title: The perioperative management of patients undergoing combined heart-liver transplantation.
abstract: BACKGROUND
  Combined heart-liver transplantation (CHLT) is an uncommonly performed procedure for patients with coexisting cardiac and liver disease.
  
  
  METHODS
  A retrospective review was performed of patients undergoing CHLT at our institution from 1999 to 2013. Information related to preoperative organ function, intraoperative management, surgical approach, transfusions, postoperative findings, and 30-day mortality was reviewed.
  
  
  RESULTS
  Twenty-seven CHLT were performed, with 4 of the 27 including simultaneous kidney transplantation. Familial amyloidosis was the indication for 21 CHLTs (78%), and 12 of these explanted livers were used for domino transplantations. Nineteen patients (70%) were receiving inotropic infusions at the time of organ availability. Median preoperative model for end-stage liver disease score was 12. Liver transplantation immediately preceded cardiac transplantation in 2 of the 27 cases because of the presence of high titer donor-specific antibodies and the potential of the liver to lead to a reduction in the antibody titer. Venovenous bypass was used in 14 operations (52%) which were performed with the caval interposition approach to liver transplantation, cardiopulmonary bypass during liver transplantation in two cases (7%), and no bypass in 11 operations (41%) performed with caval sparing (piggyback) surgical technique. Postoperatively, median duration of mechanical ventilation, intensive care unit stay, and hospital stay until discharge were 1 day, 5.5 days, and 15 days, respectively. Transfusions in the first 48 hr after CHLT were not substantial in most patients. One patient died within 30 days of CHLT.
  
  
  CONCLUSIONS
  Combined heart-liver transplantation is a life-saving operation that is performed with relatively low mortality and can be successfully performed in select patients with congenital or acquired cardiac disease.
authors.affiliation: 1 Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN. 2 Department of Surgery and William J. von Liebig Transplant Center, Mayo Clinic College of Medicine, Rochester, MN.
authors.forename: David W
authors.initials: DW
authors.lastname: Barbara
authors.forename: Kent H
authors.initials: KH
authors.lastname: Rehfeldt
authors.forename: Julie K
authors.initials: JK
authors.lastname: Heimbach
authors.forename: Charles B
authors.initials: CB
authors.lastname: Rosen
authors.forename: Richard C
authors.initials: RC
authors.lastname: Daly
authors.forename: James Y
authors.initials: JY
authors.lastname: Findlay
mesh_terms: D000328:Adult; D000368:Aged; D001803:Blood Transfusion; D005260:Female; D006331:Heart Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D007362:Intensive Care Units; D016030:Kidney Transplantation; D007902:Length of Stay; D008107:Liver Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D019990:Perioperative Care; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D012121:Respiration, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome