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Update on combined heart and liver transplantation: evolving patient selection, improving outcomes, and outstanding
Kaitlyn M Tracy1, Lea K Matsuoka, Sophoclis P Alexopoulos
1Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Insights
Combined heart and liver transplantation (CHLT) is increasingly needed for patients with single ventricle physiology. Careful patient selection and evaluation are crucial for successful outcomes in these complex cases.
Area of Science:
- Cardiology
- Hepatology
- Transplantation Surgery
Background:
- Combined heart and liver transplantation (CHLT) is an uncommon but growing procedure.
- The rising population of patients with Fontan palliation for single ventricle physiology drives the increased need for CHLT.
- Fontan-associated liver disease (FALD) is now the primary indication for CHLT, surpassing other causes.
Approach:
- This review synthesizes current literature on CHLT for FALD.
- It focuses on patient selection criteria and transplantation outcomes.
- The review also identifies remaining knowledge gaps and future research directions.
Key Points:
- Accurate assessment of liver injury recoverability in Fontan patients is challenging.
- Multifaceted evaluation is necessary to decide between isolated or dual organ transplantation.
- Patient survival rates have improved, with no significant difference between CHD and non-CHD groups.
- En bloc surgical techniques and intraoperative mechanical circulatory support are evolving areas of interest.
Conclusions:
- Further research, including prospective studies, is needed for refined patient selection and understanding indication-specific outcomes.
- Experience with CHLT is growing, leading to advancements in surgical techniques and perioperative support.
- Multifaceted evaluation is essential to determine the optimal transplantation strategy (isolated vs. dual organ) for patients with failing Fontan physiology.
Purpose Of Review:
Combined heart and liver transplantation (CHLT) is an uncommon but increasingly performed procedure with rising need as the population who has undergone Fontan palliation for single ventricle physiology grows. This article reviews the current literature to summarize what is known about patient selection and outcomes and highlights the questions that remain.
Recent Findings:
Congenital heart disease (CHD) with Fontan-associated liver disease (FALD) has surpassed noncongenital heart disease as the most common indication for CHLT. In patients with failing Fontan physiology, accurate assessment of recoverability of liver injury remains challenging and requires multifaceted evaluation to determine who would benefit from isolated versus dual organ transplantation. Patient survival has improved over time without significant differences between those with and without a diagnosis of CHD. En bloc surgical technique and best use of intraoperative mechanical circulatory support are topics of interest as the field continues to evolve.
Summary:
A more refined understanding of appropriate patient selection and indication-specific outcomes will develop as we gain more experience with this complex operation and perform prospective, randomized studies.
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