Liver Transplantation Surgery Research Articles

Dexmedetomidine use during orthotopic liver transplantation surgery on early allograft dysfunction: A randomized controlled trial.

Previous studies have shown a protective effect of dexmedetomidine use in kidney transplantation. In contrast, it is not known whether intraoperative administration of dexmedetomidine can reduce early allograft dysfunction incidence following liver transplantation. To investigate the effect of dexmedetomidine use during surgery on early allograft dysfunction following orthotopic liver transplantation (OLT). This is a single-center, double-blinded, placebo-controlled randomized clinical trial. 330 adult patients undergoing orthotopic liver transplantation were enrolled from Jan 14th, 2019 to May 22nd, 2022. Patients received dexmedetomidine or normal saline during surgery. 1 year follow-ups were recorded. Patients were randomized to two groups receiving either dexmedetomidine or normal saline intraoperatively. For patients in the dexmedetomidine group, a loading dose (1μg/kg over 10 min) of dexmedetomidine was given after induction of anesthesia followed by a continuous infusion (0.5μg/kg /h) until the end of surgery. For patients in the normal saline group, an equal volume loading dose of 0.9% saline was given after the induction of anesthesia followed by an equal volume continuous infusion until the end of surgery. The primary outcome was early allograft dysfunction. Secondary outcomes included primary graft non-function, acute kidney injury and acute lung injury/ acute respiratory distress syndrome. Of 330 patients included in the intention-to-treat analysis, 165 were in the dexmedetomidine group (mean [SD] age, 49 [10] years; 117 [70.9%] men), and 165 were in the normal saline group (mean SD age, 49 [9] years; 118 [74%] men). 39 (24.4%) patients in the dexmedetomidine group and 31 (19.4%) in normal saline group developed early allograft dysfunction and the difference was statistically insignificant (P=0.28). Secondary outcomes including primary graft non-function and acute kidney injury was similar between the two groups. Intraoperative administration of dexmedetomidine did not reduce early allograft dysfunction rate after orthotopic liver transplantation.

Enhanced external counterpulsation treatment improves multi-organ hemodynamics for postoperative liver transplantation patient. A case report

IntroductionPost liver transplantation (LT) patients endure high morbidity rate of multi-organ ischemic symptoms following reperfusion. We hypothesize that enhanced external counterpulsation (EECP) as a typical non-invasive assisted circulation procedure, which can efficiently inhibit the relative ischemic symptoms via the systemic improvement of hemodynamics.Case presentationA 51-year-old male patient, 76 kg, 172 cm, received orthotopic LT surgery for viral hepatitis B induced acute-on-chronic liver failure hepatic failure. His medical records revealed ischemic symptoms in multi-organ at the time of hospital discharge, including headache, refractory insomnia, abdominal paralysis, and lower limb pain. The EECP treatment was introduced for assisted rehabilitation and to improve the postoperative quality of life. Doppler Ultrasound examination showed significant augmentation of blood flow volume in the carotid arteries, the hepatic artery, the portal vein and the femoral artery during EECP intervention. A standard 35-hour EECP treatment led to significant improvement in quality of life, e.g. sleep quality and walking ability.ConclusionWe report a case of multi-organ ischemic symptoms in a post LT patient. EECP treatment can significantly improve the quality of life via the systematic promotion of hemodynamics.

Maralixibat (Livmarli)

CADTH recommends that Livmarli should be reimbursed by public drug plans for the treatment of cholestatic pruritus in patients with Alagille syndrome (ALGS) if certain conditions are met. Livmarli should only be covered to treat patients aged 12 months and older with a diagnosis of ALGS and who have impaired bile flow demonstrated by at least 1 of the following: elevated serum bile acids (sBAs), conjugated bilirubin, or gamma-glutamyl transferase; fat-soluble vitamin deficiency; and/or intractable itch. Patients must experience moderate to severe itch symptoms and must be currently or have been previously treated with systemic medication for itch. Livmarli should only be reimbursed if it is prescribed under the care of a specialist with experience in managing ALGS, if patients experience an improvement in their itching after using Livmarli for 6 months, and if the cost of Livmarli is reduced. Livmarli should be stopped if the patient receives a liver transplant or biliary diversion surgery.

Use of Fluorescence Imaging in Liver Transplant Surgery.

Liver transplant surgery is a complex procedure that demands high knowledge of surgical anatomy and the precise recognition and preservation of structures. To address this, the use of fluorescence imaging has facilitated the identification of anatomical structures such as biliary ducts, arteries, and liver segmentation. Indocyanine green is among the most commonly utilized fluorescent agents, not just during surgery but also in the pre- and postoperative phases, where it is used to assess graft failure by measuring the plasma disappearance rate. New advancements such as artificial intelligence paired with fluorescence imaging have the potential to enhance patient outcomes. Additionally, technologies such as augmented reality and mixed reality could be integrated into surgical procedures, broadening the scope of possibilities for improving patient safety.

Fluid Responsiveness Is Associated with Successful Weaning after Liver Transplant Surgery.

A positive fluid balance may evolve to fluid overload and associate with organ dysfunctions, weaning difficulties, and increased mortality in ICU patients. We explored whether individualized fluid management, assessing fluid responsiveness via a passive leg-raising maneuver (PLR) before a spontaneous breathing trial (SBT), is associated with less extubation failure in ventilated patients with a high fluid balance admitted to the ICU after liver transplantation (LT). We recruited 15 LT patients in 2023. Their postoperative fluid balance was +4476 {3697, 5722} mL. PLR maneuvers were conducted upon ICU admission (T1) and pre SBT (T2). Cardiac index (CI) changes were recorded before and after each SBT (T3). Seven patients were fluid-responsive at T1, and twelve were responsive at T2. No significant differences occurred in hemodynamic, respiratory, and perfusion parameters between the fluid-responsive and fluid-unresponsive patients at any time. Fluid-responsive patients at T1 and T2 increased their CI during SBT from 3.1 {2.8, 3.7} to 3.7 {3.4, 4.1} mL/min/m2 (p = 0.045). All fluid-responsive patients at T2 were extubated after the SBTs and consolidated extubation. Two out of three of the fluid-unresponsive patients experienced weaning difficulties. We concluded that fluid-responsive patients post LT may start weaning earlier and achieve successful extubation despite a high postoperative fluid balance. This highlights the profound impact of personalized assessments of cardiovascular state on critical surgical patients.

Rare and Dangerous Complication of Rhabdomyolysis in Critically Ill Patients: a Case Study

Rhabdomyolysis in critically ill patients is rare and can easily lead to serious adverse complications. We present the case of a young male patient who experienced acute liver failure resulting from closed abdominal injury, accompanied by severe complications of rhabdomyolysis and compartment syndrome. The patient underwent orthotopic liver transplantation surgery to restore liver function. Compartment syndrome of the lower legs was treated with percutaneous deep fasciotomy. Upon discharge, the patient was in a post-liver transplant state and exhibited partial dysfunction in lower limbs. Therefore, rhabdomyolysis occurs insidiously in severe patients and can easily lead to serious adverse outcomes. Clinicians should recognize symptoms of rhabdomyolysis and intervene promptly.

Percutaneous Biliary Interventions in Pediatric Patients

AbstractPercutaneous biliary interventions have become standard for a variety of indications in pediatric patients. They offer a minimally invasive approach to managing biliary pathologies often associated with liver transplantation and hepatobiliary surgery. Interventions include the insertion of drainage catheters for bilomas, percutaneous transhepatic cholangiography for diagnostic purposes, and percutaneous transhepatic biliary drainage for the treatment of biliary leaks and cholestasis. Sonography, computed tomography, and fluoroscopy are used to guide the procedures. This review aims to demonstrate the indications and technical aspects of percutaneous biliary interventions in pediatric patients with a special focus on radiation protection.

Comparative phenotypic and genotypic analysis of community-acquired and hospital-acquired intra-abdominal infections among liver transplanted patients.

During liver transplantation, both hospital-acquired (HA) and community-acquired (CA) intra-abdominal infections (IAIs) are involved causing life-threatening diseases. Therefore, comparative studies of aerobic and facultative anaerobic HA-IAIs and CA-IAIs after liver transplantation surgery are necessary. The species of detected isolates (310) from intra-abdominal fluid were identified and classified into hospital-acquired intra-abdominal infections (HA-IAIs) and community-acquired intra-abdominal infections (CA-IAIs). Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter baumannii were the most commonly detected species. The resistant phenotypes were commonly detected among the HA-IAIs; however, the virulent phenotypes were the predominant strains of CA-IAIs. Regrettably, the resistance profiles were shocking, indicating the inefficacy of monotherapy in treating these isolates. Therefore, we confirmed the use of empirical combination therapies of amikacin and meropenem for treating all IAIs (FICI≤0.5). Unfortunately, the high diversity and low clonality of all identified HA and CA-IAIs were announced with D-value in the range of 0.992-1. This diversity proves that there are infinite numbers of infection sources inside and outside healthcare centers.

Renal Replacement Therapy During Liver Transplant Surgery

Liver transplant is the treatment available for eligible patients with end-stage liver cirrhosis. Acute kidney injury and electrolyte abnormalities are associated with liver disease and can be exacerbated by surgery. Intraoperative renal replacement therapy has been tried in some large centres. The authors discuss the physiological changes and complications during liver transplant surgery, and review literature on the safety, feasibility, benefits, and drawbacks of intraoperative renal replacement therapy during liver transplant surgery.

Use of Transesophageal Echocardiography for Liver Transplantation: A Global Comparison of Practice From the ILTS, SATA, and LICAGE.

Anesthesiologists frequently use intraoperative transesophageal echocardiography (TEE) to aid in the diagnosis and management of hemodynamic problems during liver transplantation (LT). Although the use of TEE in US centers continues to increase, data regarding international use are lacking. This prospective, global, survey-based study evaluates international experience with TEE for LT. Responses from 252 LT (105 US and 147 non-US) centers representing 1789 anesthesiologists were analyzed. Routine use of TEE in the United States has increased in the last 5 y (from 37% to 47%), but only 21% of non-US LT anesthesiologists use TEE routinely. Lack of training (44% US versus 70% non-US) and equipment (9% non-US, versus 34% US) were cited as obstacles. Most survey participants preferred not to perform a complete cardiac examination but rather use only 6 of 11 basic views. Although non-US LT anesthesiologists more frequently had additional clinical training than their US counterparts, they had less TEE experience (13% versus 44%) and less frequently, TEE certification (22% versus 35%). Most LT anesthesiologists agreed that TEE certification is essential for proficiency. Of all respondents, 89% agreed or strongly agreed that TEE provides valuable information needed for immediate clinical decision-making, and >86% agreed or strongly agreed that that information could not be derived from other sources. The use of TEE for LT surgery in the US LT centers is currently higher compared with non-US LT centers. This may become a standard monitoring modality during LT in the near future.

Minimally Invasive Surgery in Liver Transplantation: From Living Liver Donation to Graft Implantation

Since the end of the 20th century and the establishment of minimally invasive techniques, they have become the preferred operative method by many surgeons. These techniques were applied to liver surgery for the first time in 1991, while as far as transplantation is concerned their application was limited to the living donor procedure. We performed a review of the literature by searching in Pubmed and Scopus using the following keywords: Liver transplantation, Minimally invasive surgery(MIS) living liver donor surgery. Applications of MIS are recorded in surgeries involving the donor and the recipient. Regarding the recipient surgeries, the reports are limited to 25 patients, including combinations of laparoscopic, robotic and open techniques, while in the living donor surgery, the reports are much more numerous and with larger series of patients. Shorter hospitalization times and less blood loss are recorded, especially in centers with experience in a large number of cases. Regarding the living donor surgery, MIS follows the same principles as a conventional hepatectomy and is already the method of choice in many specialized centers. Regarding the recipient surgery, significant questions arise mainly concerning the safe handling of the liver graft.

Limitations of antifungal prophylaxis in preventing invasive Candida surgical site infections after liver transplant surgery.

Invasive primary Candida surgical site infections (IP-SSIs) are a common complication of liver transplantation, and targeted antifungal prophylaxis is an efficient strategy to limit their occurrence. We performed a retrospective single-center cohort study among adult single liver transplant recipients at Duke University Hospital in the period between 1 January 2015 and 31 December 2020. The study aimed to determine the rate of Candida IP-SSI according to the peri-transplant antifungal prophylaxis received. Of 470 adult single liver transplant recipients, 53 (11.3%) received micafungin prophylaxis, 100 (21.3%) received fluconazole prophylaxis, and 317 (67.4%) did not receive systemic antifungal prophylaxis in the peri-transplant period. Ten Candida IP-SSIs occurred among 5 of 53 (9.4%) micafungin recipients, 1 of 100 (1.0%) fluconazole recipients, and 4 of 317 (1.3%) recipients who did not receive antifungal prophylaxis. Our study highlights the limitations of antifungal prophylaxis in preventing invasive Candida IP-SSI after liver transplant surgery. We hypothesize that pathogen, host, and pharmacokinetic-related factors contributed to the occurrence of Candida IP-SSI despite antifungal prophylaxis. Our study reinforces the need for a risk-based, multi-pronged approach to fungal prevention, including targeted antifungal administration in patients with risks for invasive candidiasis and close monitoring, especially among patients with surgically complex procedures, with timely control of surgical leaks.

Temporary Portocaval Shunt Provides Superior Intraoperative Hemodynamics and Reduces Blood Loss and Duration of Surgery in Live Donor Liver Transplantation: A Randomized Control Trial.

To compare intraoperative hemodynamic parameters, blood loss, renal function, and duration of surgery with and without temporary portocaval shunt (TPCS) in live donor liver transplantation (LT) recipients. Secondary objectives were postoperative early graft dysfunction, morbidity, mortality, total intensive care unit, and hospital stay. Blood loss during recipient hepatectomy for LT remains a major concern. Routine use of TPCS during LT is not yet elucidated. This study is a single-center, open-label, randomized control trial. The sample size was calculated based on intraoperative blood loss. After exclusion, a total of 60 patients, 30 in each arm (TPCS vs no TPCS) were recruited in the trial. The baseline recipient and donor characteristics were comparable between the groups. The median intraoperative blood loss ( P = 0.004) and blood product transfusions ( P < 0.05) were significantly less in the TPCS group. The TPCS group had significantly improved intraoperative hemodynamics in the anhepatic phase as compared with the no TPCS group ( P < 0.0001), requiring significantly less vasopressor support. This led to significantly better renal function as evidenced by higher intraoperative urine output in the TPCS group ( P = 0.002). Because of technical simplicity, the TPCS group had significantly fewer inferior vena cava injuries (3.3 vs 26.7%, P = 0.026) and substantially shorter hepatectomy time and total duration of surgery (529.4 ± 35.54 vs 606.83 ± 48.13 min, P < 0.0001). The time taken for normalization of lactate in the immediate postoperative period was significantly shorter in the TPCS group (median, 6 vs 13 h; P = 0.04). Although postoperative endotoxemia, major morbidity, 90-day mortality, total intensive care unit, and hospital stay were comparable between both groups, tolerance to enteral feed was earlier in the TPCS group. In live donor LT, TPCS is a simple and effective technique that provides superior intraoperative hemodynamics and reduces blood loss and duration of surgery.

Recipient-associated risk factors for post-liver transplantation biliary complications: A cohort study.

Biliary complications (BCs) are a well-documented post-liver transplantation concern with potential implications for patient survival. This study aims at identifying risk factors associated with the development of BCs in recipients after liver transplantation (LT) and exploring strategies for their management. We conducted a retrospective analysis of 1595 adult patients (age > 18 years) who underwent LT surgery between 2019 and 2021. The study assessed the incidence of BCs in this cohort. Of 1595 patients, 178 (11.1%) experienced BCs, while 1417 (88.8%) did not exhibit any signs of such complications. Patients who developed BCs were found to have a significantly lower average age (p < 0.001) and longer cold ischemic times (p < 0.001) compared to those without BCs. Variables such as sex, body mass index (BMI), model for end-stage liver disease (MELD) score, primary diagnosis, type of anastomosis, hepatectomy technique, type of transplanted liver and mortality did not demonstrate statistically significant differences between the two groups (p > 0.05). Univariate logistic regression analysis revealed that a cold ischemic time exceeding 12 hours and duct-to-duct anastomosis were positive predictors for BC development (odds ratios of 6.23 [CI 4.29-9.02] and 1.47 [CI 0.94-2.30], respectively). Conversely, increasing age was associated with a protective effect against BC development, with an odds ratio of 0.64 (CI 0.46-0.89). Our multi-variate analysis identified cold ischemia time (CIT) as the sole significant predictor of post-liver transplantation biliary complications. Additionally, this study observed that advancing patient age had a protective influence in this context. Notably, no significant disparities were detected between hepatectomy techniques and the etiology of liver disease types in the two study groups.

Two Decades of Minimally Invasive Surgery in Solid Organ Transplantation.

Transplant surgery has undergone significant advancements with the emergence of minimally invasive techniques, particularly in kidney and liver transplantation. This review explores the applications and impact of minimally invasive approaches in transplant surgeries. The history of laparoscopy and robotic surgery is discussed, highlighting the evolution of these techniques and their contributions to the field of minimally invasive surgery. Despite the numerous benefits offered by minimally invasive techniques, their acceptance in the transplant world remains relatively low. Factors such as technical complexity, concerns about graft function and longterm outcomes, surgical time and cost considerations, and the lack of standardized guidelines contribute to this low acceptance. However, as research and technological advancements continue, the acceptance of minimally invasive techniques is gradually increasing. Specific applications of minimally invasive techniques in kidney and liver transplant surgeries are explored, highlighting the transformative effect on patient outcomes and quality of life. The review concludes by emphasizing the ongoing evolution of transplant surgery and the potential for minimally invasive techniques to bring renewed hope and improved outcomes to transplant patients worldwide.

Association of Serum Alpha-fetoprotein with the Tumor Characters and HBV Status of Hepatocellular Carcinoma to Assess its Resectability

Background: Serum alpha-fetoprotein (AFP) has long been used to complement imaging tests in the screening and diagnosis of hepatocellular carcinoma (HCC), its utility as a predictive marker of long-term risk for HCC in HBV patients is contentious. Objective: The current study is aimed to assess the serum alpha-fetoprotein with the tumor character and HBV status of HCC to assess its resectability. Methods: This was a single-center, cross-sectional study done from September 2020 to August 2021 at the department of Hepatobiliary, pancreatic, and liver transplantation surgery at BSMMU. A total of 27 HCC patients who met the inclusion criteria were enrolled in the study. Clinical, laboratory, and imaging findings were obtained using a standardized data collecting sheet with the patients' informed agreement. AFP was measured by automated chemiluminescence analyzer (LIAISON XL, DiaSorin, Italy) in the Department of Biochemistry &amp; Molecular Biology, BSMMU. Statistical analyses were performed using SPSS version 22. Quantitative variables were expressed as mean standard deviation and examined using an unpaired t-test. The qualitative data were represented by frequencies and percentages, and the Chi-Square test and Fisher exact test (where applicable) were used to determine any association. The statistical tests were conducted with a 95% confidence interval, and P&lt;0.05 was deemed statistically significant. Results: Majority of the tumors were single and located in the right lobe. Local extension and distant metastasis were preset in unresectable patients of group 2.Hepatitis B virus was positive in 16 (59.3%) patients and DNA was detectable in 8 (29.6%) patients. HBV positivity and detectable HBV DNA was significantly associated with poor resectable status in group 2 but insignificant in group 1. Conclusions: In this study, the overall resectability was 37%. HBV positive HCC patients are significantly associated with poor resectability when serum AFP is raised and it would be more indicative when HBV DNA is detected. TAJ 2023; 36: No-2: 111-119

Clinical course of COVID-19 infection in liver transplant patients

In the presence of chronic liver diseases, the post‑infectious period of COVID‑19 is difficult and potentially mortal. The impact of COVID‑19 on liver transplant patients has not been thoroughly investigated.&#x0D; Objective — to study the characteristics of the clinical course of COVID‑19 in liver transplant patients.&#x0D; Materials and methods. At the end of December 2014, the first successful liver transplant operation in Georgia was performed at the Batumi Referral Hospital of the Autonomous Republic of Adjara. To date, a total of surgical interventions have been conducted, including 42 surgeries since the beginning of the pandemic. We analysed&#x0D; The incidence of COVID‑19 infection in the cohort of 88 patients throughout their hospital stay after liver transplant and at the late postoperative period was analysed, as well as the characteristics of the clinical course of COVID‑19. To prevent COVID‑19 transmission within the hospital, a special protocol been developed: to ensure that the patient is safely isolated from contact with the source of infection. In the postoperative period, all patients received immunosuppressive therapy. To monitor the course of the disease, an interdisciplinary team was created, which consisted of a transplant surgeon, hepatologist, gastroenterologist, infectious disease specialist, therapist, and immunologist. The consultation was held at the place of residence and treatment of a patient.&#x0D; Results. No cases of COVID‑19 infection were reported among patients at the hospital where the liver transplant was conducted. In the late period, COVID‑19 was registered in 17 (19.3%) patients, of whom one (5.9%) died from the infection. One patient was infected with COVID‑19 twice. We have identified four variants of the clinical course of COVID‑19: mild (23.5%) — without any symptoms except for mild respiratory symptoms; aggravated (41.2%) — mild respiratory symptoms and dyspeptic symptoms without significant changes in clinical diagnostic parameters; moderate (29.4%) — cough without sputum, hyperthermia for three days, decreased sense of smell, the presence of dyspeptic symptoms, increased average values of biochemical parameters (alanine aminotransferase, aspartate aminotransferase, γ‑glutamyl transpeptidase, alkaline phosphatase, total bilirubin); severe (5.9%) — development of multiple organ failure.&#x0D; Conclusions. The implemented set of preventive measures ensured the patient’s protection from COVID‑19 infection in all cases during their hospital stay. In liver transplant patients.&#x0D;

How best to combine liver transplantation and bariatric surgery?-Results from a global, web-based survey.

Obesity is a growing healthcare challenge worldwide and a significant risk factor for liver failure as seen with non-alcoholic steatohepatitis (NASH). Combining metabolic-bariatric surgery (MBS) with liver transplantation (LT) appears as attractive strategy to treat both, the underlying liver disease and obesity. However, there is an ongoing debate on best timing and patient selection. This survey was designed to explore the current treatment practice for patients with NASH and obesity worldwide. A web-based survey was conducted in 2022 among bariatric and LT surgeons, and hepatologists from Europe, North and South America and Asia. The survey completion rate was 74% (145/196). The average respondents were 41-50 years (38%), male (82.1%) and had >20 years of clinical experience (42.1%). Centres with a high LT-caseload for NASH were mainly located in the USA and United Kingdom. Almost 30% have already performed a combination of LT with MBS and 49% plan to do it. A majority of bariatric surgeons prefer MBS before LT (77.2%), whereas most of LT surgeons (52%) would perform MBS during LT. Most respondents (n = 114; 80%) favour sleeve gastrectomy over other bariatric techniques. One third (n = 42; 29.4%) has an established protocol regarding MBS for LT candidates. The most experienced centres doing LT for NASH are in the USA and United Kingdom with growing awareness worldwide. Overall, a combination of MBS and LT has already been performed by a third of respondents. Sleeve gastrectomy is the bariatric technique of choice-preferably performed either before or during LT.

Liver Transplantation Research from India During the Last 25 Years: 1998–2022

Liver transplant surgery has been performed in India for the last 25 years. We aimed to analyse the trends, characteristics, and key elements in the field of liver transplantation research from India. On April 23, 2023, we conducted a search of the Scopus database for the literature on liver transplantation research, using a well-defined search strategy. MS Excel and VOS viewersoftware programs were used to examine the articles for organisation, author, journal, keywords, and high-cited literature. This analysis examined a total of 556 papers, which constituted only a 1.55% share of the global output. These papers involved 442 organizations, 1575 authors, and 147 journals. External funding was received in 4.13% and 23.56% were involved in international collaboration. Three Delhi-NCR organizations, namely the Medanta-The Medicity (n=63), Institute of Liver & Biliary Sciences (n=60), and Indraprastha Apollo Hospital (n=48) led in publication productivity. M. Rela (n=90) and A.S. Soin (n=63) were the leading authors in publication productivity, while S. Sudhindran and P. Bhangui were the most impactful authors. Liver Transplantation (n=96) and Journal of Clinical & Experimental Hepatology (n=65) published the maximum number of these papers, whereas, Annals of Surgery and Journal of Hepatology led in the citation impact per paper. The most significant keywords were "Liver Transplantation" (n=484), and "Living Donor" (n=254). Only 1.80% (n=10) of the papers were highly cited papers that received 50 to 142 citations and they together registered 69.9 citations per paper. Although the number of publications on liver transplantation from India started growing recently, it forms only 1.55% of the global report. There is an unmet need to increase government-supported research and multicenter collaborative studies at national and international levels for high-quality patient care.

Combined Liver Transplant and Cardiac Surgery: Long-Term Outcomes and Predictors of Success.

We aim to report our institutional outcomes of single-staged combined liver transplantation (LT) and cardiac surgery (CS). Concurrent LT and CS is a potential treatment for combined cardiac dysfunction and end-stage liver disease, yet only 54 cases have been previously reported in the literature. Thus, the outcomes of this approach are relatively unknown, and this approach has been previously regarded as extremely risky. Thirty-one patients at our institution underwent combined cardiac surgery and liver transplant. Patients with at least one-year follow-up were included. The Leave-One-Out Cross-Validation (LOOCV) machine-learning approach was used to generate a model for mortality. Median follow-up was 8.2 years (IQR 4.6-13.6y). One- and five-year survival was 74.2% (N=23) and 55% (N=17), respectively. Negative predictive factors of survival included recipient age>60 years (P=0.036), NASH-cirrhosis (P=0.031), Coronary Artery Bypass-Graft (CABG)-based CS (P=0.046) and pre-operative renal dysfunction (P=0.024). The final model demonstrated that renal dysfunction had a relative weighted impact of 3.2 versus CABG (1.7), age ≥60y (1.7) or NASH (1.3). Elevated LT+CS risk score was associated with an increased five-year mortality after surgery (AUC=0.731, P=<0.001). Conversely, the widely accepted STS-PROM calculator was unable to successfully stratify patients according to 1- (P>0.99) or 5-year (P=0.695) survival rates. This is the largest series describing combined LT+CS, with joint surgical management appearing feasible in highly selected patients. CABG and pre-operative renal dysfunction are important negative predictors of mortality. The four-variable LT+CS score may help predict patients at high risk for post-operative mortality.