Heart-After-Liver Transplantation Attenuates Rejection of Cardiac Allografts in Sensitized Patients

Richard C Daly, Andrew N. Rosenbaum, Joseph Dearani, Alfredo L. Clavell, Naveen L. Pereira, Barry A. Boilson, Robert P. Frantz, Atta Behfar, Shannon M Dunlay, Richard J Rodeheffer, John A Schirger, Timucin Taner, Manish J. Gandhi, Julie Heimbach, Charles B. Rosen, Brooks Sayre Edwards, Sudhir Kushwaha

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: In patients undergoing heart transplantation, significant allosensitization limits access to organs, resulting in longer wait times and high waitlist mortality. Current desensitization strategies are limited in enabling successful transplantation. Objectives: The purpose of this study was to describe the cumulative experience of combined heart-liver transplantation using a novel heart-after-liver transplant (HALT) protocol resulting in profound immunologic protection. Methods: Reported are the results of a clinical protocol that was instituted to transplant highly sensitized patients requiring combined heart and liver transplantation at a single institution. Patients were dual-organ listed with perceived elevated risk of rejection or markedly prolonged waitlist time due to high levels of allo-antibodies. Detailed immunological data and long-term patient and graft outcomes were obtained. Results: A total of 7 patients (age 43 ± 7 years, 86% women) with high allosensitization (median calculated panel reactive antibody = 77%) underwent HALT. All had significant, unacceptable donor specific antibodies (DSA) (>4,000 mean fluorescence antibody). Prospective pre-operative flow cytometric T-cell crossmatch was positive in all, and B-cell crossmatch was positive in 5 of 7. After HALT, retrospective crossmatch (B- and T-cell) became negative in all. DSA fell dramatically; at last follow-up, all pre-formed or de novo DSA levels were insignificant at <2,000 mean fluorescence antibody. No patients experienced >1R rejection over a median follow-up of 48 months (interquartile range: 25 to 68 months). There was 1 death due to metastatic cancer and no significant graft dysfunction. Conclusions: A heart-after-liver transplantation protocol enables successful transplantation via near-elimination of DSA and is effective in preventing adverse immunological outcomes in highly sensitized patients listed for combined heart-liver transplantation.

Original languageEnglish (US)
Pages (from-to)1331-1340
Number of pages10
JournalJournal of the American College of Cardiology
Issue number10
StatePublished - Mar 16 2021


  • combined organ transplantation
  • heart transplantation
  • rejection
  • sensitization

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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