The perioperative management of patients undergoing combined heart-liver transplantation

Background. Combined heart-liver transplantation (CHLT) is an uncommonly performed procedure for patients with coexisting cardiac and liver disease.

Methods. A retrospective review was performed of patients undergoing CHLT at our institution from 1999 to 2013. Information related to preoperative organ function, intraoperative management, surgical approach, transfusions, postoperative findings, and 30-day mortality was reviewed.

Results. Twenty-seven CHLT were performed, with 4 of the 27 including simultaneous kidney transplantation. Familial amyloidosis was the indication for 21 CHLTs (78%), and 12 of these explanted livers were used for domino transplantations. Nineteen patients (70%) were receiving inotropic infusions at the time of organ availability. Median preoperative model for end-stage liver disease score was 12. Liver transplantation immediately preceded cardiac transplantation in 2 of the 27 cases because of the presence of high titer donor-specific antibodies and the potential of the liver to lead to a reduction in the antibody titer. Venovenous bypass was used in 14 operations (52%) which were performed with the caval interposition approach to liver transplantation, cardiopulmonary bypass during liver transplantation in two cases (7%), and no bypass in 11 operations (41%) performed with caval sparing (piggyback) surgical technique. Postoperatively, median duration of mechanical ventilation, intensive care unit stay, and hospital stay until discharge were 1 day, 5.5 days, and 15 days, respectively. Transfusions in the first 48 hr after CHLT were not substantial in most patients. One patient died within 30 days of CHLT.

Conclusion. Combined heart-liver transplantation is a life-saving operation that is performed with relatively low mortality and can be successfully performed in select patients with congenital or acquired cardiac disease.