A review of the United States experience with combined heart-liver transplantation

Abstract

Since first described by Starzl, combined heart and liver transplantation (CHLT) has been a relatively rare event, although utilization has increased in the past decade. This study was undertaken to review the United States experience with this procedure; UNOS data on CHLT was reviewed. CHLT was compared with liver transplantation alone and heart transplantation alone in terms of acute rejection within 12 months, graft survival, and patient survival. Survival was calculated according to Kaplan–Meier and Cox proportional hazards. Continuous variables were compared using Student’s t‐test and categorical variables with chi‐squared. Between 1987 and 2010, there were 97 reported cases of CHLT in the United States. Amyloidosis was the most common indication for both heart (n = 26, 26.8%) and liver (n = 27, 27.8%) transplantation in this cohort. Liver graft survival in the CHLT cohort at 1, 5, and 10 years was 83.4%, 72.8%, and 71.0%, whereas survival of the cardiac allograft was 83.5%, 73.2%, and 71.5%. This was similar to graft survival in liver alone transplantation (79.4%, 71.0%, 65.1%; P = 0.894) and heart transplantation alone (82.6%, 71.9%, 63.2%; P = 0.341). CHLT is a safe and effective procedure, with graft survival rates similar to isolated heart and isolated liver transplantation.

Combined Heart and Liver Transplantation Can Be Safely Performed With Excellent Short- and Long-Term Results

“…Survival at 1 year with our heart-liver transplant group is comparable, if not better, at 87% 1-year survival and 83% 5-year survival. Similarly, a large retrospective review of the US experience with combined heart and liver transplant, in a population that was mostly patients with amyloidosis as the primary pathology, demonstrated 83% 1-year and 71% 10-year survival [6]. The Mayo Clinic noted 100% 1-year and 60% 10-year survival in their experience with heart and liver transplant [14].…”

“…Various techniques for dual heart and liver transplant have been published, including staged heart and then liver transplant during a separate operation, heart then liver transplant during the same operation after separation from cardiopulmonary bypass, and heart and liver transplant done in sequence on cardiopulmonary bypass. The worldwide experience with heart-liver dual organ transplant remains rather limited, with only a handful of reports concerning the outcomes of this therapeutic strategy [5][6][7]. There are mostly case reports or series describing an individual center's experience with heart-liver transplant [8][9][10][11][12][13].…”

The liver in heart failure: a biopsy and explant series of the histopathologic and laboratory findings with a particular focus on pre-cardiac transplant evaluation

“…The findings of severe fibrosis or frank cirrhosis on liver biopsy may be used to exclude the candidate from undergoing heart transplantation with a rationale that the risk of operative mortality may be too high to justify the transplant. 16,17 A small number of these patients may undergo combined heart-liver transplant 18 but the remainder will likely succumb to progressive heart failure. Biopsies are often performed with a request to 'rule out cirrhosis', but chronic passive congestion does not appear to progress to cirrhosis in the same manner as chronic viral hepatitis or alcoholic hepatitis.…”

How to interpret liver function tests in heart failure patients?

“…(50,67), but if there is a strong suspicion of advanced liver disease, cirrhosis must be ruled out before the cardiac transplantation or combined liver-heart transplantation is performed in suitable cases (68). In HFpEF, no treatment has shown reduction in morbidity and mortality.…”