title: Combined heart and liver transplantation on cardiopulmonary bypass: report of four cases.
abstract: OBJECTIVE
  Combined heart and liver transplant is a rare procedure to treat end-stage cardiac and liver disease. First performed during cardiopulmonary bypass and anticoagulation, subsequent concerns about increased bleeding changed the strategy to performing liver implantation following separation from cardiopulmonary bypass. Considering the overall decrease in transfusion requirements during liver transplant and the potential benefits to the transplanted heart to remain on cardiopulmonary bypass during liver implantation, we revised the strategy for combined heart and liver transplant. We report the clinical course of four consecutive patients who underwent this procedure in our institution.
  
  
  METHODS
  Patient 1 was a 53-yr-old male with familial hypertrophic cardiomyopathy and congestive cirrhosis. Patient 2 was a 57-yr-old male with hypertrophic restrictive cardiomyopathy and congestive cirrhosis. Patient 3 was a 48-yr-old male with dilated cardiomyopathy and hepatitis B cirrhosis. Patient 4 was a 57-yr-old male with ischemic cardiomyopathy and congestive cirrhosis. Each patient underwent combined heart and liver transplant, with liver implantation performed during cardiopulmonary bypass and anticoagulation. Estimated blood loss ranged from 1,000 to 3,000 mL. Intraoperative transfusion included 2-5 U of packed red blood cells, 4-12 U of fresh frozen plasma, 0-20 U of cryoprecipitate, and 5-23 U of platelets. All patients remain well 25-38 months after surgery.
  
  
  CONCLUSIONS
  Combined heart and liver transplant during cardiopulmonary bypass is a viable strategy that may confer benefit to this unique type of patient.
authors.affiliation: Department of Anaesthesia, Royal Victoria Hospital, McGill University Health Centre, 687 Pine Avenue West, Montreal, Quebec, Canada.
authors.forename: Trevor
authors.initials: T
authors.lastname: Hennessey
authors.forename: Steven B
authors.initials: SB
authors.lastname: Backman
authors.forename: Renzo
authors.initials: R
authors.lastname: Cecere
authors.forename: Kevin
authors.initials: K
authors.lastname: Lachapelle
authors.forename: Benoit
authors.initials: B
authors.lastname: de Varennes
authors.forename: Patrick
authors.initials: P
authors.lastname: Ergina
authors.forename: Peter
authors.initials: P
authors.lastname: Metrakos
authors.forename: Thomas
authors.initials: T
authors.lastname: Schricker
mesh_terms: D001784:Blood Gas Analysis; D002315:Cardiopulmonary Bypass / Q000379:methods*; D003131:Combined Modality Therapy; D006333:Heart Failure / Q000601:surgery*; D016027:Heart Transplantation / Q000379:methods*; D006801:Humans; D017093:Liver Failure / Q000601:surgery*; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome