En-Block Heart-Liver Transplantation in Adults - Technique and Mid Term Outcomes

Abstract

Purpose Combined heart and liver transplantation is a live saving procedure for patients with advanced dual organ failure. Although described 35 years ago, less than 20 cases are performed every year, reflecting the complexity of the procedure. We present the first case series of adult patients receiving En-Bloc Heart-Liver Transplant (En-Bloc HLTx). Methods A present a retrospective analysis of our experience with En-Bloc HLTx in five adult patients, including demographic characteristics, indications, surgical course with operative data, surgica outcomes, and long term follow up with evaluation of rejection by myocardial biopsy results. Results Five patients received En-Block HLTx between June 2016 and December 2017. Mean recipient age was 43 years (26-63), and 3 (60%)patients were male.Indication for dual organ transplantation included hereditary ATTR amyloidosis (n=1), gestations cardiomyopathy with cardiac cirrhosis (n=2), and idiomatic dilated cardiomyopathy with cryptogenic cirrhosis (n=1) or coexistent NASH (n=1).All patients presented NYHA FC IV symptoms, and 4 were admitted to the hospital awaiting transplantation for 63 days (51-89) as status 1A, while 1 patient was on home inotropic support. Sodium MELD score ranged from 8 to 28 (mean = 17.6). Total operative time was 430 min (393-480), and ischemic times (IT) were equal for both organs, with cold IT of 85 min (32-136), and warm IT of 37.5 min (31-47). Patients required CPB support for 107 min (80-138), and aortic cross-clamp of 58 min (52-72). Abdominal fascia remained open in 4 patients, and sternum in 3 patients, with planned definitive wound closure within 48 hours in all patients. Thirty day operative survival was 100%, and 4 (80%) patients were discharged alive from the hospital on POD 36 (17-67). One patient expired on POD 55, due to fungemia and multi system organ failure. Mayor postoperative complications included prolonged ventilation requiring tracheostomy on 3 patients, and renal insufficiency requiring dialysis in 2 patients. Follow up was complete all 4 patients for up to 18 months, All patients remained on low immunosuppression regimen, and there was no evidence of grade 2 or higher rejection on anyone. Conclusion En-Bloc HL Tx is a safe procedure for patients requiring dual organ transplantation. Operative times are significantly decreased, and mid-term outcomes are comparable to single organ transplantation.