Operative Technique of Donor Organ Procurement for En Bloc Heart-liver Transplantation

Abstract

Combined heart-liver transplant is an emerging option for patients with indications for heart transplantation and otherwise prohibitive hepatic dysfunction. Heart-liver transplantation is particularly relevant for patients with single ventricle physiology who often develop Fontan-associated liver disease and fibrosis. Although only performed at a limited number of centers, several approaches to combined heart-liver transplantation have been described. The en bloc technique offers several potential advantages over the traditional sequential technique. Specifically, en bloc heart-liver transplantation may allow improved hemodynamics, decreased bleeding, reduced liver allograft ischemic time, and may result in reduced rates of graft dysfunction. Here we describe our center's en bloc heart-liver procurement technique in detail, with the aim of allowing broader use and standardization of this technique.

Review of pediatric combined heart‐liver transplantation: A roadmap to success

“…35 Proponents of the en bloc technique cite several advantages including a single reperfusion event, relatively stable hemodynamics throughout the procedure, improvement in CIT, and reduction of necessary anastomoses. 35,36 Compromise of this approach is the significantly increased cardiac CIT and continual need for both operative surgical teams for most of the case, which can be logistically challenging in a small pediatric recipient. Due to CIT restrictions, the donor liver hilar dissection is done under warm conditions prior to cross clamp.…”

“…The portal bypass cannula is then clamped, and the portal system and hepatic artery is anastomosed. Reperfusion is conducted under cardiopulmonary bypass 35,36 …”

The evolution of the liver transplant candidate

“…The majority of these procedures have been performed with the two organs separated, however enbloc heart-liver transplant maintaining the suprahepatic inferior vena cava was described by Hill et al in 2012 ( 36 ). This procedure is increasingly utilised in the situation of liver cirrhosis and failing fontan physiology ( 37 ). Lung-liver transplants are performed even less frequently than heart-liver transplants, with less than 12 being performed in the U.S in 2018 ( 38 ).…”

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

“…The recipient undergoes cardiectomy and hepatectomy with cardiopulmonary bypass (CPB) support. The heart and liver are then implanted simultaneously and reperfused together while on CPB [32,33 ▪ ,34 ▪ ].…”

“…The technique is performed by a minority of institutions but carries several advantages. Most notably, there is a solitary reperfusion event that occurs while the patient remains supported on CPB allowing for greater hemodynamic stability during the lability of reperfusion [33 ▪ ]. This in turn decreases stress on the cardiac allograft and decreases venous congestion in the liver allograft.…”