1
|
Mullis DM, Garrison A, Heng E, Zhu Y, Elde S, Nilkant R, Boyd J, Hiesinger W, Lee A, Shudo Y, Gallo A, Bonham CA, Woo YJ, MacArthur JW. Heart-liver transplantation using the en bloc technique: A single-center experience over two decades. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00765-7. [PMID: 39187122 DOI: 10.1016/j.jtcvs.2024.08.031] [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: 04/26/2024] [Revised: 07/27/2024] [Accepted: 08/17/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Combined heart-liver transplantation (CHLT) is a definitive therapy reserved for patients with concomitant heart failure and advanced liver disease. A limited number of centers perform CHLT, and even fewer use the en bloc implantation technique. Here we review clinical outcomes and immunoprotective effects following CHLT and describe our institution's more than two decades of experience in performing the en bloc technique. METHODS All patients who underwent CHLT at our institution between January 2003 and July 2023 were identified. Recipient and donor characteristics, operative details, and clinical outcomes were assessed. Kaplan-Meier analysis was performed to evaluate survival following CHLT. RESULTS A total of 20 patients underwent CHLT using the en bloc technique at our institution between January 2003 and July 2023. At a median follow-up of 3.8 years for patients who survived the perioperative period (n = 18), estimated survival was 94% at 1 year and 75% at 5 years. There was 100% freedom from acute moderate rejection, acute severe rejection, and chronic rejection in all patients. No patients required retransplantation due to rejection. CONCLUSIONS CHLT is a definitive therapy reserved for patients with multiorgan dysfunction. At our institution, the en bloc technique is the preferred operative approach, as it minimizes cardiac insult, requires fewer anastomoses, minimizes cold ischemia time, and allows for rapid correction of coagulopathy. Overall survival for this cohort is excellent. Episodes of acute rejection were rare, providing further support for the idea that the liver may serve an immunoprotective role in multiorgan transplantation.
Collapse
Affiliation(s)
- Danielle M Mullis
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Alyssa Garrison
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Elbert Heng
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; Department of Bioengineering, Stanford University, Stanford, Calif
| | - Stefan Elde
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Riya Nilkant
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Jack Boyd
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Anson Lee
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Yasuhiro Shudo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Amy Gallo
- Department of Abdominal Transplantation, Stanford University, Stanford, Calif
| | - C Andrew Bonham
- Department of Abdominal Transplantation, Stanford University, Stanford, Calif
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; Department of Bioengineering, Stanford University, Stanford, Calif
| | - John W MacArthur
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.
| |
Collapse
|
2
|
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
|
3
|
Temporary Left Ventricular Support Device as a Bridge to Heart-Liver or Heart-Kidney Transplant: Pushing the Boundaries of Temporary Support. ASAIO J 2023; 69:76-81. [PMID: 35544444 DOI: 10.1097/mat.0000000000001721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
In patients with severe cardiogenic shock, temporary mechanical circulatory support has become a viable strategy to bridge patients to heart transplantation. However, end-stage heart failure is often associated with progressive organ dysfunction of the liver or kidney. This can require a dual organ transplant for definitive management (combined heart-liver [HL] or heart-kidney [HK] transplantation). We evaluated temporary mechanical support to bridge patients to HL or HK transplant at a single, high-volume center. All patients who underwent Impella 5.0 placement from January 2014 to October 2018 were identified. From this dataset, patients who underwent placement as a bridge to dual organ transplant were selected, as were those who underwent Impella as a bridge to isolated heart transplant. Over the 5 years of evaluation, 104 patients underwent Impella 5.0 placement. Of these, 14.3% (n = 15) were identified as potential dual organ recipients (11 HK, 4 HL). In total, 80% (12/15) successfully underwent dual organ transplant (8 HK, 4 HL), with a 1-year survival of 100% in both transplanted groups. Among patients undergoing Impella 5.0 placement as a bridge to isolated heart transplant (n = 33), 78.8% (26) were successfully bridged, and 1-year survival was 92% after transplantation. Impella 5.0 is a viable bridge to dual organ transplantation and should be considered as a management strategy in these complex patients at experienced institutions.
Collapse
|
4
|
Frountzas M, Karampetsou N, Nikolaou C, Schizas D, Tsapralis D, Avgerinos D, Toutouzas K. Combined heart and liver transplantation: an updated systematic review. Ann R Coll Surg Engl 2022; 104:88-94. [PMID: 34482766 PMCID: PMC10335029 DOI: 10.1308/rcsann.2021.0103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Combined heart and liver transplantation (CHLT) is one of the most complex procedures of surgery that has been implemented in the last 35 years. The aim of our meta-analysis was to investigate the safety and efficacy of CHLT. MATERIALS The meta-analysis was designed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess systematic Reviews) recommendations. A literature search was conducted up to April 2020 using the MEDLINE,® SCOPUS,® ClinicalTrials.gov, Embase™, Cochrane Central Register of Controlled Trials and Google Scholar™ databases. RESULTS Our meta-analysis included 16 studies with 860 patients. The mortality rate following CHLT was 14.1%. One and five-year survival rates were 85.3% and 71.4% while the heart and liver rejection rates were 6.1% and 9.1% respectively. The hospital stay was 25.8 days and the intensive care unit stay was 9.9 days. Pooled values were also calculated for cardiopulmonary bypass duration, units of transfused red blood cells and fresh frozen plasma, postoperative infection rate, mechanical ventilation rate and follow-up duration. CONCLUSIONS Despite its complexity, CHLT is a safe and effective procedure for the management of lethal diseases that lead to progressive heart and/or liver failure. Nevertheless, there must be strict adherence to the indications for surgery, and future studies should compare CHLT with isolated cardiac and hepatic transplantations.
Collapse
Affiliation(s)
- M Frountzas
- National and Kapodistrian University of Athens, Greece
| | - N Karampetsou
- National and Kapodistrian University of Athens, Greece
| | - C Nikolaou
- National and Kapodistrian University of Athens, Greece
| | - D Schizas
- National and Kapodistrian University of Athens, Greece
| | | | | | - K Toutouzas
- National and Kapodistrian University of Athens, Greece
| |
Collapse
|
5
|
Schettini AV, Llado L, Heimbach JK, Costello JG, Tranäng M, Van Caenegem O, Daly RC, Van den Bergh P, Casanovas C, Fabregat J, Poterucha JJ, Foguenne M, Ericzon BG, Lerut J. Symptomatic Val122del mutated hereditary transthyretin amyloidosis: Need for early diagnosis and prioritization for heart and liver transplantation. Hepatobiliary Pancreat Dis Int 2021; 20:323-329. [PMID: 34116942 DOI: 10.1016/j.hbpd.2021.05.002] [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: 10/22/2020] [Accepted: 05/17/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hereditary transthyretin (ATTRv) amyloidosis is an autosomal dominant disease linked to transthyretin gene mutations which cause instability of the transthyretin tetramer. After dissociation and misfolding they reassemble as insoluble fibrils (i.e. amyloid). Apart from the common Val30Met mutation there is a very heterogeneous group of non-Val30Met mutations. In some cases, the clinical picture is dominated by a rapidly evolving restrictive and hypertrophic cardiomyopathy. METHODS A case series of four liver recipients with the highly clinically relevant, rare and particularly aggressive Val122del mutation is presented. Medical and surgical therapeutic options, waiting list policy for ATTRv-amyloidosis, including the need for heart transplantation, and status of heart-liver transplantation are discussed. RESULTS Three patients needed a staged (1 patient) or simultaneous (2 patients) heart-liver transplant due to rapidly progressing cardiac failure and/or neurologic disability. Domino liver transplantation was impossible in two due to fibrotic hepatic transformation caused by cardiomyopathy. After a follow-up ranging from 3.5 to 9.5 years, cardiac (allograft) function was maintained in all patients, but neuropathy progressed in three patients, one of whom died after 80 months. CONCLUSIONS This is the first report in (liver) transplant literature about the rare Val122del ATTRv mutation. Due to its aggressiveness, symptomatic patients should be prioritized on the liver and, in cases with cardiomyopathy, heart waiting lists in order to avoid the irreversible neurological and cardiac damage that leads to a rapid lethal outcome.
Collapse
Affiliation(s)
- Adriano-Valerio Schettini
- Institute for Experimental and Clinical Research (IREC), Catholic University of Louvain (UCL), Avenue Hippocrate 55, Brussels 1200, Belgium
| | - Laura Llado
- Liver Transplant Unit, Department of Surgery, Hospital Universitari de Bellvitge, Calle de la Feixa Llarga, Barcelona 08907, Spain
| | - Julie K Heimbach
- Division of Transplantation Surgery, William J. von Liebig Transplant Center, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Jose Gonzalez Costello
- Advanced Heart Failure and Transplant Unit, Cardiology Department, Hospital Universitari de Bellvitge, Calle de la Feixa Llarga, Barcelona 08907, Spain
| | - Marie Tranäng
- Familial Amyloidotic Polyneuropathy World Transplant Registry (FAPWTR), Division of Transplantation Surgery, Karolinska Universitetssjukhuset Huddinge, F82, Karolinska Institutet, Stockholm 141 86, Sweden
| | - Olivier Van Caenegem
- Cardiothoracic Intensive Care Unit, Department of Cardiovascular Diseases, University Hospitals Saint-Luc - UCL, Avenue Hippocrate 10, Brussels 1200, Belgium
| | - Richard C Daly
- Cardiovascular Surgery Department, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Peter Van den Bergh
- Neuromuscular Reference Centre, University Hospital Saint-Luc - UCL, Avenue Hippocrate 10, Brussels 1200, Belgium
| | - Carlos Casanovas
- Neuromuscular Unit, Neurology Department, Hospital Universitari de Bellvitge, Calle de la Feixa Llarga, Barcelona 08907, Spain
| | - Joan Fabregat
- Liver Transplant Unit, Department of Surgery, Hospital Universitari de Bellvitge, Calle de la Feixa Llarga, Barcelona 08907, Spain
| | - John J Poterucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St SW, Rochester MN 08907, USA
| | - Maxime Foguenne
- Institute for Experimental and Clinical Research (IREC), Catholic University of Louvain (UCL), Avenue Hippocrate 55, Brussels 1200, Belgium
| | - Bo Göran Ericzon
- Division of Transplantation Surgery, CLINTEC, Karolinska Universitetssjukhuset Huddinge, F82, Karolinska Institutet, Stockholm 14186, Sweden
| | - Jan Lerut
- Institute for Experimental and Clinical Research (IREC), Catholic University of Louvain (UCL), Avenue Hippocrate 55, Brussels 1200, Belgium.
| |
Collapse
|
6
|
Belzile D, Turgeon PY, Leblanc E, Massot M, Bourgault C, Morin J, Dupuis C, Bilodeau M, Laflamme M, Charbonneau E, Trahan S, Pagé S, Joubert P, Couture C, Sénéchal M. Non-invasive diagnostic imaging tests largely underdiagnose cardiac cirrhosis in patients undergoing advanced therapy evaluation: How can we identify the high-risk patient? Clin Transplant 2021; 35:e14277. [PMID: 33682203 DOI: 10.1111/ctr.14277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with liver cirrhosis are generally considered ineligible for isolated cardiac transplantation or left ventricular assist device (LVAD) implantation. The aim of this retrospective study is to explore the diagnostic value of abdominal ultrasound, computed tomography scan (CT scan) and liver-spleen scintigraphy to detect the presence of cirrhosis in patients with advanced heart failure. METHODS Among 567 consecutive patients who underwent pre-transplantation or LVAD evaluation, 54 had a liver biopsy to rule out cardiac cirrhosis; we compared the biopsy results with the imaging investigations. RESULTS In about 26% (n = 14) of patients undergoing liver biopsy, histopathological evaluation identified cirrhosis. The respective sensitivity of abdominal ultrasound, CT scan and liver-spleen scintigraphy to detect cirrhosis was 57% [29-82], 50% [16-84], and 25% [3-65]. The specificity was 80% [64-91], 89% [72-98], and 44% [20-70], respectively. CONCLUSION Ultrasonography has the best-combined sensitivity and specificity for the diagnosis of cirrhosis. However, more than a third of patients with cirrhosis will go undiagnosed by conventional imaging. As liver biopsy is associated with a low rate of complication, it should be considered in patients with a high-risk of cirrhosis or with evidence of portal hypertension to assess their eligibility for heart transplantation or LVAD implantation.
Collapse
Affiliation(s)
- David Belzile
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Pierre Yves Turgeon
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Evelyne Leblanc
- Department of Gastroenteorology, Centre Hospitalier Universitaire de Québec, Laval University, Quebec City, Canada
| | - Montse Massot
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Christine Bourgault
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Joёlle Morin
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Céline Dupuis
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Marc Bilodeau
- Liver Unit, Centre hospitalier de l'Université de Montréal, Montréal, Canada
| | - Maxime Laflamme
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Eric Charbonneau
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Sylvain Trahan
- Department of Pathology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Sylvain Pagé
- Department of Pathology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Philippe Joubert
- Department of Pathology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Christian Couture
- Department of Pathology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| | - Mario Sénéchal
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada
| |
Collapse
|
7
|
Sganga D, Hollander SA, Vaikunth S, Haeffele C, Bensen R, Navaratnam M, McDonald N, Profita E, Maeda K, Concepcion W, Bernstein D, Chen S. Comparison of combined heart‒liver vs heart-only transplantation in pediatric and young adult Fontan recipients. J Heart Lung Transplant 2021; 40:298-306. [PMID: 33485775 PMCID: PMC8026537 DOI: 10.1016/j.healun.2020.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/23/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Indications for a heart‒liver transplantation (HLT) for Fontan recipients are not well defined. We compared listing characteristics, post-operative complications, and post-transplant outcomes of Fontan recipients who underwent HLT with those of patients who underwent heart-only transplantation (HT). We hypothesized that patients who underwent HLT have increased post-operative complications but superior survival outcomes compared with patients who underwent HT. METHODS We performed a retrospective review of Fontan recipients who underwent HLT or HT at a single institution. Characteristics at the time of listing, including the extent of liver disease determined by laboratory, imaging, and biopsy data, were compared. Post-operative complications were assessed, and the Kaplan‒Meier survival method was used to compare post-transplant survival. Univariate regression analyses were performed to identify the risk factors for increased mortality and morbidity among patients who underwent HT. RESULTS A total of 47 patients (9 for HLT, 38 for HT) were included. Patients who underwent HLT were older, were more likely to be on dual inotrope therapy, and had evidence of worse liver disease. Whereas ischemic time was longer for the group who underwent HLT, post-operative complications were similar. Over a median post-transplant follow-up of 17 (interquartile range: 5-52) months, overall mortality for the cohort was 17%; only 1 patient who underwent HLT died (11%) vs 7 patients who underwent HT (18%) (p = 0.64). Among patients who underwent HT, cirrhosis on pre-transplant imaging was associated with worse outcomes. CONCLUSIONS Despite greater inotrope need and more severe liver disease at the time of listing, Fontan recipients undergoing HLT have post-transplant outcomes comparable with those of patients undergoing HT. HLT may offer a survival benefit for Fontan recipients with liver disease.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Nancy McDonald
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvannia
| | - Waldo Concepcion
- Department of Transplantation Services, Mohammed Bin Rashid University School of Medicine, Dubai, UAE
| | | | | |
Collapse
|
8
|
Considerations and experience driving expansion of combined heart-liver transplantation. Curr Opin Organ Transplant 2021; 25:496-500. [PMID: 32796180 DOI: 10.1097/mot.0000000000000804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Heart transplantation concomitant with a liver transplant may be warranted when end-stage heart failure results in irreversible liver failure. Previously reported outcomes have been excellent yet the specific immunoprotective role of the liver allograft is not known. We review the current literature about the immunologic benefit for combined heart and liver transplantation (CHLT). RECENT FINDINGS The total number of combined heart and liver transplants continues to increase and accounts for approximately 25 cases per year. Familial amyloid polyneuropathy with cardiac cirrhosis is the most common indication for CHLT while adult congenital heart disease (CHD) with associated cirrhosis is increasing in frequency. The majority of recent registry data suggest a statistically equivalent to modestly improved survival advantage for CHLT compared with isolated heart transplantation. Direct mechanisms accounting for this survival advantage are not proven, but combined heart and liver transplants experience lower rates of acute cardiac rejection and cardiac allograft vasculopathy (CAV). SUMMARY Combined heart and liver transplants remain a small percentage of the total heart transplants worldwide, but the majority of recent literature confirms the safety and viability of this option for patients with end-stage heart and liver disease. Equivalent to modestly improved survival outcomes, lower rates of acute cardiac rejection and CAV warrant further investigation into the liver allograft's immunoprotective effect on the transplanted heart. The key mechanisms of tolerogenicity have important implications for surgical technique and immunosuppression requirements. Future directions include development of criteria for heart-liver transplant candidacy and identification of equitable allocation protocols.
Collapse
|
9
|
Kovac D, Choe J, Liu E, Scheffert J, Hedvat J, Anamisis A, Salerno D, Lange N, Jennings DL. Immunosuppression considerations in simultaneous organ transplant. Pharmacotherapy 2021; 41:59-76. [PMID: 33325558 DOI: 10.1002/phar.2495] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/21/2020] [Accepted: 12/01/2020] [Indexed: 12/12/2022]
Abstract
Solid organ transplantation is a life-saving procedure for patients in the end stage of heart, lung, kidney, and liver failure. For patients with more than one failing organ, simultaneous organ transplantation has emerged as a viable treatment option. Immunosuppression strategies and outcomes for simultaneous organ transplant recipients have been reported, but often involve limited populations. Transplanting dual organs poses challenges in terms of balancing immunosuppression with immunologic risk and allograft damage from surgical complications. Furthermore, transplanting certain organs can impose considerations on the management of immunosuppression. For example, liver allografts may confer immunologic privilege and lower rates of rejection of other allografts. This review article evaluates immunosuppression strategies for simultaneous kidney-pancreas, liver-kidney, heart-kidney, heart-liver, heart-lung, lung-liver, and lung-kidney transplants. To date, no comprehensive review exists to address immunosuppressive strategies in simultaneous organ transplant populations. Our review summarizes the available literature and provides evidence-based recommendations regarding immunosuppression strategies in simultaneous organ transplant recipients.
Collapse
Affiliation(s)
- Danielle Kovac
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jason Choe
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Esther Liu
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Jenna Scheffert
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Anastasia Anamisis
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - David Salerno
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Nicholas Lange
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Douglas L Jennings
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA.,Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, New York, USA
| |
Collapse
|
10
|
Abstract
Lupus myocarditis is a serious, potentially deadly disease. When it presents as an acute or fulminant myocarditis in a patient without an established diagnosis of lupus, lupus as an etiology of the condition is not commonly suspected. Meanwhile, it has a distinct treatment which may be lifesaving. Review of the literature can shed more light as current management is mostly based on clinical experience and case reports rather than randomized control trials. In this review we are discussing this diagnostic entity, focusing on cardiogenic shock as a manifestation of lupus myocarditis, and discussing management including aggressive immunosuppression, mechanical circulatory support, and cardiac transplantation.
Collapse
|
11
|
Kassel CA, Fremming BA, Brown BA, Markin NW. 2019 Clinical Update in Liver Transplantation. J Cardiothorac Vasc Anesth 2020; 35:1495-1502. [PMID: 32173208 DOI: 10.1053/j.jvca.2020.01.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/31/2020] [Indexed: 11/11/2022]
Abstract
Liver transplantation continues be the standard for treatment of end-stage liver disease, and even with recent advances in organ preservation, the anesthetic management continues to require understanding of multiple organ systems beyond the liver. Multiple factors contribute to hemodynamic changes after reperfusion of the liver graft that anesthesiologists should be aware of before unclamping. Concomitant renal dysfunction in end-stage liver disease is not uncommon, and preparation for continuous renal replacement therapy may need to be considered in certain cases. Cardiac evaluation of liver transplantation patients with an emphasis on arrhythmias, including atrial fibrillation, can help prevent both intraoperative and postoperative complications detrimental to the patient and graft. Finally, combined liver and thoracic organ transplantations may be indicated for certain disease processes that affect multiple organs. These cases require an understanding of the surgical technique and acknowledgment that some goals of the procedures may be in direct opposition to each other.
Collapse
|
12
|
Martin AK, Ripoll JG, Wilkey BJ, Jayaraman AL, Fritz AV, Ratzlaff RA, Ramakrishna H. Analysis of Outcomes in Heart Transplantation. J Cardiothorac Vasc Anesth 2020; 34:551-561. [DOI: 10.1053/j.jvca.2019.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/08/2019] [Indexed: 12/22/2022]
|
13
|
|
14
|
|
15
|
Vaikunth SS, Concepcion W, Daugherty T, Fowler M, Lutchman G, Maeda K, Rosenthal DN, Teuteberg J, Woo YJ, Lui GK. Short-term outcomes of en bloc combined heart and liver transplantation in the failing Fontan. Clin Transplant 2019; 33:e13540. [PMID: 30891780 DOI: 10.1111/ctr.13540] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/09/2019] [Accepted: 03/15/2019] [Indexed: 12/18/2022]
Abstract
Patients with failing Fontan physiology and liver cirrhosis are being considered for combined heart and liver transplantation. We performed a retrospective review of our experience with en bloc combined heart and liver transplantation in Fontan patients > 10 years old from 2006 to 18 per Institutional Review Board approval. Six females and 3 males (median age 20.7, range 14.2-41.3 years) underwent en bloc combined heart and liver transplantation. Indications for heart transplant included ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, and/or lymphatic abnormalities. Indication for liver transplant included portal hypertension and cirrhosis. Median Fontan/single ventricular end-diastolic pressure was 18/12 mm Hg, respectively. Median Model for End-Stage Liver Disease excluding International Normalized Ratio score was 10 (7-26), eight patients had a varices, ascites, splenomegaly, thrombocytopenia score of ≥ 2, and all patients had cirrhosis. Median cardiopulmonary bypass and donor ischemic times were 262 (178-307) and 287 (227-396) minutes, respectively. Median intensive care and hospital stay were 19 (5-96) and 29 (13-197) days, respectively. Survival was 100%, and rejection was 0% at 30 days and 1 year post-transplant. En bloc combined heart and liver transplantation is an acceptable treatment in the failing Fontan patient with liver cirrhosis.
Collapse
Affiliation(s)
- Sumeet S Vaikunth
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Waldo Concepcion
- Department of Transplant Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Tami Daugherty
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California
| | - Michael Fowler
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Glen Lutchman
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Teuteberg
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - George K Lui
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California.,Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| |
Collapse
|
16
|
Serfas JD, Patel PA, Krasuski RA. Heart Transplantation and Mechanical Circulatory Support in Adults with Congenital Heart Disease. Curr Cardiol Rep 2018; 20:81. [PMID: 30094510 DOI: 10.1007/s11886-018-1028-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To assess current management strategies for advanced heart failure in adults with congenital heart disease, including heart transplantation and mechanical circulatory support. RECENT FINDINGS Current data demonstrate that adults with CHD generally experience higher short-term mortality after heart transplantation and MCS implantation, but enjoy superior long-term survival. Such patients are nonetheless less likely to receive a transplant than non-ACHD peers due to a variety of factors, including lack of applicability of current listing criteria to HF in ACHD. MCS is underutilized in ACHD, but provides similar quality of life benefits for ACHD and non-ACHD patients alike. Heart failure in ACHD is complex and difficult to treat, and both heart transplantation and mechanical circulatory support are often challenging to implement in this patient population. However, long-term results are encouraging, and existing data supports increasing use of MCS and transplant earlier in their disease course. Multidisciplinary care is critical to success in these complex patients.
Collapse
|
17
|
Chacon MM, Schulte TE. Liver Dysfunction in Cardiac Surgery – What Causes It and Is There Anything We Can Do? J Cardiothorac Vasc Anesth 2018; 32:1719-1721. [DOI: 10.1053/j.jvca.2018.02.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 11/11/2022]
|
18
|
Gitman M, Albertz M, Nicolau-Raducu R, Aniskevich S, Pai SL. Cardiac diseases among liver transplant candidates. Clin Transplant 2018; 32:e13296. [PMID: 29804298 DOI: 10.1111/ctr.13296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2018] [Indexed: 11/29/2022]
Abstract
Improvements in early survival after liver transplant (LT) have allowed for the selection of LT candidates with multiple comorbidities. Cardiovascular disease is a major contributor to post-LT complications. We performed a literature search to identify the causes of cardiac disease in the LT population and to describe techniques for diagnosis and perioperative management. As no definite guidelines for preoperative assessment (except for pulmonary heart disease) are currently available, we recommend an algorithm for preoperative cardiac work-up.
Collapse
Affiliation(s)
- Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL, USA
| | - Megan Albertz
- Department of Anesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| | | | - Stephen Aniskevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
19
|
|
20
|
Transplantation and Mechanical Circulatory Support in Adult Congenital Heart Disease-Related Advanced Heart Failure. HEART FAILURE IN ADULT CONGENITAL HEART DISEASE 2018. [DOI: 10.1007/978-3-319-77803-7_13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
21
|
Park H, Park J, Lee J, Kim G. Anesthetic management during the first combined heart-liver transplant performed in Korea: a case report. Korean J Anesthesiol 2017; 70:571-576. [PMID: 29046779 PMCID: PMC5645592 DOI: 10.4097/kjae.2017.70.5.571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/27/2017] [Accepted: 05/02/2017] [Indexed: 12/14/2022] Open
Abstract
Herein, we describe the anesthetic management during the first combined heart-liver transplant (CHLT) performed in Korea. Though CHLT is a rare procedure, accumulating evidence suggests that it is a feasible option for patients with coexisting heart and liver failure. A 45-year-old female patient presented with severe cardiac dysfunction requiring extracorporeal membrane oxygenation (ECMO) support and secondary congestive hepatopathy. The patient underwent consecutive heart and liver transplantation using extracorporeal circulatory devices—heart transplant with cardiopulmonary bypass, and liver transplant with peripheral ECMO. In this case report, we focus on the specific anesthetic considerations for CHLT pertaining to the challenges associated with dual pathophysiology.
Collapse
Affiliation(s)
- Hyejin Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jonghwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaabsoo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
22
|
Choi HI, Yun TJ, Jung SH, Lee JW, Song GW, Lee SG, Kim KM, Kim JJ. Combined Heart and Liver Transplantation: The Asan Medical Center Experience. KOREAN JOURNAL OF TRANSPLANTATION 2017. [DOI: 10.4285/jkstn.2017.31.2.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hyo-In Choi
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Jin Yun
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
23
|
Robinson MR, Al-Kindi SG, Oliveira GH. Heart and heart-liver transplantation in patients with hemochromatosis. Int J Cardiol 2017; 244:226-228. [PMID: 28655414 DOI: 10.1016/j.ijcard.2017.06.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/26/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hemochromatosis predisposes to dilated or restrictive cardiomyopathy which can progress to end-stage heart failure, requiring the use of advanced heart therapies including heart (HT) and heart liver (HLT) transplantation. Little is known about the characteristics and outcomes of these patients. METHODS AND RESULTS We queried the United Network for Organ Sharing (UNOS) registry for all patients listed for HT or HLT for a diagnosis of 'hemochromatosis' between 1987 and 2014. Waitlist and post-transplantation outcomes were compared between patients with hemochromatosis (HT vs HLT) and other etiologies. Of the 81,356 adults listed for heart transplantation, 23 patients with hemochromatosis were identified (16 listed for HLT; and 7 listed for HT). Compared with other etiologies, HC patients were younger (39 vs 51years, p<0.0001), and more likely to need inotropes (56.5% vs 25.6%, p=0.003) and mechanical ventilation (13% vs 3.4%, p=0.041). Cumulative hazards of waitlist mortality or delisting were higher in hemochromatosis patients than for other etiologies of heart failure (p<0.001). There were 4 HT and 4 HLT during the study period. Post-transplantation, patients with HC had a 1- and 2-year cumulative survival of 88% and 75%, respectively. CONCLUSIONS Both HT and HLT are viable options for patients with hemochromatosis. Patients with hemochromatosis are younger with increased wait-list mortality compared with other etiologies.
Collapse
Affiliation(s)
- Monique R Robinson
- Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.
| | - Sadeer G Al-Kindi
- Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Guilherme H Oliveira
- Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| |
Collapse
|
24
|
Koehne de Gonzalez AK, Lefkowitch JH. Heart Disease and the Liver: Pathologic Evaluation. Gastroenterol Clin North Am 2017; 46:421-435. [PMID: 28506373 DOI: 10.1016/j.gtc.2017.01.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Liver injury due to acute and chronic heart failure has long been recognized. This article discusses the concepts of acute cardiogenic liver injury (ACLI) and cardiac or congestive hepatopathy (CH) along with their clinical manifestations and sequelae. Histologically, ACLI manifests as centrilobular hepatocellular necrosis, whereas CH is associated with centrilobular hepatocyte atrophy, dilated sinusoids, and perisinusoidal fibrosis, progressing to bridging fibrosis and ultimately cirrhosis. ACLI is associated with marked increases in aminotransferase levels, whereas CH is associated with a cholestatic pattern of laboratory tests. Certain cardiac medications have also been implicated as a cause of liver fibrosis.
Collapse
Affiliation(s)
- Anne Knoll Koehne de Gonzalez
- Department of Pathology and Cell Biology, Columbia University, 630 West 168th Street, PH 15 West, Rm 1574, New York, NY 10032-3725, USA
| | - Jay H Lefkowitch
- Department of Pathology and Cell Biology, Columbia University, 630 West 168th Street, PH 15 West, Rm 1574, New York, NY 10032-3725, USA.
| |
Collapse
|
25
|
Menachem JN, Golbus JR, Molina M, Mazurek JA, Hornsby N, Atluri P, Fuller S, Birati EY, Kim YY, Goldberg LR, Wald JW. Successful cardiac transplantation outcomes in patients with adult congenital heart disease. Heart 2017; 103:1449-1454. [DOI: 10.1136/heartjnl-2016-310933] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 01/13/2017] [Accepted: 02/15/2017] [Indexed: 11/03/2022] Open
|
26
|
|
27
|
Ceulemans LJ, Strypstein S, Neyrinck A, Verleden S, Ruttens D, Monbaliu D, De Leyn P, Vanhaecke J, Meyns B, Nevens F, Verleden G, Van Raemdonck D, Pirenne J. Combined liver-thoracic transplantation: single-center experience with introduction of the‘Liver-first’principle. Transpl Int 2016; 29:715-26. [DOI: 10.1111/tri.12781] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/09/2015] [Accepted: 03/31/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Laurens J. Ceulemans
- Department of Microbiology and Immunology; Abdominal Transplant Surgery; University Hospitals Leuven; KU Leuven Belgium
- Department of Clinical and Experimental Medicine; Thoracic Surgery; University Hospitals Leuven; KU Leuven Belgium
| | - Sébastien Strypstein
- Department of Microbiology and Immunology; Abdominal Transplant Surgery; University Hospitals Leuven; KU Leuven Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences; Anaesthesiology; University Hospitals Leuven; KU Leuven Belgium
| | - Stijn Verleden
- Department of Clinical and Experimental Medicine; Pneumology; University Hospitals Leuven; KU Leuven Belgium
| | - David Ruttens
- Department of Clinical and Experimental Medicine; Pneumology; University Hospitals Leuven; KU Leuven Belgium
| | - Diethard Monbaliu
- Department of Microbiology and Immunology; Abdominal Transplant Surgery; University Hospitals Leuven; KU Leuven Belgium
| | - Paul De Leyn
- Department of Clinical and Experimental Medicine; Thoracic Surgery; University Hospitals Leuven; KU Leuven Belgium
| | - Johan Vanhaecke
- Department of Cardiovascular Sciences; Cardiology; University Hospitals Leuven; KU Leuven Belgium
| | - Bart Meyns
- Department of Cardiovascular Sciences; Cardiac Surgery; University Hospitals Leuven; KU Leuven Belgium
| | - Frederik Nevens
- Department of Clinical and Experimental Medicine; Hepatology; University Hospitals Leuven; KU Leuven Belgium
| | - Geert Verleden
- Department of Clinical and Experimental Medicine; Pneumology; University Hospitals Leuven; KU Leuven Belgium
| | - Dirk Van Raemdonck
- Department of Clinical and Experimental Medicine; Thoracic Surgery; University Hospitals Leuven; KU Leuven Belgium
| | - Jacques Pirenne
- Department of Microbiology and Immunology; Abdominal Transplant Surgery; University Hospitals Leuven; KU Leuven Belgium
| |
Collapse
|