Significance of asymptomatic biliary tract disease in heart transplant recipients

Biliary disease in conjunction with heart transplantation was encountered in 13 of 33 patients: in the past history (three patients), at pretransplant evaluation (nine patients), and appearing de novo after transplantation (one patient). Four patients with asymptomatic cholelithiasis underwent transplantation: biliary complications requiring emergency and/or urgent surgery occurred in all, with two deaths. Potentially complicating factors included (1) untoward effects of steroids on tissue healing and infection and (2) interaction between liver dysfunction and/or external bile loss and cyclosporine metabolism. Therapeutic lessons learned from this experience involve (1) selection of monoclonal antibodies over methylprednisolone for rejection control, (2) return of drained bile to the gastrointestinal tract, and (3) careful cyclosporine level and dosage monitoring. Five candidates with asymptomatic cholelithiasis underwent elective pretransplant biliary surgery; despite their compromised heart function, all patients had an uncomplicated postoperative course. We conclude that asymptomatic biliary disease is frequent in transplant candidates, can lead to serious morbidity and/or mortality after transplantation, and ideally can and should be treated before transplantation.