Sequential Versus Combined Heart-Liver Transplantation in the USA

Combined Heart-Liver vs Isolated Heart Transplantation in Adults With Congenital Heart Disease

BACKGROUND

Despite an increasing number of adults with congenital heart disease undergoing combined heart-liver transplantation (CHLT), there is a paucity of literature analyzing posttransplant outcomes. We analyzed the incidence and outcomes of congenital heart disease patients undergoing CHLT compared with those undergoing isolated heart transplantation (HT).

METHODS

This was a retrospective analysis of all adult (≥18 years) congenital heart disease patients undergoing CHLT or HT between 2000 and 2020 in the Organ Procurement and Transplantation Network database. The primary outcome was death at 30 days and 1 year after transplantation.

RESULTS

Of 1214 recipients included for analysis, 92 (8%) underwent CHLT and 1122 (92%) underwent HT. Patients undergoing CHLT and HT were similar in the distribution of age, sex, and serum bilirubin. Upon adjusted analysis with HT as the reference, undergoing CHLT was associated with a similar hazard of 30-day mortality between 2000 and 2017 (hazard ratio [HR], 0.51; 95% CI, 0.12-2.08; P = .35) and 2018 and 2020 (HR, 2.32; 95% CI, 0.88-6.13; P = .09). Similarly, there was no difference in the hazard of 1-year mortality for patients undergoing CHLT between 2000 and 2017 (HR, 0.60; 95% CI, 0.22-1.63; P = .32) and 2018 and 2020 (HR, 1.52; 95% CI, 0.66-3.53; P = .33) compared with HT.

CONCLUSIONS

The number of adults undergoing CHLT continues to rise. Given comparable survival outcomes between CHLT and HT, our findings demonstrate the former as a viable option for complex congenital heart disease patients with failing cavopulmonary circulation and associated liver disease. Future studies should delineate factors associated with early hepatic dysfunction to help identify congenital heart disease patients that would benefit from CHLT.

Update on combined heart and liver transplantation: evolving patient selection, improving outcomes, and outstanding questions

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.

Two is better than one: when to consider multiorgan transplant

PURPOSE OF REVIEW

Patients with end-stage heart failure often present with concomitant end-stage renal or end-stage liver disease requiring transplantation. There are limited data regarding the risks, benefits and long-term outcomes of heart-kidney (HKT) and heart-liver transplantation (HLT), and guidelines are mainly limited to expert consensus statements.

RECENT FINDINGS

The incidence of HKT and HLT has steadily increased in recent years with favourable outcomes. Both single-centre and large database studies have shown benefits of HKT/HLT through improved survival, freedom from dialysis and lower rates of rejection and coronary allograft vasculopathy. Current guidelines are institution dependent and controversial due to the ethical considerations surrounding multiorgan transplantation (MOT).

SUMMARY

MOT is an effective and necessary option for patients with end-stage heart and kidney/liver failure. MOT is ethically permissible, and efforts should be made to consider eligible patients as early as possible to limit morbidity and mortality. Further research is needed regarding appropriate listing criteria and long-term outcomes.