2016 - IPTA Fellows Meeting


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Mini Oral Abstract Presentations

18.56 - Outcomes after combined heart and liver transplant in children

Presenter: Thomas, Pham, , United States
Authors: Thomas Pham , Waldo Concepcion , C. Andrew Bonham , Carlos Esquivel

Outcome after combined heart and liver transplant in children

Thomas Pham1, Waldo Concepcion1, C. Andrew Bonham1, Carlos Esquivel1.

1Surgery, Stanford University School of Medicine, Palo Alto, CA, United States

Introduction

Those born with congenital heart disease are now living well into adolescence and adulthood. As a result, chronic conditions related to heart failure such as end stage liver disease secondary to hepatic congestion are becoming more prevalent. This is especially true in patients with single ventricle physiology who undergo successful fontan palliation. Combined heart liver transplantation is an uncommon procedure offered to patients with heart and liver failure. Given the rarity of the condition and procedure, guidelines directing when combined transplant should or should not be performed remain elusive.

Materials and Methods

Five patients underwent combined heart and liver transplant between the years 2006 and 2014 at a single institution. Retrospective chart review was performed analyzing survival, graft function, liver imaging and liver pathology. Donor organs were procured en bloc and placed into the recipient in similar fashion. Significance was measured using students t-test.

Results and Discussion

Age at the time of transplant ranged from 8 to 23 years with mean age of 17 years. Three patients had single ventricle physiology requiring fontan procedure prior to transplant. Of the two remaining patients, one patient was diagnosed with teratology of fallot and the other had double outlet right ventricle without a fontan. Those that underwent a fontan tended to be older with a mean age of 17.6 as compared to those who did not undergo fontan (15.5 years) although this did not reach significance. All patients had findings of cirrhosis and abdominal varices on pre-operative imaging. All patients except for one had cirrhosis on their explant pathology. Graft and patient survival remains 100% at 9 years. This is significantly better than previously published results where patient survival is 72.2% at 10 years (p<0.05). There have been no documented episodes of cellular rejection in either the cardiac or liver graft. One episode of suspected antibody mediated rejection of the heart was documented less than 10 days after transplant. This was treated with IVIG but the patient never had any graft dysfunction and never experienced another episode of rejection.

Conclusion

Combined heart and liver transplant is a safe and effective procedure for those with end stage heart and liver disease. The indication for performing a combined heart liver versus and heart alone remain unclear. Our criteria included cirrhosis on pre transplant biopsy as well as on imaging, abdominal varices on imaging and a biopsy which shows cirrhosis. No long term or chronic rejection has been found in these patients as far as 10 years out from surgery suggesting an immune protective role of the liver.

References:

[1] Gambino A. Outcome after pediatric heart transplantation: two decades of a single center experience. European Journal of Cardio-thoracic Surgery. 2007; 32: 220-224
[2] Hollander SA. Intermediate term outcomes after combined heart-liver transplantation in children with a univentricular heart. Journal of Heart and Lung Transplantation. 2013; 32: 369-370
[3] bradley E. Fontan liver disease: review of an emergin epidemic and mangement options. Curr Treat Options Cardio Med. 2015.; 17:51


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