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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.
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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
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2
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Van Loon K, Rega F, Pirenne J, Jansen K, Van De Bruaene A, Dewinter G, Rex S, Eerdekens GJ. Anesthesia for Combined Heart-Liver Transplantation: A Narrative Review. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00227-1. [PMID: 38918097 DOI: 10.1053/j.jvca.2024.03.036] [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: 10/12/2023] [Revised: 03/04/2024] [Accepted: 03/25/2024] [Indexed: 06/27/2024]
Abstract
In 1984, 21 years after the first liver transplantation, Thomas Starzl achieved a milestone by performing the world's first combined heart-liver transplantation. While still uncommon, the practice of combined heart-liver transplants is on the rise globally. In this review, the authors delve into the current literature on this procedure, highlighting the evolving landscape and key considerations for anesthesiologists. Over the years, there has been a remarkable increase in the number of combined heart-liver transplantations conducted worldwide. This surge is largely attributed to the growing population of adult survivors with single-ventricle physiology, palliated with a Fontan procedure, who later present with late Fontan failure and Fontan-associated liver disease. Research indicates that combined heart-liver transplantation is an effective treatment option, with reported outcomes comparable with isolated heart or liver transplants. Managing anesthesia during a combined heart-liver transplant procedure is challenging, especially in the context of underlying Fontan physiology. International experience in this field remains somewhat limited, with most techniques derived from expert opinions or experiences with single-organ heart and liver transplants. These procedures are highly complex and performed infrequently. As the number of combined heart-liver transplants continues to rise globally, there is a growing need for clear guidance on periprocedural surgical and anesthetic management. Anesthesiologists overseeing these patients must consider multiple factors, balancing various comorbidities with significant hemodynamic and metabolic shifts. An increase in (multicenter) studies focusing on specific interventions to enhance patient and organ outcomes is anticipated in the coming years.
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Affiliation(s)
- Kathleen Van Loon
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Katrijn Jansen
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Geertrui Dewinter
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Leuven, Belgium
| | - Gert-Jan Eerdekens
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
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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.
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Affiliation(s)
- Kaitlyn M Tracy
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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4
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Goyal A, Dalia T, Ranka S, Sauer AJ, Hu J, Cernik C, Nuqali A, Chandler J, Parimi N, Dennis K, Majmundar M, Tayeb T, Haglund J, Shah Z, Vidic A, Gupta B, Haglund NA. Impact of Biopsy Proven Liver Fibrosis on Patients Undergoing Evaluation and Treatment for Advanced Heart Failure Surgical Therapies. Am J Cardiol 2023; 194:46-55. [PMID: 36947946 DOI: 10.1016/j.amjcard.2023.02.004] [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] [Received: 11/20/2022] [Revised: 01/28/2023] [Accepted: 02/06/2023] [Indexed: 03/24/2023]
Abstract
There is a paucity of data regarding the impact of liver fibrosis on patients with stage D heart failure (HF). We conducted a retrospective study (January 1, 2017 to December 12, 2020) in patients with stage D HF who underwent liver biopsy as part of their advanced HF therapy evaluation. Baseline characteristics and 1-year outcomes were compared between no- or mild-to-moderate-fibrosis (grade 0 to 2) and advanced-fibrosis (grade 3 to 4) groups. Of 519 patients with stage D HF, 136 who underwent liver biopsy (113 [83%] no or mild-to-moderate fibrosis and 23 [17%] advanced fibrosis) were included. A total of 71 patients (52%) received advanced HF therapies (23 heart transplantation, 48 left ventricular assist devices). One-year mortality was higher among patients with advanced fibrosis (52% vs 18%, p <0.001). Further subgroup analysis suggested a trend toward increased 1-year mortality among patients with advanced fibrosis who underwent advanced therapies (37% vs 13%, p = 0.09). There was a trend of lower likelihood of receiving advanced HF therapies in the advanced-fibrosis group, only 1 heart transplantation and 7 left ventricular assist devices, but it did not reach statistical significance (35% vs 56%, p = 0.06). After adjustment for confounders, degree of liver fibrosis was an independent predictor of mortality (odds ratio 6.2; 95% 1.27 to 30.29, p = 0.02). We conclude that advanced liver fibrosis is common among patients with stage D HF who undergo evaluation for advanced HF surgical therapies and significantly increases 1-year mortality. Further larger studies are needed to support our findings.
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Affiliation(s)
- Amandeep Goyal
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Tarun Dalia
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Sagar Ranka
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Andrew J Sauer
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Jinxiang Hu
- Departments of Biostatistics and Data Science, The University of Kansas Health System, Kansas City, Kansas
| | - Colin Cernik
- Departments of Biostatistics and Data Science, The University of Kansas Health System, Kansas City, Kansas
| | - Abdulelah Nuqali
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Jonathan Chandler
- Departments of Internal Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Nikhil Parimi
- Departments of Internal Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Katie Dennis
- Departments of Pathology, The University of Kansas Health System, Kansas City, Kansas
| | - Monil Majmundar
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Taher Tayeb
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Jennifer Haglund
- Departments of Gastroenterology and Hepatology, The University of Kansas Health System, Kansas City, Kansas
| | - Zubair Shah
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Andrija Vidic
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Bhanu Gupta
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Nicholas A Haglund
- Departments of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas.
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5
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Zhu YK, Zhou YF, Zhang TX, Yao YX. Anesthesia management of combined sequential heart-liver transplantation using a caval clamp without venovenous bypass: A case report. Heliyon 2022; 8:e10730. [PMID: 36177239 PMCID: PMC9513618 DOI: 10.1016/j.heliyon.2022.e10730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/24/2022] [Accepted: 09/16/2022] [Indexed: 11/30/2022] Open
Abstract
Familial amyloid polyneuropathy, an autosomal-dominant disease due to mutations in the transthyretin gene, often affects the heart and liver, and is treated best with a combined heart–liver transplantation (CHLT). Although it remains an uncommonly performed procedure, the number of patients undergoing CHLT is increasing. Because of the complexity associated with dual pathophysiology, CHLT poses an extraordinary challenge for anesthesia management. Either both heart and liver transplantation are performed on cardiopulmonary bypass (CPB); or heart transplantation is performed on CPB, followed by liver transplantation with venovenous bypass. Recent reports suggested that liver transplantation can be performed without bypass using the inferior vena cava-sparing technique. However, both bypass and caval sparing technique have their own complications. Here, we present the anesthesia management in a case of sequential heart–liver transplantation using a routine caval cross-clamp technique without venovenous bypass. A 48-year-old man complaining of chest tightness, chest pain, and shortness of breath was diagnosed with amyloid cardiomyopathy. Cardiac ultrasonography revealed thickening of ventricular walls and left ventricular systolic insufficiency (ejection fraction decreased from 46% to ∼20% in 6 months), which was refractory to medical therapy. Symptoms occurred repeatedly. Therefore, CHLT was planned. Heart transplantation was performed smoothly under general anesthesia and standard CPB. His heart functioned well with dobutamine and epinephrine infusion. Subsequently, the patient was weaned from CPB. Liver transplantation was planned using the piggyback procedure with the caval sparing technique. However, upon caval clamping, unexpected blood loss occurred. Clamping of the caval was tested followed by cross-clamping. Norepinephrine, epinephrine, and dobutamine were administered. After the hepatic vein was anastomosed, the clamp was released and nitroglycerin was administered. Hemodynamics was stable, and the patient was discharged after 37 days of hospitalization. The case indicates that CHLT could be performed using caval clamp without venovenous bypass in selected patients.
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Affiliation(s)
- Ye-Ke Zhu
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Yan-Feng Zhou
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Tian-Xiang Zhang
- Department of Anesthesia, First Affiliated Hospital Beilun Branch, Zhejiang University School of Medicine, Ningbo, People's Republic of China
| | - Yong-Xing Yao
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
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Miklin DJ, Mendoza M, DePasquale EC. Two is better than one: when to consider multiorgan transplant. Curr Opin Organ Transplant 2022; 27:86-91. [PMID: 34890379 DOI: 10.1097/mot.0000000000000951] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
| | - Matthew Mendoza
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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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.
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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
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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.
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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
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9
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Occlusion of aortopulmonary and venovenous collaterals prior to heart or combined heart-liver transplantation in Fontan patients: A single-center experience. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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10
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Choudhry S, Dreyer WJ, Hope KD, Wang Y, Spinner JA, Tunuguntla HP, Cabrera AG, Price JF, Denfield SW. Pediatric heart-liver transplant outcomes in the United States: A 25-year National Cohort Study. Pediatr Transplant 2021; 25:e14066. [PMID: 34120386 DOI: 10.1111/petr.14066] [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: 10/28/2020] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric HLT remains uncommon in the United States and criteria for HLT are unclear. The objectives of this study were to review the indications, and outcomes of pediatric HLT. METHODS Data from the Scientific Registry of Transplant Recipients heart and liver databases were used to identify 9245 pediatric isolated heart transplants (PHT), 14 134 pediatric isolated liver transplant (PLT), and 20 pediatric HLT (16 patients underwent sHLT [same organ donor] and four patients with a history of PHT followed by PLT [different organ donors]; age ≤21 years) between 1992 and 2017. Outcomes included patient survival, and 1-year rates of acute heart and liver rejection. RESULTS The median age for pediatric HLT was 15.6 (IQR: 10.5, 17.9) years, and included 12 males (12/20 = 60%). In the HLT group, the most common indication for HT was CHD (12/20 = 60%), and the most common indication for liver transplant was cirrhosis (9/20 = 45%). The 1, 3, and 5 year actuarial survival rates in pediatric simultaneous HLT recipients (n = 16) were 93%, 93%, and 93%, respectively, and was similar to isolated PHT alone (88%, 81%, and 75.5%, respectively and isolated PLT alone (84%, 82%, and 80%), respectively. There was no heart or liver rejection reported in the HLT group versus 9.9% in heart and 10.6% in liver transplant-only groups, respectively. CONCLUSION Pediatric HLT is an uncommon but acceptable option for recipients with combined end-organ failure, with intermediate survival outcomes comparable to those of single-organ recipients.
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Affiliation(s)
- Swati Choudhry
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - William J Dreyer
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Kyle D Hope
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Yunfei Wang
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Joseph A Spinner
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Hari P Tunuguntla
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Antonio G Cabrera
- Section of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jack F Price
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Susan W Denfield
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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11
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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.
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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.
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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.
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Kuppuswamy M, Ramamurthy A, Thirugnanasambandam S, Thangaraj P. En bloc combined heart–liver transplantation for Ebstein's anomaly and cardiac cirrhosis - A case report. INDIAN JOURNAL OF TRANSPLANTATION 2021. [DOI: 10.4103/ijot.ijot_159_20] [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
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Smeltz AM, Kumar PA, Arora H. Anesthesia for Combined Heart and Liver Transplantation. J Cardiothorac Vasc Anesth 2020; 35:3350-3361. [PMID: 33384228 DOI: 10.1053/j.jvca.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/26/2020] [Accepted: 12/03/2020] [Indexed: 01/23/2023]
Abstract
A heart or liver transplantation procedure performed in isolation itself presents multiple challenges for the perioperative team. Accordingly, combining both transplants yields a vastly more complicated surgery, with many unique multisystem and multidisciplinary considerations. Although combined heart and liver transplantations are being performed with increasing frequency, nationwide experience is relatively limited at most institutions. The aim of this review is to discuss the perioperative challenges presented to the anesthesiology teams and provide evidence-based guidance for the management of these daunting procedures.
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Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
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Bui CCM, Tanner C, Nguyen-Buckley C, Scovotti J, Wray C, Xia VW. Combined Cardiothoracic Surgery and Liver Transplantation Versus Isolated Liver Transplantation. J Cardiothorac Vasc Anesth 2020; 35:2363-2369. [PMID: 32951998 DOI: 10.1053/j.jvca.2020.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Combined cardiothoracic surgery and liver transplantation (cCSLT) recently increasingly has been used. Despite that, liver transplant immediately after cardiothoracic surgery has not been well-characterized. The authors aimed to compare perioperative management and postoperative outcomes between patients undergoing cCSLT and isolated liver transplantation (iLT). DESIGN A retrospective study. SETTING University tertiary medical center. PARTICIPANTS Twenty-five cCSLT patients and 1091 iLT patients at a single institution from 2010 to 2017. INTERVENTIONS Twenty-five cCSLT patients were compared with 100 randomly selected and 100 propensity-matched iLT patients. MEASUREMENTS AND MAIN RESULTS All cCSLT patients underwent comprehensive preoperative evaluation by a multidisciplinary team. Of 25 cardiothoracic surgeries, heart transplant (n = 9) was most common, followed by coronary artery bypass grafting (n = 5) and lung transplant (n = 3). Intraoperative management of cCSLT was provided by 2 separate teams, one for cardiothoracic surgery and one for liver transplantation. Patients undergoing cCSLT often required cardiopulmonary bypass, an intra-aortic balloon pump, extracorporeal membrane oxygenation, or cardiac pharmacologic therapies and, additionally, needed more interventions including antifibrinolytic administration, venovenous bypass, massive blood transfusion, and platelet transfusions compared with iLT patients. Ninety-day survival rates were similar in the cCSLT (100%) and iLT groups (random iLT 87% and matched iLT 93%, log-rank test p = 0.089). CONCLUSIONS Despite having end-stage liver disease and advanced cardiothoracic disorders and experiencing a complex intraoperative course, cCSLT patients had comparable 90-day survival to iLT patients. Comprehensive planning before transplant, optimal patient/donor selection, the multiple-team model, and meticulous intraoperative management are critical to the success of cCSLT.
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Affiliation(s)
- Christine C Myo Bui
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Colby Tanner
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christine Nguyen-Buckley
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jennifer Scovotti
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Victor W Xia
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Anesthetic considerations for combined heart--liver transplantation in patients with Fontan-associated liver disease. Curr Opin Organ Transplant 2020; 25:501-505. [PMID: 32773506 DOI: 10.1097/mot.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The success of the Fontan procedure has led to increased survival of patients born with certain congenital heart disease to the point that new sequlae, as a result of Fontan circulation, are being discovered. Included among these is Fontan-associated liver disease (FALD). The purpose of this review is to present available literature on the perioperative management of the combined heart--liver transplantation (CHLT) in patients with FALD. RECENT FINDINGS The perioperative management of a combined heart-liver transplant in a patient with Fontan circulation is complex. The patient is at risk for hemodynamic disturbances, significant blood loss, coagulopathies, and metabolic derangements. The maintenance of an appropriate transpulmonary pressure gradient is paramount to success. Postoperative management should be accomplished by a multidisciplinary care team. Limited series have demonstrated good outcomes in patients who have undergone CHLT. SUMMARY The perioperative management of CHLT in patients with FALD is complex and available literature is limited. Future studies are needed to further assess proper perioperative management of patients with FALD who undergo CHLT.
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Emamaullee J, Zaidi AN, Schiano T, Kahn J, Valentino PL, Hofer RE, Taner T, Wald JW, Olthoff K, Bucuvalas J, Fischer R. Fontan-Associated Liver Disease: Screening, Management, and Transplant Considerations. Circulation 2020; 142:591-604. [PMID: 32776846 PMCID: PMC7422927 DOI: 10.1161/circulationaha.120.045597] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Surgical innovation and multidisciplinary management have allowed children born with univentricular physiology congenital heart disease to survive into adulthood. An estimated global population of 70 000 patients have undergone the Fontan procedure and are alive today, most of whom are <25 years of age. Several unexpected consequences of the Fontan circulation include Fontan-associated liver disease. Surveillance biopsies have demonstrated that virtually 100% of these patients develop clinically silent fibrosis by adolescence. As they mature, there are increasing reports of combined heart-liver transplantation resulting from advanced liver disease, including bridging fibrosis, cirrhosis, and hepatocellular carcinoma, in this population. In the absence of a transplantation option, these young patients face a poor quality of life and overall survival. Acknowledging that there are no consensus guidelines for diagnosing and monitoring Fontan-associated liver disease or when to consider heart transplantation versus combined heart-liver transplantation in these patients, a multidisciplinary working group reviewed the literature surrounding Fontan-associated liver disease, with a specific focus on considerations for transplantation.
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Affiliation(s)
- Juliet Emamaullee
- Liver Transplant Center, Children’s Hospital-Los Angeles, Los Angeles, CA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ali N. Zaidi
- Mount Sinai Cardiovascular Institute & The Children’s Heart Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas Schiano
- Division of Hepatology, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeff Kahn
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of USC, Los Angeles, CA
| | - Pamela L. Valentino
- Section of Gastroenterology and Hepatology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Ryan E. Hofer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Timucin Taner
- Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - Joyce W. Wald
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kim Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John Bucuvalas
- Division of Pediatric Hepatology, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan Fischer
- Department of Gastroenterology, Liver Care Center, Children’s Mercy Kansas City, Kansas City, MO
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Sequential Versus Combined Heart-Liver Transplantation in the USA. Dig Dis Sci 2020; 65:2427-2432. [PMID: 31776860 DOI: 10.1007/s10620-019-05958-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 11/13/2019] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Combined heart-liver transplantation (CHLT) has resulted in acceptable survival rates compared to orthotopic liver transplantation (OLT) alone and orthotopic heart transplantation alone. Using the US transplant registry, we compared outcomes following sequential and combined HLT. METHODS We conducted a retrospective cohort study. De-identified data were obtained from the United Network Organ Sharing Registry. The primary outcome was patient survival from the date of OLT. Secondary outcomes included liver allograft survival and heart allograft survival. RESULTS The study cohort included 301 CHLT recipients and six sequential heart-liver transplantation (SHLT) recipients. Patient survival after CHLT was 88% at 1 year, 84% at 3 years, and 82% at 5 years compared to 83%, 67%, and 50% in the SHLT group (p = 0.010). Liver allograft survival at 1, 3, and 5 years was 88%,83% and 82%, respectively, in the CHLT group compared to 83% and 67%, and 50%, respectively, in the SHLT group (p = 0.009). After OLT, heart allograft survival at 1, 3, and 5 years was 86%, 79%, and 74% in the CHLT group, respectively, compared to 83%, 67%, and 50% in the SHLT group (p = 0.037). CONCLUSIONS Despite the limited size of the SHLT cohort, we found that CHLT was superior to SHLT in survival rate and graft survival. The better outcomes noted in CHLT may relate to immunoprotection provided by liver transplantation from the same donor.
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Ing RJ, Mclennan D, Twite MD, DiMaria M. Anesthetic Considerations for Fontan-Associated Liver Disease and the Failing Fontan Circuit. J Cardiothorac Vasc Anesth 2020; 34:2224-2233. [PMID: 32249074 DOI: 10.1053/j.jvca.2020.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 02/19/2020] [Accepted: 02/23/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO.
| | - Daniel Mclennan
- Stead Family Children's Hospital, University of Iowa, Iowa City, IA
| | - Mark D Twite
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
| | - Michael DiMaria
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
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Zeillemaker-Hoekstra M, Buis CI, Cernak V, Reyntjens KMEM. Anesthesia for combined liver-thoracic transplantation. Best Pract Res Clin Anaesthesiol 2020; 34:101-108. [DOI: 10.1016/j.bpa.2020.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/23/2019] [Accepted: 01/08/2020] [Indexed: 10/25/2022]
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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]
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Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2020; 139:e698-e800. [PMID: 30586767 DOI: 10.1161/cir.0000000000000603] [Citation(s) in RCA: 233] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Karen K Stout
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Curt J Daniels
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Jamil A Aboulhosn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Biykem Bozkurt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Craig S Broberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Jack M Colman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Stephen R Crumb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Joseph A Dearani
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Stephanie Fuller
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Michelle Gurvitz
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Paul Khairy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Michael J Landzberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Arwa Saidi
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Anne Marie Valente
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - George F Van Hare
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
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Lebray P, Varnous S. Combined heart and liver transplantation: State of knowledge and outlooks. Clin Res Hepatol Gastroenterol 2019; 43:123-130. [PMID: 30635235 DOI: 10.1016/j.clinre.2018.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/05/2018] [Accepted: 08/15/2018] [Indexed: 02/08/2023]
Abstract
Various types of liver impairment have been described in patients with end-stage heart failure who are awaiting heart transplantation. The liver impairment may be severe, characterized by a high model for end-stage liver disease (MELD) Score and/or the presence of ascites, both of which are associated with a high risk of failure after single heart transplantation. A liver function assessment is therefore necessary before registration on the heart transplant list, moreover in case of long-developing heart failure, such as with congenital heart disease or in the presence of risk factors for chronic liver disease including excessive alcohol consumption, metabolic syndrome or chronic viral hepatitis B or C. In these instances, screening for cirrhosis with liver biopsy and for hepatocellular carcinoma through imaging must be systematic and when present, the indication for combined heart-liver transplantation must be considered. Its benefits, however, in case of liver failure with a high MELD score or multi-organ failure remains to be demonstrated. An exception in which the liver shows no morphological or functional alteration is with familial amyloid neuropathy, during which moderate to severe heart failure implies surgical treatment consisting of a liver or even heart-liver transplantation. These must be done early and are mainly contraindicated according to the level of neurological damage.
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Affiliation(s)
- Pascal Lebray
- Hepato-gastroenterology department, hôpital de la Pitié-Salpêtrière (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Shaida Varnous
- Cardio-thoracic surgery department, hôpital de la Pitié-Salpêtrière (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France
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Simultaneous Versus Sequential Heart-liver Transplantation: Ideal Strategies for Organ Allocation. Transplant Direct 2018; 5:e415. [PMID: 30656213 PMCID: PMC6324910 DOI: 10.1097/txd.0000000000000854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/24/2018] [Accepted: 11/09/2018] [Indexed: 12/04/2022] Open
Abstract
Background Simultaneous heart-liver (SHL) transplantation is an efficacious therapeutic modality for patients with combined heart and liver failure. However, the extent to which heart transplantation followed by sequential liver transplantation (LAH) can match the benefit of simultaneous transplantation has not previously been examined. Our objective was to determine if LAH offers comparable survival to SHL. Methods The Organ Procurement and Transplantation Network/United Network for Organ Sharing Standard Transplant Analysis and Research file was queried for adult recipients waitlisted for both heart and liver transplantation. The United Network for Organ Sharing thoracic and liver databases were linked to facilitate examination of waitlist and transplant characteristics for simultaneously listed patients. Univariate survival analysis was used to determine overall survival. Results Of the 236 patients meeting inclusion criteria, 200 underwent SHL, 7 sequentially underwent LAH, and 29 received heart transplantation only (isolated orthotopic heart transplantation [iOHT]). Recipients of SHL were less likely to have an episode of acute rejection before discharge (LAH, 14.2%; SHL, 2.4%; iOHT, 3.6%; P = .019) or be treated for acute rejection within 1 year after transplantation (LAH, 14.3%; SHL, 2.5%; iOHT, 13.8%; P = .007). Otherwise, postoperative hospital length of stay, stroke, need for dialysis, and need for pacemaker placement were comparable across groups. Ten-year survival similarly favored both LAH and SHL over iOHT (LAH: 100%, 71.4%, 53.6%; SHL: 87.1%, 80.4%, 52.1%, iOHT: 70.1%, 51.6%, 27.5% for 1-, 5-, and 10-year survivals, respectively, P = .003). However, median time between heart and liver transplant was 302 days in patients undergoing sequential transplantation. Conclusions Although transplantation in a simultaneous or sequential fashion yields equivalent outcomes, a high fraction of patients undergoing initial heart transplant alone fail to proceed to subsequent liver transplantation. Therefore, in patients with combined heart and liver failure with a projected need for 2 allografts, simultaneous transplantation is associated with maximum benefit.
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Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 73:e81-e192. [PMID: 30121239 DOI: 10.1016/j.jacc.2018.08.1029] [Citation(s) in RCA: 491] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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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]
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Contemporary Outcomes of Combined Heart-Liver Transplant in Patients With Congenital Heart Disease. Transplantation 2018; 102:e67-e73. [DOI: 10.1097/tp.0000000000001978] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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VanWagner LB, Harinstein ME, Runo JR, Darling C, Serper M, Hall S, Kobashigawa JA, Hammel LL. Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: An evaluation of the evidence and consensus recommendations. Am J Transplant 2018; 18:30-42. [PMID: 28985025 PMCID: PMC5840800 DOI: 10.1111/ajt.14531] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 09/12/2017] [Accepted: 09/28/2017] [Indexed: 01/25/2023]
Abstract
Liver transplant (LT) candidates today are older, have greater medical severity of illness, and have more cardiovascular comorbidities than ever before. In addition, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Cirrhotic cardiomyopathy, a condition characterized by increased cardiac output and a reduced ventricular response to stress, is present in up to 30% of patients with cirrhosis, thus challenging perioperative management. Current noninvasive tests that assess for subclinical coronary and myocardial disease have low sensitivity, and altered hemodynamics during the LT surgery can unmask latent cardiovascular disease either intraoperatively or in the immediate postoperative period. Therefore, this review, assembled by a group of multidisciplinary experts in the field and endorsed by the American Society of Transplantation Liver and Intestine and Thoracic and Critical Care Communities of Practice, provides a critical assessment of the diagnosis of cardiac and pulmonary vascular disease and interventions aimed at managing these conditions in LT candidates. Key points and practice-based recommendations for the diagnosis and management of cardiac and pulmonary vascular disease in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.
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Affiliation(s)
- Lisa B. VanWagner
- Division of Gastroenterology and Hepatology, Department of Medicine and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Matthew E. Harinstein
- Heart and Vascular Institute, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - James R. Runo
- Division of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Christopher Darling
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Marina Serper
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Shelley Hall
- Division of Transplant Cardiology, Baylor University Medical Center, Dallas, TX USA
| | - Jon A. Kobashigawa
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Laura L. Hammel
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
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Abstract
The provision of anesthesia for a liver transplant program requires a dedicated team of anesthesiologists. Liver transplant anesthesiologists must have an understanding of liver physiology and anatomy; the spectrum of clinical disease associated with liver dysfunction; the impact of warm and cold ischemia times, surgical techniques in liver transplantation, and the impact of ischemia-reperfusion syndrome; and optimal practices to protect the liver. The team must provide a 24-hour service, be actively involved in the selection committee process, and stay current with advances in the subspecialty.
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Affiliation(s)
- Dieter Adelmann
- Department of Anesthesiology and Perioperative Care, University of California San Francisco, Box O648, 4th Floor MUE, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Kate Kronish
- Department of Anesthesiology and Perioperative Care, University of California San Francisco, Box O648, 4th Floor MUE, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Michael A Ramsay
- Department of Anesthesiology, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA.
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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
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Navaratnam M, Ng A, Williams GD, Maeda K, Mendoza JM, Concepcion W, Hollander SA, Ramamoorthy C. Perioperative management of pediatric en-bloc combined heart-liver transplants: a case series review. Paediatr Anaesth 2016; 26:976-86. [PMID: 27402424 DOI: 10.1111/pan.12950] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Combined heart and liver transplantation (CHLT) in the pediatric population involves a complex group of patients, many of whom have palliated congenital heart disease (CHD) involving single ventricle physiology. OBJECTIVE The purpose of this study was to describe the perioperative management of pediatric patients undergoing CHLT at a single institution and to identify management strategies that may be used to optimize perioperative care. METHODS We did a retrospective database review of all patients receiving CHLT at a children's hospital between 2006 and 2014. Information collected included preoperative characteristics, intraoperative management, blood transfusions, and postoperative morbidity and mortality. RESULTS Five pediatric CHLTs were performed over an 8-year period. All patients had a history of complex CHD with multiple sternotomies, three of whom had failing Fontan physiology. Patient age ranged from 7 to 23 years and weight from 29.5 to 68.5 kg. All CHLTs were performed using an en-bloc technique where both the donor heart and liver were implanted together on cardiopulmonary bypass (CPB). The median operating room time was 14.25 h, median CPB time was 3.58 h, and median donor ischemia time was 4.13 h. Patients separated from CPB on dopamine, epinephrine, and milrinone infusions and two required inhaled nitric oxide. All patients received a massive intraoperative blood transfusion post CPB with amounts ranging from one to three times the patient's estimated blood volume. The patient who required the most transfusions was in decompensated heart and liver failure preoperatively. Four of the five patients received an antifibrinolytic agent as well as a procoagulant (prothrombin complex concentrate or recombinant activated Factor VII) to assist with hemostasis. There were no 30-day thromboembolic events detected. Postoperatively the median length of mechanical ventilation, ICU stay and stay to hospital discharge was 4, 8, and 37 days, respectively. All patients are alive and free from allograft rejection at this time. CONCLUSION Combined heart and liver transplantation in the pediatric population involves a complex group of patients with unique perioperative challenges. Successful management starts with thorough preoperative planning and communication and involves strategies to deal with massive intraoperative hemorrhage and coagulopathy in addition to protecting and supporting the transplanted heart and liver and meticulous surgical technique. An integrated multidisciplinary team approach is the cornerstone for successful outcomes.
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Affiliation(s)
- Manchula Navaratnam
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Ann Ng
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Glyn D Williams
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Julianne M Mendoza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Waldo Concepcion
- Department of Transplant Surgery, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Seth A Hollander
- Division of Cardiology, Department of Pediatrics, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Chandra Ramamoorthy
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
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Beal EW, Mumtaz K, Hayes D, Whitson BA, Black SM. Combined heart-liver transplantation: Indications, outcomes and current experience. Transplant Rev (Orlando) 2016; 30:261-8. [PMID: 27527917 DOI: 10.1016/j.trre.2016.07.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 04/06/2016] [Accepted: 07/12/2016] [Indexed: 11/15/2022]
Abstract
Combined heart-liver transplantation is a rare, life-saving procedure that treats complex and often fatal diseases including familial amyloidosis polyneuropathy and late stage congenital heart disease status-post previous repair. There were 159 combined heart-liver transplantations performed between January 1, 1988 and October 3, 2014 in the United States. A multitude of potential techniques to be used for combined heart and liver transplant including: orthotopic heart transplant (OHT) and orthotopic liver transplant (OLT) on full cardiopulmonary bypass (CPB), OHT with CPB and OLT with venovenous bypass (VVB), OHT with CPB and OLT without VVB, en-bloc technique and sequential transplantation. Outcomes of combined heart-liver transplant have been demonstrated to be comparable to outcomes of isolated heart and isolated liver transplant. The liver graft may provide some tolerance of other allografts.
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Affiliation(s)
- Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khalid Mumtaz
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Don Hayes
- Departments of Pediatrics and Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Bryan A Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Cardiothoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sylvester M Black
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Transplantation Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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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
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35
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Current indications, strategies, and outcomes with cardiac transplantation for cardiac amyloidosis and sarcoidosis. Curr Opin Organ Transplant 2015; 20:584-92. [DOI: 10.1097/mot.0000000000000229] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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