March 26, 2024
Treating multiorgan disease and organ failure with combined heart and liver transplantation procedures (CHLT) is increasingly more common today. That's because advancements in surgical techniques and immunosuppression are expanding successful outcomes for this complex procedure. And with the aging population, more cardiac interventions such as coronary artery bypass surgery combined with liver transplantation are needed.
Common indications for CHLT include:
- Familial amyloidosis.
- Cardiac cirrhosis caused by congenital heart disease and dilated cardiomyopathy.
- Homozygous familial hypercholesterolemia.
CHLT procedure challenges are due to:
- Hemodynamic instability following implantation.
- Prolonged organ ischemia during organ preservation.
"We felt that these challenging CHLT cases would be a perfect situation that could benefit from machine perfusion technology," says Kristopher P. Croome, M.D., a transplant surgeon at Mayo Clinic in Jacksonville, Florida. Dr. Croome and his colleagues describe using normothermic machine perfusion (NMP) in a case series published in Transplantation Direct.
What's new?
"The ability to pump organs outside of the body with oxygenated blood is a relatively new technology in the U.S. These devices were only FDA-approved in the fourth quarter of 2021," says Dr. Croome, lead author of the paper. "We've embraced machine perfusion technology at Mayo Clinic. This approach allows us to do CHLT cases that historically many centers were hesitant to do. Multiorgan transplants are a technically complex surgery and Mayo Clinic excels at this due to our strong multidisciplinary team."
In CHLT procedures NMP offers:
- More preservation time — allowing for hemodynamic stabilization and weaning of cardiopulmonary bypass after the cardiac part of the procedure.
- Fewer metabolic disturbances with hepatic reperfusion including hyperkalemia, fluid overload and acidosis, taking the stress off the newly implanted cardiac graft or revascularized heart.
Fewer concerns for cold ischemia time allows for an expansion of donor pools. "We can take organs from further distances and this is a huge advantage," says Dr. Croome.
Case series review
In all three cases, surgeries were performed safely utilizing liver NMP. The patients had heart failure or coronary artery disease in addition to liver failure. The three procedures were performed between 2022 and 2023. The patients were male and ages 54, 58 and 63 at the time of transplant.
Two patients had CHLT procedures and one had a coronary artery bypass graft (CABG) and liver transplant. The cases with more challenging hepatectomies didn't need to be rushed using NMP. The patients in all three cases did not experience post reperfusion syndrome (PRS) or early allograft dysfunction (ESD).
The successful use of NMP in the three cases led to a change in CHLT protocol at Mayo Clinic. Now, NMP is routinely used for cases with cardiac transplant or CABG combined with liver transplant. By utilizing new technology early and accepting donor organs from a wider distance, Mayo Clinic is saving more lives.
For more information
Das I, et al. The use of ex situ normothermic machine perfusion in combined cardiac and liver transplantation procedures. Transplant Direct. 2024;10(2):e1574.
Refer a patient to Mayo Clinic.