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26 Combined Heart and Other Organ Transplants
329
Fig. 26.1 Adult heart transplant by multiorgan transplant type (2011–2022). Source OPTN/SRTR 2022
Annual Data Report. HHS/HRSA; 2024. Accessed
The Ethics of Dual Organ Transplantation: Evaluating Fairness in Organ Allocation
Organ Procurement and Transplantation
Network’s (OPTN) policies for organ allocation
make an implicit distinction between life-saving
organs (heart, lung and liver) and those that are
life-prolonging, or that improve the quality of
life for recipients (kidney and pancreas). The
most recent UNOS policy states: “When multiorgan candidates are registered on the heart,
lung, or liver waiting list, the second required
organ will be allocated to the multi-organ candidate from the same donor if the candidate is
qualified for dual organ transplant. In practice,
this means that a recipient listed for sHKT or
simultaneous liver/kidney (a) will have the primary life-saving organ allocated on the basis of
the acuity of need and (b) will then receive the
second, life-prolonging organ based on qualification of need for that organ. Another ethically
distinctive feature of simultaneous multi-organ
transplantation (sMOT) is that this ethical reasoning based on life-saving and life-prolonging views support bypassing other potential
[October 1st 2024]., not copyrighted. https://srtr.trans-
plant.hrsa.gov/ADR/Chapter?name=Heart&year=2022
recipients who may be on the waiting list for a
life-prolonging organ, whereas the sMOT recipient may have a more immediate need for that
organ. Preemptive KT for patients requiring
another life-saving solid organ is a rare instance
when a future event is considered in the evaluation and allocation of an organ.
Is an immediate or proven need more ethi-
cally justified than an anticipated or potential need? In this sense, eligible patients are
not unfairly disadvantaged because they have
a life-sustaining alternative (dialysis) until an
organ becomes available and because the allocation of both a life-saving organ and a lifeprolonging organ is well-supported by both
beneficence and utility. The most obvious issue
with utility in a sMOT is the single recipient.
Rather than helping two or three people, only
one person benefits. Typically, utility beyond
the individual has not been considered in either
candidate consideration or allocation policies.
The methods for determining social utility are
imperfect, and they are not generally considered
in transplantation decisions. In the setting of
sMOT, however, when there are multiple waiting
lists of competing recipients for several organs,
330 J. Kobashigawa and Y. Manla
some consideration of utility might help determine which patient would be the most appropriate candidate for sMOT. The usual criteria for
determining transplant outcomes are affected by
other considerations such as quality of life and
potential alternative treatments, namely dialysis.
These and other issues around fairness and distribution of organs across waitlists and different
types of candidates warrant ongoing discussion
and consensus in order to move toward sensible
policy.
Heart-Kidney Transplantation
These patients with kidney disease who undergo
alone have reduced survival. Kidney failure is
a predictor of morbidity and mortality in postpatients [5, 6]. sHKT has enabled the successful transplantation of patients with end-stage
heart disease and concomitant kidney disease,
with increasing numbers since 2010. The rise
of sHKs has raised concerns due to the incremental benefit attributable to the kidney in the
sHKT recipient is difficult to assess, proper
candidate selection remains debated, and sHKT
diverts deceased donor kidneys away from candidates for kidney transplant alone. The decision
for sHKT transplantation is further challenged
by difficulties in differentiating those patients
with a reversible kidney injury due to cardiorenal syndrome who may recover kidney function
after HTx, from those with intrinsic advanced
kidney disease who would benefit most from
sHKT.
The Pathophysiology of Cardiorenal Disease Leading to End Organ Failure
Heart failure and kidney failure share complex
pathophysiological pathways that affect myocardial and vascular remodeling, endothelial
dysfunction, as well as systemic neurohormonal
activation, inflammation and oxidative stress [7,
8]. Hemodynamic factors in myocardial dys-
function leading to kidney failure include not
only impaired cardiac output and arterial underfilling, but also venous congestion leading to
kidney congestion. All this leads to reduced glomerular filtration and rise in serum creatinine
which we call cardiorenal syndrome [9–11]. In
the acute setting, restoration of cardiac performance often results in improvement of kidney
function.
Kidney disease can also affect the heart.
Progressive kidney failure triggers metabolic
disorders that can accelerate atherosclerosis,
as well as precipitate uremic cardiomyopathy.
Concomitant anemia from kidney failure, as
well as the presence of an arteriovenous fistula,
can create a state of “high performance” volume
overload that may be reversible after restoration of cardiac function [12, 13]. It is important
to emphasize that the ongoing findings of traditional biomarkers of kidney function such as
creatinine and proteinuria may not reflect the
spectrum of kidney dysfunction seen in heart
failure and kidney disease. Specifically, the frequent occurrence of electrolyte imbalances,
metabolic disturbances, and persistent volume
overload may further exacerbate cardiorenal
syndrome [14].
Evaluation for Combined HeartKidney Transplantation
CKD is defined as having documentation of
GFR < 60 ml/min/1.73 m2 on at least 2 occasions
90 days apart. In addition, any history of kidney disease or kidney disease risk factors, such
as diabetes or hypertension, will be helpful. In
addition, kidney ultrasound to assess for kidney
size asymmetry, shrinkage or cortical thinning
can indicate the diagnosis of CKD [15]. Native
kidney biopsies are not always feasible and
can carry significant risk but may be valuable
in select clinical circumstances. Some patients
with normal kidney function who develop sudden decompensated heart failure or cardiogenic
shock may experience an acute rise in serum
creatinine and, in some cases, temporary dialysis may even be necessary. These patients will
33126 Combined Heart and Other Organ Transplants
have predominantly cardiorenal syndrome and/
or acute tubular injury and will typically recover
kidney function with HTx alone.
There remains some uncertainty as to what
lower GFR threshold should warrant evaluation
allograft showing less rejection [18]. A recent
intravascular ultrasound (IVUS) study has demonstrated less first-year allograft vasculopathy
in sHKT recipients when compared with HTx
alone [19].
of a pre-HTx patient for sHKT. Large registry
studies on pre-HTx patients have demonstrated
post-HTx mortality and complication risks for
various baseline levels of GFR. A large review
Medical Eligibility Criteria for Heart-
Kidney Allocation
of the UNOS database assessed pre-HTx GFR
in patients aged ≥ 18 years who underwent HTx
between 1988 and 2013 [16]. In this study,
patients were stratified into 5 different GFR categories (≥ 90, 60–89, 45–59, 30–44 and < 30 ml/
As of September 2023, UNOS made formal
guidelines for the criteria for when to proceed
with sHKT. To qualify for sHKT evaluation the
following must occur.
min/1.73 m2). A total of 30,090 patients were
included in the study; of these, 46.1% and
39.9% had an GFR < 60 ml/min/1.73 m2 by
Modification of Diet in Renal Disease (MDRD)
confirms a diagnosis of: CKD with a measured
or estimated GFR less than or equal to 60 mL/
min/1.73 m2 for greater than 90 consecutive days.
and Chronic Kidney Disease Epidemiology
Collaboration (CKD-EPI), respectively.
Compared with GFR ≥ 90 ml/min/1.73 m2, the
the OPTN and document in the candidate’s med-
ical record at least one of the following:
adjusted hazard ratio of mortality was 1.09 (95%
confidence interval [CI] 1.02–1.26) for GFR
• That the candidate has begun regularly admin-
45–59 ml/min/1.73 m2, 1.22 (95% CI −1.23 to
1.31) for GFR 30–44 ml/min/1.73 m2 and 1.55
(95% CI 1.41–1.70) for GFR < 30 ml/min/1.73
m2 by MDRD. There was no advantage for
• At the time of registration on the kidney
CKD-EPI over MDRD in determining post-HTx
mortality. Pre-HTx GFR by either equation was
predictive of post-HTx end-stage kidney disease and the need for KT, with the highest risk
in those with pre-HTx GFR < 30 ml/min/1.73
• On a date after registration on the kidney
m2 by either equation.
In other studies, pre-HTx GFR < 60 mL/
min/1.73 m2 was similarly associated with
increased mortality after HTx. Thus, lower GFR
portended higher mortality after isolated HTx
but there was no indication that all patients with
GFR < 60 mL/min/1.73 m2 would require sHKT
[5, 6].
As noted, sHKT improves survival in patients
If the candidate’s transplant nephrologist confirms a diagnosis of: Sustained acute kidney
injury at least one of the following, or a combination of both of the following, for the last
6 weeks:
with a recent International Society for Heart and
Lung Transplant registry analysis, demonstrat-
• That the candidate has been on dialysis at
ing that multiorgan transplantation is associated
with a survival advantage in comparison with
• That the candidate has a measured or estiHTx alone [17]. In addition, recent data show
that heart-kidney and heart-liver transplantation provide immune-protection to the cardiac
If the candidate’s transplant nephrologist
Then the transplant program must report to
istered dialysis as an end-stage renal disease
(ESRD) patient in a hospital based, independent non-hospital based, or home setting.
waiting list, that the candidate’s most recent
measured or estimated creatinine clearance
(CrCl) or GFR is less than or equal to 30 mL/
min/1.73 m
2
waiting list, that the candidate’s measured or
estimated CrCl or GFR is less than or equal
to 30 mL/min/1.73 m2.
least once every 7 days.
mated CrCl or GFR less than or equal to
25 mL/min/1.73 m2 at least once every
7 days.
332 J. Kobashigawa and Y. Manla
If the candidate’s eligibility is not confirmed at
least once every seven days for the last 6 weeks,
the candidate is not eligible to receive a heart
and a kidney from the same donor.
Safety Net
To reduce unnecessary KTs a safety net policy
for HTx patients was initiated (September 2023)
for those patients who do not undergo sHKT,
a policy currently applied to kidney after liver
transplantation [20]. For pre-HTx patients who
do not undergo sHKT but HTx alone, a safety
net policy for after HTx (modified from liverkidney policy) is in place. This safety net policy
provides that HTx patients on chronic dialysis
or with persistent GFR ≤ 20 ml/min/1.73 m2 for
6 weeks during day 30 to day 365 post-transplant, should be given priority for kidney transplantation (donors with kidney donor profile
index, KDPI, >20%). The safety net thus alleviates the burden of “guessing incorrectly,” and
incentivizes isolated HTx when there remains
potential for kidney recovery.
Outcomes of Heart-Kidney Transplantation
Patients who undergo sHKT may have improved
survival, less rejection, and less cardiac allograft
vasculopathy than patients undergoing HTx
alone. Nonetheless, sHKT does not fully mitigate the risk of adverse renal disease after HTx.
Recipients of sHKT experience a higher rate of
severe AKI after transplantation due to adverse
effect of medications and abnormal cardiac
hemodynamics, with 26–37% of sHKT recipients needing dialysis in the early post transplantation period compared with recipients of
HTx alone (7–22%) [21]. Furthermore, similar
to patients undergoing HTx, progressive renal
dysfunction may still develop over time after
sHKT in part due to chronic immunosuppression
medications.
Management of the sHKT Patient
There is a lack of specific evidence on the benefit of induction therapy and an absence of consensus among centers performing induction
therapy for sHKT. If induction is to be used, the
choice of agent for induction therapy needs to be
personalized based on recipient’s risk factors for
infection, presence or absence of delayed graft
function and recipient’s immunologic profile
[22]. For sensitized recipients and patients with
delayed graft function, anti-thymocyte globulin (ATG) induction can be considered [23]. For
recipients with lower immunologic risk or at risk
for infection, basiliximab induction can be considered. Although it is believed that calcineurin
inhibitor (CNI) delay is not necessary for kidney
protection, if ATG is used for induction, a delay
in initiation of CNI of 1–2 days was considered safe, especially if kidney function appears
impaired post-operatively [24]. There was no
consensus on a specific goal level for CNI in the
case of delayed kidney graft function, but CNI
can be safely continued through kidney dysfunction. If basiliximab is used for induction, CNI
introduction should not be delayed and preferably given within 24 h of sHKT. Lastly, it is
believed that corticosteroids can be weaned in
select (low immunologic risk) sHKT recipients
carefully weighing the risks versus benefits.
Low risk is understood as no treated rejection
episodes, no donor-specific antibodies and normal heart/kidney function. For those sHKT
patients not weaned off steroids, they may be
maintained on 5 mg Prednisone per day which is
standard for alone patients.
Heart-Liver Transplantation
Patients with severe heart disease may have coexisting liver disease from various causes. The
incidence of combined heart-liver transplant
(CHLT) is increasing as more patients with congenital heart disease are surviving to adulthood.
However, these patients over time may develop
33326 Combined Heart and Other Organ Transplants
advanced heart failure with associated liver disease from chronic right-sided heart or Fontan
failure. Patients with advanced heart failure and
chronic liver disease who undergo alone have
reduced survival compared to those without liver
disease. In recent years, approximately 40–50
CHLT surgeries have been performed annually
in 25 centers in the United States with comparable 1-year survival outcomes to heart alone [25].
However, the decision of when liver transplantation is warranted in a patient with advanced HF
and compensated chronic liver disease is challenged by difficulties in differentiating those
patients with moderate hepatic fibrosis (which
may be reversible) from those with advanced
fibrosis and/or cirrhosis who could benefit from
this intervention. This can be particularly challenging given the overlap in clinical symptoms
in advanced cardiac and liver disease.
Indications and the Standard LiverRelated Workup of the CHLT Patient
The most common indications for liver transplant in CHLT include cardiomyopathy with
non-cardiac cirrhosis (e.g., hepatitis C virus
(HCV), alcohol-associated cirrhosis), congenital heart disease (CHD) with congestive
hepatopathy and transthyretin cardiac amyloidosis (though less common in the current era
due to the advent of effective disease-directed
therapies).
All candidates should undergo liver-related
assessment, with those patients who are found
to have abnormal findings referred to transplant hepatology for further testing (Fig. 26.2)
[26]. An example protocol has been suggested
(Fig. 26.3) [27]. Dedicated liver imaging should
be performed for candidates with presence
or prior history of liver disease or greater than
10 years of cardiac disease. If the liver has nodularity on imaging, suggestive of cirrhosis, then
liver transplant evaluation should be pursued. In
these cases, a liver biopsy should be performed
when technically feasible and safe.
A liver biopsy may not be required if there
are clinical signs of portal hypertension (e.g.,
varices, ascites) [28]. Isolated hepatic venous
pressure gradient (HVPG) should not be used to
rule in or rule out portal hypertension especially
in patients with Fontan-associated liver disease
(FALD) as it may not be reliable. If cross-sectional imaging reveals portosystemic collaterals,
upper endoscopy should be performed for variceal
screening. In lower-risk patients (those with compensated HF), a normal elastography result can be
used to exclude advanced liver disease.
Concerns for CHD Patients, Particularly the Fontan Population Who Require CHLT
Many survivors of specific CHD had undergone
the Fontan procedure, with an estimated global
population of 70,000 by the mid-2020s, which
creates the potential for chronic FALD warranting CHLT. Survival has been shown to be comparable between the CHD-Heart transplant alone
and CHD-CHLT groups [29]. Therefore, it is
important that chronic CHD patients with disease of several years undergo liver assessment to
exclude the need for CHLT [30].
There are numerous considerations for
Fontan patients undergoing including anatomical complexity and surgical reconstruction (may
result in longer bypass, ischemic time, and prolonged bleeding). Fontan patients are generally
not candidates for temporary or durable mechanical circulatory support (MCS) due to anatomical considerations. Therefore these patients may
qualify for prioritization at Status 1–3 only by
seeking exceptions. CHD specific conditions
such as hepatocellular cancer (HCC), cyanosis,
protein losing enteropathy, plastic bronchitis,
unsuitability for inotropic support or MCS may
be considered for exception status [31].
Liver cirrhosis identified by computed
tomography (CT) imaging may not be an absolute contraindication to alone in the Fontan
population [32]. In one study, 41% of Fontan
patients evaluated for had cirrhosis suggested
by imaging, however, one-year mortality and
post-transplant liver function was comparable
between alone and CHLT.
334 J. Kobashigawa and Y. Manla
Fig. 26.2 Workflow for liver-related assessment in noncongenital combined heart-liver transplant. Reused with
permission from American Journal of Transplantation,
24(3), Kobashigawa, Jon, Lisa B. VanWagner, Shelley
Criteria to Proceed with CHLT
Biopsy-proven cirrhosis, regardless of the presence of portal hypertension, is generally considered an indication for CHLT. Biopsy-proven
stage 3 fibrosis (F3) and/or clinical evidence of
portal hypertension should be a consideration
Hall, Juliet Emamaullee, John W. Entwistle, Daniel
Ganger, Howard Gebel et al., Summary of a consensus conference on heart-liver transplantation, 380–390,
Copyright Elsevier (2024)
for CHLT. In patients with F3 fibrosis, consideration for CHLT may also depend on recipient’s
age, the chronicity of right-sided heart or Fontan
failure, and presence of clinical signs of portal
hypertension. In patients with biopsy proven F3
fibrosis, F4 fibrosis (cirrhosis) is likely imminent due to the natural history of congestive
26 Combined Heart and Other Organ Transplants
335
Fig. 26.3 Proposed algorithm for evaluation of liver disease in potential heart transplant candidates. *An early
hepatology consultation may result in a clear recommendation for liver biopsy (e.g., in a patient with a history or imaging suggestive of cirrhosis, but no prior tissue diagnosis), thereby obviating the need for additional
testing. CMP, cardiomyopathy; CT, computed tomography; HCV, hepatitis C virus; LFTs, liver function tests;
hepatopathy or under-staging due to sampling
error [28]. In contrast, patients with F3 fibrosis
may also have regression of fibrosis as has been
observed in patients with nonalcoholic steatohepatitis (NASH) post bariatric surgery and in
those with HCV post curative antiviral treatment [33, 34]. In rare circumstances patients
with F3 fibrosis who are highly sensitized have
been considered for CHLT due to reported superior heart outcomes, where the donor liver is
known to absorb circulating antibodies [35].
Regarding contraindications, although some
programs reported an upper age limit for CHLT
MELD, model for end-stage liver disease; US, ultrasound. Reused with permission from American Journal
of Transplantation, 24(3), Kobashigawa, Jon, Lisa B.
VanWagner, Shelley Hall, Juliet Emamaullee, John W.
Entwistle, Daniel Ganger, Howard Gebel et al., mary of
a consensus conference on heart-liver transplantation,
380–390, Copyright Elsevier (2024)
of 60 years, one should consider a physiological age rather than chronological age for older
patients being evaluated for CHLT.
Liver biopsy may play a smaller role in the
evaluation of FALD, owing to low inter-rater
reliability among pathologists for qualitative
interpretation of degree of fibrosis in FALD.
Information from imaging and biomarkers
may be sufficient to determine need for CHLT.
However, in certain patients biopsy may be helpful where there is ambiguity about the severity of liver disease. Workup of patients with
FALD should be based on multiple assessment
336 J. Kobashigawa and Y. Manla
modalities to include staging of liver fibrosis (if
biopsy done), portal hypertension assessment
and HCC screening imaging. From previous
studies, it is expected that most Fontan patients
will have some degree of liver disease due to
chronic congestive hepatopathy [36].
Surgical Approach and CHLT for Highly Sensitized Patients
Surgical approaches of CHLT include heartfirst approach, en-bloc technique, or liver-first
approach [37]. The heart-first approach is most
used and provides maximal technical flexibility
and less procurement risk. It also allows rapid
cardiac implantation and cardiac recovery prior
to liver reperfusion. However, there are advantages to the other methods. The en-bloc CHLT
technique reduces surgery time and shortens
liver cold ischemic time but increases the risk
for phrenic nerve injury [38]. There is no clear
indication for the liver-first approach except
possibly in the highly sensitized patient. The
liver-first approach may be applicable in experienced centers for the highly sensitized patient
where it has been demonstrated to provide a protective effect on the donor heart by absorption of
circulating antibodies [39]. For all approaches, a
comprehensive team approach is critical to optimize care for patients.
Performing CHLT solely for the purpose of
sensitization (no F3/F4 on liver biopsy) may
not be appropriate because of significant surgical risk, ethical issues (i.e., the liver doesn’t
go to the patient who is highest on the list) and
the current effective strategies for managing
desensitization.
Recommendations for Post-CHLT Management
The use of induction therapy in CHLT has not
been established. It is usually administered to
patients at higher risk for rejection and to allow
delayed initiation of nephrotoxic immunosuppressive drugs in patients with compromised
renal function (i.e., anti-thymocyte globulin or
IL-2 receptor monoclonal antibody, basiliximab). According to the UNOS registry queried
January 2000 to June 2018, 135 of 260 CHLT
recipients (52%) were administered induction therapy with no difference in survival with
induction versus no induction [40].
Surveillance protocols for acute rejection in
both heart and liver transplant recipients vary
across respective programs. Because CHLT
recipients have a lower risk of acute rejection
than heart-alone recipients, less frequent rejection surveillance may be feasible [41]. The role
of noninvasive methods of rejection surveillance
such as gene expression profiling and donorderived cell-free DNA (dd-cfDNA) is uncertain
given the lack of validation in heart-liver transplant recipients.
In addition, CHLT recipients have a reported
lower risk of CAV than recipients of alone [41].
Therefore, routine surveillance with annual coronary angiography is also less frequent. Noninvasive measures of surveillance for CAV are
currently being utilized in place of these angiograms [42].
In low-risk patients, prednisone could be
weaned off in the setting of CHLT given the
immunologically privileged status of CHLT.
However, pre-transplant conditions may support
ongoing steroid maintenance, such as autoimmune hepatitis and sarcoidosis. Proliferation
signal inhibitors (PSI) should be avoided early
given the risk for early renal insufficiency
(potentiating CNI nephrotoxicity) and delayed
wound healing as well as the box warning for
increased risk of hepatic artery thrombosis in
the first 30 days post-transplant. Using PSIs
later after CHLT should be considered for renal
sparing in liver transplant and possible benefits
regarding HCC [43]. The immunosuppression
protocols in CHLT recipients should involve
multidisciplinary collaboration between and
liver transplant specialists balancing the risk of
infection and rejection.
33726 Combined Heart and Other Organ Transplants
Heart–Lung Transplantation
Combined HLT is an effective and definitive
treatment option for patients with advanced cardiopulmonary failure [44]. In a historical course
like that of HTx alone, HLT in humans was first
attempted in the late 1960s. Still, it was not a viable procedure for favorable long-term outcomes
until the early 1980s, with the first successful
HLT in 1981 by Reitz [45]. By 2018, 4,128 adult
HLT were performed worldwide [46].
Indications for Heart–Lung Transplantation
In an analysis of the 2019 International Heart
and Lung Transplantation Registry report of
more than 3000 adults undergoing HLT between
1988 and 2018, non-idiopathic pulmonary arterial hypertension (PAH) due to congenital heart
disease, cardiomyopathy, or other conditions
(37.7%), idiopathic PAH (28.4%), and cystic
fibrosis (14.9%) were the overall leading indications [46, 47]. More recent data of 216 patients
listed for HLT following an allocation system
change in 2018 revealed that World Health
Organization group 1 PAH accounted for twothirds of transplants, including IPAH, representing 64% of these cases [47, 48]. In the past, HLT
was far more common for primary lung diseases
such as emphysema, idiopathic pulmonary fibrosis, and suppurative lung diseases. However, due
to the shortage of donor hearts and increasing
evidence of the non-inferiority of the doublelung transplant, there has been a decreased rate
of HLT for these indications [49].
Recipient and Donor Considerations for Heart–Lung Transplant
Regarding formal evaluation for transplant, the
process is very similar to that of HTx alone, as
addressed in Chap. 3. Additional factors such
as the consistency of low oxygen saturation,
the frequency of exacerbations, and a forced
expiratory volume of below 30% of predicted
have been associated with poor survival [50].
A thorough pre-operative assessment can guide
listing and aid in achieving optimal management. For those with congenital heart disease
and Eisenmenger’s syndrome, clinical features
should be evaluated in conjunction with hemodynamics, each patient’s unique cardiac anatomy, and the overall health and functionality
of the patient [51]. Many congenital heart disease patients present with their unique complications and pathophysiology and do not fit
neatly into the standard model of single-organ
failure on which current recommendations are
based. Factors explaining the decreased use of
HLT in patients with congenital heart disease
may include HLA antibody development due
to blood transfusions and size shorter height in
patients with congenital heart disease. In addition to adhesions due to multiple prior surgeries, anatomical alterations, and collateral blood
vessels, thereby creating technical difficulties
[49, 52, 53]. In addition to the usual pre-operative assessments mentioned in Chap. 3. Detailed
imaging with computed tomography should be
performed in patients with primary lung disease,
as well as to assess for aortopulmonary collaterals in congenital heart disease patients [51]. As
with HTx, patients should be constantly monitored and reassessed as to whether they remain
eligible for dual HLT. A failure to delist when
patients deteriorate while on the waiting list may
result in worse outcomes [49
ied 997 patients who underwent HLT between
1987 and 2017 [44] and analyzed 25 donor and
26 recipient characteristics. Among significant
recipient characteristics significantly predicting worse outcomes, they identified advanced
donor age, recipient male sex, earlier transplant
year, recipient ECMO support, and HLT performed in low- and medium-volume centers
as independent predictors of death or retransplant. Importantly, they found donor LVEF,
donor or recipient history of cigarette usage,
recipient lung allocation score, and allograft
ischemic time, did not impact post-HLT outcomes. Additionally, Weingarten et al. recently
]. Shudo et al. stud-
338 J. Kobashigawa and Y. Manla
found in their study of HLT that those receiving
extended criteria donor (ECD) hearts and lungs
did not experience worse mortality compared to
recipients of ECD lung only, ECD heart only,
or standard donor criteria organs. However,
advanced donor age and the ratio of arterial oxygen partial pressure to the fraction of inspired
oxygen (P/F ratio) were significant predictors of
mortality overall in this study [54].
Management and Complications of Heart Lung Transplant Recipients:
Overall, the post-operative management guidelines outlined in Chap. 11 still hold true for
dual HLT, and as detailed in Chaps. 12 and 13,
the immunosuppression and infection protocols used in HTx are also applicable to patients
undergoing HLT. However, the day-to-day management of the HLT patient is primarily done by
the lung transplant team due to most complications occurring in that organ. The use of induction therapy after dual HLT is center-dependent
and usually follows the protocols used for lung
transplantation alone [46, 55, 56]. Acute cellular rejection of either the heart or lung allografts
is less common than after isolated heart or lung
transplantation, and most of the common complications are infections arising from the lung
allograft [46].
Survival After Heart–Lung Transplantation
HLT recipients continue to have lower survival
than isolated HTx or other combined HTx [3].
In a long-term analysis of 1,294 HLT recipients from the UNOS database. Kaplan–Meier
Survival Curve showed 1, 3, 5, and 10-year survival outcomes of 68.5, 53.1, 44.7, and 29.8%,
respectively [52]. During the first month after
HLT, graft failure, technical complications, and
infection remain the leading causes of death,
whereas bronchiolitis obliterans syndrome and
chronic lung allograft dysfunction cause the most
deaths beyond the first year [57]. High-volume
centers have been found to have better HLT outcomes, which could be due to an interdisciplinary
approach to HLT workup, optimal pre-transplant
assessment before transplant, well-tailored protocols for donor selection, improving procurement and preservation, and surgical techniques
[44]. Furthermore, the US 2018 allocation policy
change has been associated with improvements
in waitlist outcomes of HLT candidates, including increased likelihood of and decreased waitlist
mortality. Despite increased ischemic times and
the use of ECMO after the policy change, early
post-transplant survival was comparable to HLT
recipients in the pre-policy change [48].
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