Adult Combined Heart-Liver Transplantation: The United States Experience

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.

Dual-Organ Transplantation: Indications, Evaluation, and Outcomes for Heart-Kidney and Heart-Liver Transplantation: A Scientific Statement From the American Heart Association

“…Both single-center studies and analyses of large databases have demonstrated favorable outcomes after SHLT. [110][111][112][113] In an SRTR analysis, survival of SHLT at 1, 3, and 5 years was 86.8%, 82.8%, and 81.3%, respectively. 111 In a UNOS registry analysis, survival after SHLT was comparable to that after HT alone.…”

“…[110][111][112][113] In an SRTR analysis, survival of SHLT at 1, 3, and 5 years was 86.8%, 82.8%, and 81.3%, respectively. 111 In a UNOS registry analysis, survival after SHLT was comparable to that after HT alone. 114…”

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

“…Further multivariate analysis demonstrated that recipient diabetes and a sequential liver-first approach were independently associated with an increased risk of mortality [6 ▪ ]. Higher donor left ventricular ejection fraction was associated with decreased risk of mortality.…”

“…Studies analyzing UNOS registry data through 2020 describe the current, national landscape of CHLT with improvement in patient survival over time [6 ▪ ,23,24]. Analysis of 364 recipients who underwent CHLT shows overall survival of 86.8, 80.1, and 77.9% at 1, 3, and 5 years, respectively [6 ▪ ]. Although indications for CHLT have changed over time with a predominance of congenital heart disease in the modern era, interestingly, there was no difference in survival when stratified by cardiac diagnosis.…”

Combined heart-liver transplantation practices survey in North America: Evaluation and organ listing practices

“…[4,7] Subsequently, CHD patients, which originally represented 17%-50% of all CHLTs from 2009 to 2017, have increased to 95% CHLTs in 2019, whereas other indications, such as nonischemic cardiomyopathy and amyloidosis-related cardiomyopathy, have decreased in frequency. [7] A subject of intense debate in the transplant community is the decision of which patients with CHD and liver disease benefit from CHLT compared with HT. [8] Uncertainties surrounding the diagnosis of cirrhosis and portal hypertension in CHD patients make listing decisions complicated.…”