Combined heart-liver transplant in an acute-on-chronic liver failure (ACLF) setting

Combined heart and liver transplantation (CHLT) is a rare, complex procedure for dual-organ failure. This report describes a 58-year-old male with ischemic cardiomyopathy and severe congestive heart failure who developed secondary acute-on-chronic liver failure (ACLF), necessitating a simultaneous orthotopic CHLT. This is believed to be the first reported CHLT for ACLF. The patient had long-standing diabetes and ischemic heart disease, progressing to dilated cardiomyopathy (DCMP) and recurrent heart failure despite maximal medical therapy and automated implantable cardioverter-defibrillator (AICD) implantation. Evaluation revealed severely reduced biventricular function (left ventricular ejection fraction (LVEF) 17%) and liver dysfunction with advanced fibrosis, initially attributed to cardiac congestion. While awaiting heart transplantation, his condition deteriorated to cardiogenic shock requiring a biventricular assist device (BiVAD) and continuous renal replacement therapy (CRRT), complicated by hepatic encephalopathy and worsening liver function, meeting ACLF criteria. A multidisciplinary team opted for CHLT. He underwent a single-stage procedure with organs from a 38-year-old donor. The complex surgery involved transitioning from BiVAD to cardiopulmonary bypass (CPB) and sequential organ implantation. The postoperative course was challenging, marked by tacrolimus toxicity, cytomegalovirus (CMV) infection, and multidrug-resistant sepsis leading to acute kidney injury (AKI) requiring dialysis. Significant nutritional support and physical rehabilitation were necessary due to sarcopenia and critical illness myopathy. Despite these hurdles, he was discharged stable 3 months post-transplant. He showed normal biventricular and liver function at 5 months with no rejection. This case demonstrates the feasibility of CHLT in the difficult setting of ACLF secondary to advanced heart failure, highlighting the need for a coordinated, multidisciplinary approach to manage complex perioperative challenges.