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Ann Thorac Surg 2007;83:1544-1545
© 2007 The Society of Thoracic Surgeons

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Case Reports

Combined Simultaneous Heart and Liver Transplantation With Complete Cardiopulmonary Bypass Support

^a Division of Cardiothoracic Surgery, McGill University Health Center, Montréal, Québec, Canada
^b Division of General Surgery, Department of Surgery, McGill University Health Center, Montréal, Québec, Canada
^c Department of Anesthesia, McGill University Health Center, Montréal, Québec, Canada

Accepted for publication October 4, 2006.

^_* Address correspondence to Dr Lachapelle, Division of Cardiothoracic Surgery, Department of Surgery, McGill University Health Center, 687 Pine Ave West, Montréal, QC H3A 1A1, Canada (Email: kevin.lachapelle{at}muhc.mcgill.ca).

	Abstract

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Despite its initial description more than 20 years ago, combined orthotopic heart and liver transplantation is still performed infrequently. We report a 53-year-old man with familial hypertrophic restrictive cardiomyopathy who presented with right heart failure and end-stage liver failure and required combined orthotopic heart and liver transplantation. Rather then using a staged approach, the surgery was performed using a technique of simultaneous implantation supported by cardiopulmonary bypass. The relative merits of using a simultaneous approach are discussed. The patient had an uneventful postoperative course and went home on postoperative day 14.

	Introduction

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Combined orthotopic heart and liver transplantation (CHLT) is still, more than 20 years after Starzl and colleagues’ [1] initial description, an uncommonly performed procedure. It has, however, been shown to be a lifesaving operation for individuals with concurrent end-stage hepatic and cardiac disease. Initially performed for patients with familial hypercholesterolemia, the indications for CHLT have since been expanded in light of early reports of satisfactory survival. Combined orthotopic heart and liver transplantation is now performed for a variety of illnesses that result in dual vital organ failure (hemochromatosis, familial hypercholesterolemia, amyloidosis) as well as for patients with end-stage liver failure who are considered unfit for isolated liver transplantation because of severe ischemic cardiac disease [2–6].

An otherwise healthy 53-year-old man with a history of familial hypertrophic restrictive cardiomyopathy (FHRC) presented to a peripheral hospital for pretransplantation work-up. This evaluation revealed profound right heart failure and end-stage liver failure (Child grade C). His history was negative for abusive alcohol consumption, and this evaluation revealed negative hepatitis serologies. Hemochromatosis was also ruled out. Echocardiography showed he had normal left-ventricular systolic function, but right heart catheterization revealed a severe restrictive diastolic pattern. A liver biopsy specimen was consistent with cryptogenic liver cirrhosis, and his end-stage liver disease was attributed to severe right-sided heart failure. In light of this assessment, he was referred to our institution for CHLT and listed for transplantation.

When ABO compatible, weight-matched organs became available, our liver and heart procurement teams were dispatched to the donor site. As the donor heart was being procured, the patient was taken to the operating theatre and appropriate monitoring lines were placed. Once the donor heart and liver were confirmed as "good fits," a midline sternotomy extending into bilateral subcostal incisions was performed. Abdominal dissection to isolate the structures, including the porta hepatitis and suprahepatic vena cava was done first, but without completing the hepatectomy. Preparation took place concurrently for cardiopulmonary bypass (CPB). Bicaval cannulation was obtained via the superior vena cava (No. 24, metal tip) and femoral vein with a single-stage venous cannula (No. 21) going to the inferior vena cava and standard aortic cannulation (No. 24).

Once the donor heart arrived, the recipient’s heart was explanted and bicaval heart transplantation was performed in the usual fashion. During the reperfusion period (on full CPB with the femoral cannula withdrawn to the iliac vein), the recipient hepatectomy was completed, and donor liver was implanted, with the entire liver transplantation occurring on complete CPB.

After unclamping the portal and caval systems, the hepatic artery anastomosis was completed. At this time, the heart rate became unstable and peaked T waves were noted. Fortunately, this led to no deleterious consequences because the patient was on full CPB. Ten minutes after the hepatic artery was unclamped, the patient was easily weaned from CPB and decannulated. The common bile duct anastomosis was then done after reinitiation of hepatic artery flow. Anticoagulation was reversed using protamine sulfate and hemostasis was achieved. The CPB time was 197 minutes with a cross-clamp time of 73 minutes. The cardiac and hepatic ischemic times were 185 and 288 minutes respectively.

The patient had a completely uneventful recovery. He remained in the intensive care unit for 5 days and was then transferred to our dedicated cardiac surgery ward. He did not demonstrate any signs of pulmonary or renal dysfunction, and his postoperative course was free of arrhythmic episodes or signs of rejection. He was discharged home on postoperative day 14.

	Comment

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This report describes a successful case of a combined simultaneous heart and liver transplantation performed completely on CPB for FHRC with secondary end-stage liver failure. A review of the literature reveals that FHRC with secondary end-stage liver disease is a rare indication for CHLT. With the experience of this case, we believe (1) that FHRC with associated terminal liver failure should be extended as an indication for CHLT, and (2) the technique of simultaneous heart and liver transplantation performed completely under CPB should be considered as a valid surgical option for cases of CHLT.

The surgical approach reported here is similar to the one described by Starzl and colleagues [1] in 1985. Other approaches include the sequential implantation of the heart and liver during two independent procedures, or the more frequently performed simultaneous implantation of both organs with the use of portal-systemic venovenous bypass [4] or inferior vena caval flow preservation [7]. We believe that the technique reported here could prove useful in preventing complications associated with previously described cases of combined heart and liver transplantation, including acute renal failure.

A priori, we decided to use this approach to save on the precious time required for cardiac reperfusion. Indeed, the hepatectomy having already begun before the implantation of the donor heart. Its final steps were performed very quickly and the liver team was able to go ahead with the liver implantation expeditiously.

It seems that the main attraction of this technique is that it uses the reperfusion time on CPB to implant the liver. The reperfusion stage is clearly longer, but the heart weans from bypass easily. Second, the metabolic derangements resulting from hepatic reperfusion, such as hyperkalemia, have a lesser effect on the patient’s hemodynamics because CPB support is still provided. This can potentially prevent an already weak heart from being affected by serious insults in the initial hours after implantation. Finally, this technique reduces the ischemia time of the liver.

This technique of CPB support for combined heart and liver transplantation seems to have been abandoned since Starzl and colleagues’ early accounts mostly because of the fear of coagulopathy and inflammatory response associated with the extended use of the CPB circuit. In the age of antifibrinolytic agents, this may be worth reconsidering. Second, the reperfusion time provides a period of hemodynamic stability helpful for the expeditious implantation of the liver in cases where the hepatectomy has been started before the heart explantation or the cannulation of the patient. This technique obviously requires great cooperation and communication between the various surgical teams involved. Although only a single case, it is interesting to note that our patient did not experience any renal dysfunction postoperatively, contrary to many of the recently reported cases of CHLT done without full CPB support.

In summary, CHLT should be considered a therapeutic option for FHRC patients with secondary end-stage liver failure. Furthermore, the technique of CPB-supported simultaneous combined heart and liver transplantation appears to be a valuable option to bring to the surgical armamentarium because it has the potential to facilitate the procedure and decrease the occurrence of complications associated with other techniques of CHLT.

	References

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1. Shaw Jr BW, Bahnson HT, Hardesty RL, Griffith BP, Starzl TE. Combined transplantation of the heart and liver Ann Surg 1985;202:667-672.[Medline]
2. Wallwork J, Williams R, Calne RY. Transplantation of liver, heart, and lungs for primary biliary cirrhosis and primary pulmonary hypertension Lancet 1987;2:182-185.[Medline]
3. Olivieri NF, Liu PP, Sher GD, et al. Brief report: combined liver and heart transplantation for end-stage iron-induced organ failure in an adult with homozygous beta-thalassemia N Engl J Med 1994;330:1125-1127.[Free Full Text]
4. Nardo B, Beltempo P, Bertelli R, et al. Combined heart and liver transplantation in four adults with familial amyloidosis: experience of a single center Transplant Proc 2004;36:645-647.[Medline]
5. Barbir M, Khaghani A, Kehely A, et al. Normal levels of lipoproteins including lipoprotein(a) after liver-heart transplantation in a patient with homozygous familial hypercholesterolaemia Q J Med 1992;85:807-812.[Medline]
6. Bahnson HT, Gordon RD. Transplantation of other organs with the heart Cardiovasc Clin 1990;20:237-248.[Medline]
7. Detry O, Honore P, Meurisse M, et al. Advantages of inferior vena caval flow preservation in combined transplantation of the liver and heart Transpl Int 1997;10:150-151.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Patrick Ergina Kevin Lachapelle Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bernier, P.-L. Articles by Lachapelle, K. Search for Related Content PubMed PubMed Citation Articles by Bernier, P.-L. Articles by Lachapelle, K. Related Collections Transplantation - heart