11. Novel combined heart-liver transplantation strategy in Fontan-associated heart and liver disease

Purpose:
Combined heart–liver transplantation (CHLT) in patients with failing Fontan physiology remains surgically challenging. We describe our protocolized surgical strategy designed to optimize outcomes in this high-risk population.

Methods:
Since 2023, we have implemented a standardized CHLT approach for patients with Fontan-associated heart and liver disease. Key elements include routine utilization of the TransMedics Organ Care System (OCS) for both cardiac and hepatic allograft preservation; dual attending coverage by adult and pediatric heart surgeons; staged implantation with routine pre-emptive veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support with portal vein drainage following heart implantation and continued hemodynamic optimization during hepatic implantation. We reviewed outcomes for 10 consecutive CHLT procedures performed using this strategy.

Results:
The median patient age was 26 years (14–46), and 3 (30%) were female. All had single-ventricle physiology following Fontan palliation, with a median of 3 prior sternotomies; 3 patients had heterotaxy syndrome. All demonstrated biopsy-confirmed cirrhosis. Concomitant cardiac procedures included pulmonary artery plasty (n = 10), left superior vena cava reconstruction (n = 2), ascending aortic graft replacement (n = 3), inferior vena cava conduit reconstruction (n = 1), and left ventricular assist device explantation (n = 1). All but one donor were donation-after-brain-death. Median OCS support times for the heart and liver grafts were 225 and 609 minutes, respectively. The median estimated ischemic time for the heart was 87 minutes, and the median cardiopulmonary bypass time was 236 minutes. ECMO was established via femoral vein to ascending aorta cannulation in 9 patients and via right atrium to ascending aorta cannulation in 1 patient with bilateral femoral vein occlusion. The median duration of post-transplant ECMO support was 0.5 days (IQR, 0–2); intraoperative decannulation was achieved in 5 cases (50%). There was 1 early death in a highly sensitized patient who developed severe infection and rejection. None developed stroke and renal failure. At a median follow-up of 276 days, all surviving patients remain alive and free of graft failure, an estimated 1-year survival of 90%.
Conclusions: A structured, protocolized CHLT strategy can achieve favorable early and mid-term outcomes in carefully selected patients with Fontan-associated heart and liver disease.

Koji Takeda (1), Andrew Goldstone (2), Farhana Latif (3), Matthew Lewis (4), Ersilia Defilippis (5), Gabriel Sayer (3), Nir Uriel (6), Nathaly Llore (5), Peter Liou (5), Jason Hawksworth (5), Alyson Fox (5), Tomoaki Kato (5), Emile Bacha (2), (1) Columbia University, New York, NY, (2) NewYork- Presbyterian/Columbia University Medical Center, New York, NY, (3) Columbia University Medical Center, NYC, NY, (4) NewYork-Presbyterian Hospital, New York, NY, (5) Columbia university, New York, NY, (6) Columbia University Irving Medical Center, New York, NY

Koji Takeda

Abstract Presenter

oji Takeda, MD, PhD

Assistant Professor of Surgery

Surgical Director of Heart Transplant and Mechanical Circulatory Support

Director of Pulmonary Endarterectomy

Department of Surgery, Division of Cardiac, Thoracic & Vascular Surgery, Columbia University

 

Pedro Catarino

Commentator

Pedro Catarino is a Professor of Cardiac Surgery and Director of Aortic Surgery at Cedars-Sinai Medical Center, Los Angeles. He graduated from Oxford University Medical School; then trained in cardiothoracic surgery at the Royal Brompton Hospital in London, and was a transplant fellow at Duke. He was a consultant surgeon at the Royal Papworth Hospital in Cambridge, England where he was Director of Heart and Lung Transplant and MCS, until moving to his current position in the USA in 2020. At Papworth he was responsible for what was the largest volume DCD heart transplant program in the world, and he oversaw the establishment of a national procurement service for DCD hearts for the UK, incluing for pediatric use. Currently, he is particularly involved in minimally invasive lung transplantation and lung transplant post-COVID.