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Mackenzie C, Anderson M, Shah KS. Use of Evolocumab in Familial Hyperlipidemia With Isolated Heart Transplant. JACC Case Rep 2024; 29:102426. [PMID: 39157565 PMCID: PMC11328786 DOI: 10.1016/j.jaccas.2024.102426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 08/20/2024]
Abstract
We describe a novel use of evolocumab for successful postoperative lipid control in a patient with familial hyperlipidemia who underwent isolated heart transplantation. We believe that this case carries valuable lessons regarding post-transplant proprotein convertase subtilisin kexin 9 inhibitor use with implications for the future of combined organ allocation and transplantation waitlist times.
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Affiliation(s)
- Colin Mackenzie
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - McHale Anderson
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kevin S. Shah
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah, USA
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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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Akbar AF, Rokui S, Zhou AL, Kilic A, King E, Cho SM. Incidence and Risk Factors for Stroke After Combined Heart-Kidney and Heart-Liver Transplantation. Clin Transplant 2024; 38:e15369. [PMID: 39031709 PMCID: PMC11262467 DOI: 10.1111/ctr.15369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 07/22/2024]
Abstract
OBJECTIVE While stroke is a well-recognized complication of isolated heart transplantation, stroke in patients undergoing simultaneous heart-liver (HLT) and heart-kidney transplantation (HKT) has not been explored. This study assessed postoperative stroke incidence, risk factors, and outcomes in HLT and HKT compared with isolated heart transplant. METHODS The United Network for Organ Sharing database was queried for adult patients undergoing HLT, HKT, and isolated heart transplants between 1994 and 2022. Patients were stratified by presence of in-hospital stroke after transplant. Post-transplant survival at 1-year was assessed using Kaplan-Meier analysis and log-rank tests. Separate multivariable logistic regression models were constructed to identify risk factors for stroke after HKT and HLT. RESULTS Of 2326 HKT recipients, 85 experienced stroke, and of 442 HLT recipients, 19 experienced stroke. Stroke was more common after HKT and HLT than after an isolated heart transplant (3.7% vs. 4.3% vs. 2.9%, p = 0.01). One-year post-transplant survival was lower in those with stroke among both HKT recipients (64.5% vs. 88.7%, p(log-rank) < 0.001) and HLT recipients (43.8% vs. 87.4%, p(log-rank) < 0.001. Pre-transplant pVAD, prior stroke, postoperative dialysis, diabetes, prior cardiac surgery, and heart cold ischemic time were independent risk factors for stroke after HKT, after adjusting for age, sex, and need for blood transfusion on the waitlist. For HLT, postoperative dialysis was a significant risk factor. CONCLUSIONS Stroke is more common after HKT and HLT than after isolated heart transplant, and results in poor survival. Independent risk factors for stroke include pre-transplant percutaneous VAD (HKT) and postoperative dialysis (HKT and HLT).
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Affiliation(s)
- Armaan F. Akbar
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Sorush Rokui
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
- Division of Cardiac Surgery, University of British Columbia, Vancouver, Canada
| | - Alice L. Zhou
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Ahmet Kilic
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Elizabeth King
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
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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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Das I, Pham SM, Perry DK, Croome KP. The Use of Ex Situ Normothermic Machine Perfusion in Combined Cardiac and Liver Transplantation Procedures. Transplant Direct 2024; 10:e1574. [PMID: 38274474 PMCID: PMC10810592 DOI: 10.1097/txd.0000000000001574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/05/2023] [Accepted: 10/24/2023] [Indexed: 01/27/2024] Open
Affiliation(s)
- Ian Das
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Si M. Pham
- Division of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Dana K. Perry
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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Nuqali A, Bellumkonda L. Dual organ transplantation: when heart alone is not enough. Curr Opin Organ Transplant 2023; 28:370-375. [PMID: 37582057 DOI: 10.1097/mot.0000000000001093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW The number of dual organ transplantations (DOT) are steadily increasing over the past few years. This is both a reflection of increasing complexity and advanced disease process in the patients and greater transplant center experience with performing dual organ transplants. Due to lack of standardization of the process, there remains significant center-based variability in patient selection, perioperative and long-term management of these patients. RECENT FINDINGS Overall posttransplant outcomes for DOT have been acceptable with some immunological advantages because of partial tolerance offered by the second organ. These achievements should, however, be balanced with the ethical implications of bypassing the patients who are listed for single organ transplantation because of the preferential allocation of organs for DOT. SUMMARY The field of DOT is expanding rapidly, with good long-term outcomes. There is an urgent need for guidelines to standardize the process of patient selection and listing dual organ transplantation.
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Affiliation(s)
- Abdulelah Nuqali
- Division of Cardiology, Department of Medicine Yale University School of Medicine, New Haven, Connecticut, USA
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