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Considerations and experience driving expansion of combined heart-liver transplantation
Timothy Gong1,2,3, Shelley Hall1,2,3
1Center for Advanced Heart and Lung Disease, Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center.
Insights
Combined heart and liver transplants offer survival benefits and reduced rejection rates. Further research is needed to understand the liver allograft's immunoprotective effects in heart transplant patients.
Area of Science:
- Cardiology
- Hepatology
- Transplant Immunology
Background:
- Combined heart and liver transplantation (CHLT) is indicated for end-stage heart failure with irreversible liver failure.
- The immunologic benefits of the liver allograft in CHLT are not fully understood.
- CHLT is a growing procedure, accounting for approximately 25 cases annually.
Purpose of the Study:
- To review the current literature on the immunologic benefit of combined heart and liver transplantation (CHLT).
- To explore the potential immunoprotective role of the liver allograft in CHLT outcomes.
- To investigate the implications of CHLT for surgical techniques and immunosuppression.
Main Methods:
- Literature review of combined heart and liver transplantation outcomes.
- Analysis of registry data comparing CHLT with isolated heart transplantation.
- Examination of reported rates of acute cardiac rejection and cardiac allograft vasculopathy (CAV).
Main Results:
- CHLT survival rates are equivalent to or modestly improved compared to isolated heart transplantation.
- CHLT is associated with lower rates of acute cardiac rejection.
- CHLT demonstrates reduced incidence of cardiac allograft vasculopathy (CAV).
Conclusions:
- CHLT is a safe and viable option for patients with combined end-stage heart and liver disease.
- The liver allograft may confer an immunoprotective effect on the transplanted heart, warranting further investigation.
- Future research should focus on candidacy criteria, allocation protocols, and understanding the mechanisms of tolerogenicity in CHLT.
Purpose Of Review:
Heart transplantation concomitant with a liver transplant may be warranted when end-stage heart failure results in irreversible liver failure. Previously reported outcomes have been excellent yet the specific immunoprotective role of the liver allograft is not known. We review the current literature about the immunologic benefit for combined heart and liver transplantation (CHLT).
Recent Findings:
The total number of combined heart and liver transplants continues to increase and accounts for approximately 25 cases per year. Familial amyloid polyneuropathy with cardiac cirrhosis is the most common indication for CHLT while adult congenital heart disease (CHD) with associated cirrhosis is increasing in frequency. The majority of recent registry data suggest a statistically equivalent to modestly improved survival advantage for CHLT compared with isolated heart transplantation. Direct mechanisms accounting for this survival advantage are not proven, but combined heart and liver transplants experience lower rates of acute cardiac rejection and cardiac allograft vasculopathy (CAV).
Summary:
Combined heart and liver transplants remain a small percentage of the total heart transplants worldwide, but the majority of recent literature confirms the safety and viability of this option for patients with end-stage heart and liver disease. Equivalent to modestly improved survival outcomes, lower rates of acute cardiac rejection and CAV warrant further investigation into the liver allograft's immunoprotective effect on the transplanted heart. The key mechanisms of tolerogenicity have important implications for surgical technique and immunosuppression requirements. Future directions include development of criteria for heart-liver transplant candidacy and identification of equitable allocation protocols.
