2266 Simultaneous Coronary Artery Bypass Grafting and Orthotopic Liver Transplantation

Abstract

INTRODUCTION: Patients with Decompensated Cirrhosis requiring Coronary artery bypass grafting (CABG) before liver transplantation are at significant risk of liver failure and death. We discuss a simultaneous CABG and liver transplantation approach to offer the best therapeutic option in such cases. CASE DESCRIPTION/METHODS: Our patient is a 56-year-old male with decompensated cirrhosis related to Ethanol and Fatty liver. He had severe coronary artery disease of the proximal, mid and distal Right coronary artery (RCA) not amenable to PCI. Once a donor liver allograft was found to be suitable, simultaneous CABG with liver transplantation was performed. Initially after procuring the saphenous vein from the right leg, a median sternotomy incision was performed and the pericardium was opened. Single vessel CABG to RCA was performed using the Saphenous vein graft off cardiopulmonary bypass. Chest was left open for the liver transplantation surgery. A bilateral subcostal incision with midline extension was performed. After explantation of the native liver, donor liver implantation was performed in a piggyback fashion where the venocavoplasty formed using middle and left hepatic vein of the recipient was anastomosed with the donor IVC. Venovenous bypass was not used. A Choledochocholedochostomy was performed. There were no major perioperative complications. A month after surgery, he has normal liver function and is recovering at home. DISCUSSION: In advanced liver disease patients needing liver transplantation and with concurrent CAD not amenable to PCI, it is not always possible to perform staged surgeries. In our case the anticipated morbidity and mortality rate was high with either surgery performed alone. Our patient’s probability of post operative mortality one year after major surgery according to the Mayo Clinic risk calculator was 32%. Recipient hepatectomy during liver transplantation in the background of severe CAD and with already reduced systemic pressure could result in major hemodynamic instability and acute coronary ischemia. He underwent simultaneous CABG and liver transplantation successfully. Survival rates of 80% have been reported in case series from more than a decade ago (Table 1). All patients should have preserved ventricular function. Simultaneous CABG and liver transplantation can offer the best therapeutic option with good perioperative and long term survival rate for patients with advanced liver disease who have severe CAD not amenable to PCI.