Combined Heart and Liver Transplant Attenuates Cardiac Allograft Vasculopathy Compared with Isolated Heart Transplantation

Abstract

Background We evaluated whether combined heart liver transplant can protect the heart graft from the development of Cardiac allograft vasculopathy (CAV) using coronary 3D volumetric IVUS. Methods From 2004 to 2009, we identified 24 isolated heart transplant (HTx) and 10 combined heart liver transplant (H+Liver Tx) recipients in whom two coronary 3D IVUS studies were performed one year apart. Baseline 3D IVUS was performed at 0.22 [0.17, 1.16] years after transplant with follow up 3D IVUS exams performed 0.96 [0.83, 1.08] after baseline exam. Results Rate of plaque volume and plaque index (plaque volume/vessel volume) progression was attenuated in the H+Liver Tx group (0.3±1.1 mm3/mm vs. 1.5±2.9 mm3/mm; P=0.08, and 0.01±0.03 vs. 0.1±0.1; P=0.004 respectively). Rejection burden was much lower in the H+Liver Tx patients. Outcome analysis in 66 consecutive patients (56 HTx and 10 H+Liver Tx) was performed irrespective of performance of second coronary IVUS. Combined heart and liver transplant was associated with reduced rate of cardiac events (p=0.04), which remained significant when adjusted for the difference in the primary etiology for heart disease (p=0.05). Conclusions Our preliminary serial 3D coronary IVUS data show that combined heart and liver transplant attenuates CAV by decreasing the rate of plaque volume and plaque index progression and improves coronary related outcomes. Because of the small numbers and the differences in etiology of heart disease our data should be interpreted cautiously, and larger clinical trials would be required to recommend combined heart liver transplant for improved coronary remodeling.

Assessing the liver to predict outcomes in heart transplantation

“…Alternative options are available for those found to have advanced liver disease, as defined by Farr et al 13 Recent single-center 23 and registry 24 data suggest that combined heart and liver transplantation is highly feasible and associated with excellent short-term and long-term survival (up to 87% at 1 year and 83% at 5 years). In addition, similar to findings in combined heart-kidney transplant, less rejection 23 and early attenuation of cardiac allograft vasculopathy 25 have been observed. Whether this is due to enhanced immunologic protection or differences in immunosuppressive therapy requires further study.…”

Combined Heart and Liver Transplantation Can Be Safely Performed With Excellent Short- and Long-Term Results

“…Similarly, the teams at the Tel Aviv Medical Center and the Mayo Clinic noted very low rates of cardiac allograft vasculopathy, adverse cardiac events, and rejection burden in their dual organ heart-liver population [18]. The liver is a highly immunotolerant organ.…”

Organ-specific differences in achieving tolerance

“…Recipients of combined heart-liver transplants require less immunosuppression than recipients of isolated hearts or kidneys (55) and despite the lower immunosuppression, rejection rates for heart and liver are low (13% and 10%, respectively) (56,57). In combined liver/lung transplantation, acute rejection of the lung graft was observed at comparatively low rates (58,59) although definitive conclusions about a potential liver-protective effect cannot be drawn from these small series.…”