, patients in era 2 has longer ischemic times (3.5 ± 1.1 vs 3.1 ± 1.1 hours, P < .01) and more intraaortic balloon pump use (8.9% vs 3.9%, P = .016). Era 2 was associated with lower subdistribution hazard for death (hazard ratio 0.37; 95% CI, 0.13-1.02; P = .054) and increased transplantation (hazard ratio 1.35; 95% CI, 1.06-1.72; P = .015). CONCLUSIONS The implementation of the US donor heart allocation policy was associated with more preoperative intraaortic balloon pump use for patients listed for heart-liver transplantation. Despite that, the modern era was associated with lower waitlist mortality and more frequent transplantation, without increased risk of delisting due to illness.
Collapse
Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Herbst
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Danika Meldrum
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica Dominic
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara Guevara-Plunkett
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
7
|
Taner T, Hilscher MB, Broda CR, Drenth JPH. Issues in multi-organ transplantation of the liver with kidney or heart in polycystic liver-kidney disease or congenital heart disease: Current practices and immunological aspects. J Hepatol 2023; 78:1157-1168. [PMID: 37208103 DOI: 10.1016/j.jhep.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 05/21/2023]
Abstract
Solid organ transplantation has become an integral part of the management of patients with end-stage diseases of the kidney, liver, heart and lungs. Most procedures occur in isolation, but multi-organ transplantation of the liver with either the kidney or heart has become an option. As more patients with congenital heart disease and cardiac cirrhosis survive into adulthood, particularly after the Fontan procedure, liver transplant teams are expected to face questions regarding multi-organ (heart-liver) transplantation. Similarly, patients with polycystic kidneys and livers may be managed by multi-organ transplantation. Herein, we review the indications and outcomes of simultaneous liver-kidney transplantation for polycystic liver-kidney disease, and discuss the indications, timing and procedural aspects of combined heart-liver transplantation. We also summarise the evidence for, and potential mechanisms underlying, the immunoprotective impact of liver allografts on the simultaneously transplanted organs.
Collapse
Affiliation(s)
- Timucin Taner
- Departments of Surgery & Immunology, Mayo Clinic, Rochester, MN, USA.
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher R Broda
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University, Nijmegen, the Netherlands
| |
Collapse
|
8
|
Shingina A, Chadha R, Lim N, Pillai A, Vodkin I, Montenovo M, Heller T, Yardeni D, Ganger D. Combined heart-liver transplantation practices survey in North America: Evaluation and organ listing practices. Liver Transpl 2023; 29:591-597. [PMID: 36745932 PMCID: PMC10191975 DOI: 10.1097/lvt.0000000000000079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/04/2023] [Indexed: 02/07/2023]
Abstract
We conducted a web-based survey to characterize liver transplant (LT) evaluation and listing practices for patients being evaluated for combined heart-liver transplantation (CHLT), with a specific emphasis on patients with congenital heart disease (CHD), around transplant centers in North America. Very few protocols for liver evaluation and listing in patients undergoing combined heart-liver transplantation are published, and no guidelines currently exist on this topic. A subject of intense debate in the transplant community is the decision of which patients with CHD and liver disease benefit from CHLT compared with heart transplantation. A focus group from the American Society of Transplantation Liver-Intestine Community of Practice Education Subcommittee developed a web-based survey that included questions (1) respondee demographic information; (2) LT evaluation practices in CHLT; (3) liver organ listing practices in CHLT, and (4) 4 clinical vignettes with case-based scenarios in CHLT liver listings among CHD patients who underwent Fontan palliation. The survey was distributed to medical and surgical LT program directors of 47 centers that had completed at least 1 CHLT up to July 2021 in the US and the University of Toronto, Canada. The survey had an excellent 83% response rate (87% for centers that completed at least 1 CHLT in the past 5 y). Total 66.7% used transjugular liver biopsy with HVPG measurements, 30% used percutaneous liver biopsy with no consensus on the use of a fibrosis staging system, 95% mandated contrasted cross-sectional imaging, and 65% upper endoscopy. The following isolated findings evaluation mandated CHLT listing: isolated elevated HVPG (61.5%); the presence of portosystemic collaterals on imaging (67.5%); the endoscopic presence of esophageal or gastric varices (75%), and the presence of HCC (80%), whereas the majority of centers did not feel that the presence of isolated splenomegaly (100%), thrombocytopenia (81.6%), endoscopic findings of portal hypertensive gastropathy (66.7%), or highly sensitized patients (84.6%) justified CHLT. In our survey of North American centers that had performed at least 1 CHLT in the past 5 years, we observed heterogeneity in practices for both evaluation and listing protocols in these patients.
Collapse
Affiliation(s)
- Alexandra Shingina
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan Chadha
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology and Nutrition, Center for Liver Diseases, University of Chicago, Chicago, Illinois, USA
| | - Irene Vodkin
- Division of Gastroenterology and Hepatology, University of California, San Diego, San Diego, California
| | - Martin Montenovo
- Division of Liver Transplant and Hepatobiliary Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland, USA
| | - David Yardeni
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland, USA
| | - Daniel Ganger
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA
| |
Collapse
|
9
|
Tracy KM, Matsuoka LK, Alexopoulos SP. Update on combined heart and liver transplantation: evolving patient selection, improving outcomes, and outstanding questions. Curr Opin Organ Transplant 2023; 28:104-109. [PMID: 36454232 PMCID: PMC9994850 DOI: 10.1097/mot.0000000000001041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
PURPOSE OF REVIEW Combined heart and liver transplantation (CHLT) is an uncommon but increasingly performed procedure with rising need as the population who has undergone Fontan palliation for single ventricle physiology grows. This article reviews the current literature to summarize what is known about patient selection and outcomes and highlights the questions that remain. RECENT FINDINGS Congenital heart disease (CHD) with Fontan-associated liver disease (FALD) has surpassed noncongenital heart disease as the most common indication for CHLT. In patients with failing Fontan physiology, accurate assessment of recoverability of liver injury remains challenging and requires multifaceted evaluation to determine who would benefit from isolated versus dual organ transplantation. Patient survival has improved over time without significant differences between those with and without a diagnosis of CHD. En bloc surgical technique and best use of intraoperative mechanical circulatory support are topics of interest as the field continues to evolve. SUMMARY A more refined understanding of appropriate patient selection and indication-specific outcomes will develop as we gain more experience with this complex operation and perform prospective, randomized studies.
Collapse
Affiliation(s)
- Kaitlyn M Tracy
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | |
Collapse
|
10
|
de Lange C, Möller T, Hebelka H. Fontan-associated liver disease: Diagnosis, surveillance, and management. Front Pediatr 2023; 11:1100514. [PMID: 36937979 PMCID: PMC10020358 DOI: 10.3389/fped.2023.1100514] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
The Fontan operation is a lifesaving procedure for patients with functional single-ventricle congenital heart disease, where hypoplastic left heart syndrome is the most frequent anomaly. Hemodynamic changes following Fontan circulation creation are now increasingly recognized to cause multiorgan affection, where the development of a chronic liver disease, Fontan-associated liver disease (FALD), is one of the most important morbidities. Virtually, all patients with a Fontan circulation develop liver congestion, resulting in fibrosis and cirrhosis, and most patients experience childhood onset. FALD is a distinctive type of congestive hepatopathy, and its pathogenesis is thought to be a multifactorial process driven by increased nonpulsatile central venous pressure and decreased cardiac output, both of which are inherent in the Fontan circulation. In the advanced stage of liver injury, complications of portal hypertension often occur, and there is a risk of developing secondary liver cancer, reported at young age. However, FALD develops with few clinical symptoms, a surprisingly variable degree of severity in liver disease, and with little relation to poor cardiac function. The disease mechanisms and modifying factors of its development are still not fully understood. As one of the more important noncardiac complications of the Fontan circulation, FALD needs to be diagnosed in a timely manner with a structured monitoring scheme of disease development, early detection of malignancy, and determination of the optimal time point for transplantation. There is also a clear need for consensus on the best surveillance strategy for FALD. In this regard, imaging plays an important role together with clinical scoring systems, biochemical workups, and histology. Patients operated on with a Fontan circulation are generally followed up in cardiology units. Ultimately, the resulting multiorgan affection requires a multidisciplinary team of healthcare personnel to address the different organ complications. This article discusses the current concepts, diagnosis, and management of FALD, with special emphasis on the role of different imaging techniques in the diagnosis and monitoring of disease progression, as well as current recommendations for liver disease surveillance.
Collapse
Affiliation(s)
- Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Möller
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hanna Hebelka
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
11
|
Emamaullee J, Martin S, Goldbeck C, Rocque B, Barbetta A, Kohli R, Starnes V. Evaluation of Fontan-associated Liver Disease and Ethnic Disparities in Long-term Survivors of the Fontan Procedure: A Population-based Study. Ann Surg 2022; 276:482-490. [PMID: 35766375 PMCID: PMC9388565 DOI: 10.1097/sla.0000000000005581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fontan-associated liver disease (FALD) has emerged as a nearly universal chronic comorbidity in patients with univentricular congenital heart disease who undergo the Fontan procedure. There is a paucity of data reporting long-term outcomes and the impact of FALD in this population. METHODS Patients who underwent the Fontan procedure between 1992 and 2018 were identified using California registry data. Presumed FALD was assessed by a composite of liver disease codes. Primary outcomes were mortality and transplant. Multivariable regression and survival analyses were performed. RESULTS Among 1436 patients post-Fontan, 75.9% studied were adults, with a median follow-up of 12.6 (8.4, 17.3) years. The population was 46.3% Hispanic. Overall survival at 20 years was >80%, but Hispanic patients had higher mortality risk compared with White patients [hazard ratio: 1.49 (1.09-2.03), P =0.012]. Only 225 patients (15.7%) had presumed FALD, although >54% of patients had liver disease by age 25. FALD was associated with later deaths [median: 9.6 (6.4-13.2) years post-Fontan] compared with patients who died without liver disease [4.1 (1.4-10.4) years, P =0.02]. Patients with FALD who underwent combined heart liver transplant had 100% survival at 5 years, compared with only 70.7% of patients who underwent heart transplant alone. CONCLUSIONS In this population-based analysis of long-term outcomes post-Fontan, Hispanic ethnicity was associated with increased all-cause mortality. Further, the prevalence of FALD is underrecognized, but our data confirms that its incidence increases with age. FALD is associated with late mortality but excellent posttransplant survival. This emphasizes the need for FALD-specific liver surveillance strategies in patients post-Fontan.
Collapse
Affiliation(s)
- Juliet Emamaullee
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Sean Martin
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Cameron Goldbeck
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Brittany Rocque
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Arianna Barbetta
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rohit Kohli
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Pediatrics, University of Southern California, Los Angeles, CA
- Division of Gastroenterology, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Vaughn Starnes
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| |
Collapse
|
12
|
Hilscher MB, Wells ML, Venkatesh SK, Cetta F, Kamath PS. Fontan-associated liver disease. Hepatology 2022; 75:1300-1321. [PMID: 35179797 DOI: 10.1002/hep.32406] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Moira B Hilscher
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Michael L Wells
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Sudhakar K Venkatesh
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Frank Cetta
- Division of Pediatric CardiologyDepartment of Pediatric and Adolescent MedicineMayo ClinicRochesterMinnesotaUSA
| | - Patrick S Kamath
- Division of Gastroenterology and HepatologyDepartment of MedicineMayo ClinicRochesterMinnesotaUSA
| |
Collapse
|
13
|
Alexopoulos SP, Wu WK, Ziogas IA, Matsuoka LK, Rauf MA, Izzy M, Perri R, Schlendorf KH, Menachem JN, Shah AS. Adult Combined Heart-Liver Transplantation: The United States Experience. Transpl Int 2022; 35:10036. [PMID: 35185360 PMCID: PMC8842230 DOI: 10.3389/ti.2021.10036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/12/2021] [Indexed: 12/11/2022]
Abstract
Background: We aimed to review the indications and outcomes of adults undergoing combined heart-liver transplantation (CHLT) in the US using national registry data. Methods: Adult (≥18 years) CHLT recipients in the United Network for Organ Sharing database were included (09/1987–09/2020; era 1 = 1989–2000, era 2 = 2001–2010, era 3 = 2011–2020). Survival analysis was conducted by means of Kaplan-Meier method, log-rank test, and Cox regression. Results: We identified 369 adults receiving CHLT between 12/1989–08/2020. The number of adult CHLT recipients (R2 = 0.75, p < 0.001) and centers performing CHLT (R2 = 0.80, p < 0.001) have increased over the study period. The most common cardiac diagnosis in the first two eras was restrictive/infiltrative cardiomyopathy, while the most common in era 3 was congenital heart disease (p = 0.03). The 1-, 3-, and 5-years patient survival was 86.8, 80.1, and 77.9%, respectively. In multivariable analysis, recipient diabetes [adjusted hazard ratio (aHR) = 2.35, 95% CI: 1.23–4.48], CHLT between 1989-2000 compared with 2011–2020 (aHR = 5.00, 95% CI: 1.13–22.26), and sequential-liver first CHLT compared with sequential-heart first CHLT (aHR = 2.44, 95% CI: 1.15–5.18) were associated with increased risk of mortality. Higher left ventricular ejection fraction was associated with decreased risk of mortality (aHR = 0.96, 95% CI: 0.92–0.99). Conclusion: CHLT is being increasingly performed with evolving indications. Excellent outcomes can be achieved with multidisciplinary patient and donor selection and surgical planning.
Collapse
Affiliation(s)
- Sophoclis P. Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- *Correspondence: Sophoclis P. Alexopoulos,
| | - W. Kelly Wu
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ioannis A. Ziogas
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lea K. Matsuoka
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Muhammad A. Rauf
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Manhal Izzy
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Roman Perri
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kelly H. Schlendorf
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jonathan N. Menachem
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ashish S. Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| |
Collapse
|
14
|
Márquez-González H, Hernández-Vásquez JG, Del Valle-Lom M, Yáñez-Gutiérrez L, Klünder-Klünder M, Almeida-Gutiérrez E, Koretzky SG. Failures of the Fontan System in Univentricular Hearts and Mortality Risk in Heart Transplantation: A Systematic Review and Meta-Analysis. Life (Basel) 2021; 11:1363. [PMID: 34947894 PMCID: PMC8709145 DOI: 10.3390/life11121363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 02/07/2023] Open
Abstract
The Fontan procedure (FP) is the standard surgical treatment for Univentricular heart diseases. Over time, the Fontan system fails, leading to pathologies such as protein-losing enteropathy (PLE), plastic bronchitis (PB), and heart failure (HF). FP should be considered as a transitional step to the final treatment: heart transplantation (HT). This systematic review and meta-analysis aims to establish the risk of death following HT according to the presence of FP complications. There was a total of 691 transplanted patients in the 18 articles, immediate survival 88% (n = 448), survival from 1 to 5 years of 78% (n = 427) and survival from 5.1 to 10 years of 69% (n = 208), >10 years 61% (n = 109). The relative risk (RR) was 1.12 for PLE (95% confidence interval [CI] = 0.89-1.40, p = 0.34), 1.03 for HF (0.7-1.51, p = 0.88), 0.70 for Arrhythmias (0.39-1.24, p = 0.22), 0.46 for PB (0.08-2.72, p = 0.39), and 5.81 for CKD (1.70-19.88, p = 0.005). In patients with two or more failures, the RR was 1.94 (0.99-3.81, p = 0.05). After FP, the risk of death after HT is associated with CKD and with the presence of two or more failures.
Collapse
Affiliation(s)
- Horacio Márquez-González
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Jose Gustavo Hernández-Vásquez
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Montserrat Del Valle-Lom
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Lucelli Yáñez-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Miguel Klünder-Klünder
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Eduardo Almeida-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Solange Gabriela Koretzky
- Department of Clinical Research, Nacional de Cardiología “Ignacio Chávez”, Mexico City 14080, Mexico
| |
Collapse
|
15
|
Menteer J, Goldbeck C, Herrington C, Yanni G, Emamaullee JA. Immunologic and Survival Benefits of Combined Heart-liver Transplantation in Children. Transplantation 2021; 105:e107-e108. [PMID: 34416752 PMCID: PMC8932196 DOI: 10.1097/tp.0000000000003810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Jondavid Menteer
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Cameron Goldbeck
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, CA
| | - Cynthia Herrington
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - George Yanni
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Juliet A. Emamaullee
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, CA
| |
Collapse
|
16
|
Rodriguez DS, Mao C, Mahle WT, Kanter KR, Alazraki A, Braithwaite K, Rytting H, Caltharp S, Magliocca JF, Romero R. Pretransplantation and Post-Transplantation Liver Disease Assessment in Adolescents Undergoing Isolated Heart Transplantation for Fontan Failure. J Pediatr 2021; 229:78-85.e2. [PMID: 32976893 DOI: 10.1016/j.jpeds.2020.09.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 08/17/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe the assessment of Fontan-associated liver disease and determine the clinical and imaging measures that may identify hepatic morbidity risk in isolated heart transplantation candidates and trend those measures post-isolated heart transplantation. STUDY DESIGN Retrospective analysis of pre-isolated heart transplantation and post-isolated heart transplantation Fontan-associated liver disease (FALD) status using blood tests, magnetic resonance imaging (MRI), and liver biopsy analysis within 6 months before isolated heart transplantation and 12 months after isolated heart transplantation in 9 consecutive patients with Fontan. Pre- and post-isolated heart transplantation standard laboratory values; varices, ascites, splenomegaly, thrombocytopenia (VAST) score; Fontan liver MRI score; liver biopsy scores; Model for End-stage Liver Disease (MELD); MELD excluding the International Normalized Ratio (MELD-XI); AST to platelet ratio index, and cardiac catheterization data were compared. RESULTS Pretransplantation maximum MELD and MELD-XI was 15 and 16, respectively. Central venous pressures and VAST scores decreased significantly post-transplantation. In 5 paired studies, Fontan liver MRI score maximum was 10 pretransplantation and decreased significantly post-transplantation. Arterially enhancing nodules on MRI persisted in 2 patients post-transplantation. Pretransplantation and post-transplantation liver biopsy scores did not differ in 4 paired biopsy specimens. CONCLUSIONS Patients with FALD and MELD <15, MELD-XI <16, Fontan liver MRI score <10, and VAST score ≤2 can have successful short-term isolated heart transplantation outcomes. Liver MRI and VAST scores improved post-transplantation. Post-transplantation liver biopsy scores did not change significantly. Pretransplantation liver biopsy demonstrating fibrosis alone should not exclude consideration of isolated heart transplantation. The persistence of hepatic vascular remodeling and fibrosis post-isolated heart transplantation suggests that continued surveillance for hepatic complications post-transplantation for patients with Fontan is reasonable.
Collapse
Affiliation(s)
- Dellys Soler Rodriguez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Chad Mao
- Sibley Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - William T Mahle
- Sibley Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Kirk R Kanter
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Adina Alazraki
- Division of Pediatric Radiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Kiery Braithwaite
- Division of Pediatric Radiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Heather Rytting
- Department of Pathology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Shelley Caltharp
- Department of Pathology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Joseph F Magliocca
- Transplant Section, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - René Romero
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA.
| |
Collapse
|
17
|
Fortea JI, Puente Á, Cuadrado A, Huelin P, Pellón R, González Sánchez FJ, Mayorga M, Cagigal ML, García Carrera I, Cobreros M, Crespo J, Fábrega E. Congestive Hepatopathy. Int J Mol Sci 2020; 21:ijms21249420. [PMID: 33321947 PMCID: PMC7764741 DOI: 10.3390/ijms21249420] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/20/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Abstract
Liver disease resulting from heart failure (HF) has generally been referred as “cardiac hepatopathy”. One of its main forms is congestive hepatopathy (CH), which results from passive venous congestion in the setting of chronic right-sided HF. The current spectrum of CH differs from earlier reports with HF, due to ischemic cardiomyopathy and congenital heart disease having surpassed rheumatic valvular disease. The chronic passive congestion leads to sinusoidal hypertension, centrilobular fibrosis, and ultimately, cirrhosis (“cardiac cirrhosis”) and hepatocellular carcinoma after several decades of ongoing injury. Contrary to primary liver diseases, in CH, inflammation seems to play no role in the progression of liver fibrosis, bridging fibrosis occurs between central veins to produce a “reversed lobulation” pattern and the performance of non-invasive diagnostic tests of liver fibrosis is poor. Although the clinical picture and prognosis is usually dominated by the underlying heart condition, the improved long-term survival of cardiac patients due to advances in medical and surgical treatments are responsible for the increased number of liver complications in this setting. Eventually, liver disease could become as clinically relevant as cardiac disease and further complicate its management.
Collapse
Affiliation(s)
- José Ignacio Fortea
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
- Correspondence: or ; Tel./Fax: +34-(94)-220-2520 (ext. 72929)
| | - Ángela Puente
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Antonio Cuadrado
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Patricia Huelin
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Raúl Pellón
- Radiology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (R.P.); (F.J.G.S.)
| | | | - Marta Mayorga
- Pathological Anatomy Service, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (M.M.); (M.L.C.)
| | - María Luisa Cagigal
- Pathological Anatomy Service, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (M.M.); (M.L.C.)
| | - Inés García Carrera
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
| | - Marina Cobreros
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
| | - Javier Crespo
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Emilio Fábrega
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| |
Collapse
|