Abstract 16533: Heterogeneity of Fibrosis in Patients Undergoing Combined Heart-Liver Transplant

Abstract

Introduction: Combined heart-liver transplant (CHLT) is indicated for patients with end-stage heart failure and concomitant irreversible liver injury. Given that liver dysfunction from congestive hepatopathy is common in patients with end-stage heart failure, it can be difficult to determine reversible from irreversible liver injury. Transjugular liver biopsy (TJLB) is frequently used to evaluate the severity of parenchymal injury, but is limited by heterogeneity of fibrosis across biopsy specimens. We sought to compare the fibrosis evaluation of the TJLB specimens as compared to the pathology of the liver explant at the time of CHLT. Methods: All CHLT cases at CSMC between 2007 and 2017 were included. Demographic and liver ultrasound (US) or abdominal computed tomography (CT) imaging was retrieved by chart review. TJLB was performed prior to transplant to determine the severity of liver fibrosis and was compared to the pathology of the liver explant. A biopsy was considered to show heterogenous fibrosis if there was at least a 2 stage difference between the predominant and secondary patterns. Results: Thirteen CHLTs were performed at our center during the study period. The median follow-up was 59 months (IQR 48-67). Mean age at transplant was 53 years (SD +/- 14.9) and 77% of patients were male. Indications for CHLT included cardiac cirrhosis (7), amyloidosis (2), HCV cirrhosis (2), and congenital heart disease (2). By imaging, 3/7 patients (43%) had US and CT evidence, 2/7 (29%) had US or CT evidence, and 2/7 (29%) had no evidence of liver nodularity US or CT. All patients diagnosed with cardiac cirrhosis had both TJLB and explant pathology for review. All TJLBs were graded as stage 4 fibrosis. Fibrosis on analysis of the liver explant was variable: stage 4 (2), stage 3-4 (3), stage 2-4 (1), and stage 1-4 (1). Thus, 2/7 patients (29%) showed heterogeneity of fibrosis in their explant as compared to their TJLB. Conclusions: We found heterogeneity of fibrosis in liver explants of patients that had stage 4 fibrosis (cirrhosis) by TJLB and underwent CHLT. Further work is needed to identify which heart transplant candidates will most benefit from CHLT.