Invited Lecture(JSGS)
Sat. November 4th   11:30 - 12:00   Room 9: Portopia Hotel Main Building Kairaku 3
Invited Lecture17
 Outcomes of en bloc heart-liver transplantation in children with end stage cardiac failure and cirrhosis
Carlos O. Esquivel
Department of Surgery - Multi-Organ Transplantation, Stanford University School of Medicine
Introduction: Combined heart-liver transplantation (CHLT) is an established therapy for patients with heart failure requiring transplantation and concomitant end-stage liver disease. An increasing indication for CHLT is heart failure in the presence of cirrhosis, as seen in aging congenital heart disease patients with single ventricle physiology. Commonly, CHLT has been done sequentially; however, the extraction of the heart may be technically difficult, particularly, in children who had multiple previous thoracic operations to create a Fontan circulation. The prolonged cold storage -until the heart transplant operation is finished-may result in preservation injury of the liver leading to increased morbidity and mortality. To minimize the risk of liver injury, we developed an en bloc technique (ebCHLT) to implant both organs simultaneously. (Fig 1.) Herein, I will report the outcomes of ebCHLT in children with heart failure and cardiac cirrhosis.
Patients and Methods: A retrospective outcome analysis was performed in children (<21 years of age) who underwent ebCHLT at Stanford Children’s. The immunosuppression consisted of a combination of antithymocyte globulin for induction, and maintenance with tacrolimus mycophenolate (MMF). A tapering dose of steroids was giving during the first two weeks post-transplant. The technique and logistics of the operation will be described during the presentation.
Results: The 10-year actuarial survival was 85%. (Fig 2.) There were only 2 episodes of mild rejection of the heart in the first 200 consecutive biopsies. (Fig 3.) Most common complications were sepsis, sternal wound infection, respiratory failure and a single case of bile duct stricture. There were two deaths due to post-transplant lymphoproliferative disorder, and septicemia, respectively. There were no cases of primary liver graft dysfunction. The observed patient survival is better than that of reported in the Scientific Registry for Transplant Recipients (SRTR).
Conclusions: ebCHLT is associated with good outcomes. The combined approach reduced the ischemic reperfusion injury of the grafts. The liver graft seems to protect the heart from rejection. Lastly, infection is the most common cause of morbidity.
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