Cite this article as: Barac YD, McCartney SL, Sudan D, Schroder JN. Planned right ventricular support for combined heart–liver transplantation. Interact CardioVasc Thorac Surg 2019;29:969–70. Planned right ventricular support for combined heart–liver transplantation Yaron D. Barac a, *, Sharon L. McCartney b , Debra Sudan c and Jacob N. Schroder a a The Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA b Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA c Department of Surgery, Duke University Medical Center, Durham, NC, USA * Corresponding author. The Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, 10 Duke Medicine Cir, Durham, NC 27710, USA. Tel: +1-919-6843243; fax: +1-919-6848563; e-mail: yaronbar@icloud.com (Y.D. Barac). Received 6 May 2019; received in revised form 3 July 2019; accepted 4 July 2019 Abstract Right ventricular dysfunction post heart transplantation (HTx) is a common problem and its likelihood to occur after combined heart–liver transplantation is even higher. The placement of an extracorporeal planned right ventricular assist device following the HTx during liver transplantation may assist in preventing this complication. Keywords: Right ventricular assist device • Heart–liver combined transplantation INTRODUCTION The first combined heart–liver transplantation was performed in 1984, an additional 192 combined heart–liver transplantations were performed ever since in the USA [1]. Although it is a more complex operation, patient survival is similar to that of an iso- lated heart/liver transplantation [2]. Indications for a combined heart–liver transplantation include familial amyloidosis, familial hypercholesterolaemia, haemochromatosis, alcoholic cardiomy- opathy and cryptogenic cirrhosis with underlying cardiomyopa- thy [2]. The course of this operation has evolved from performing both transplantations on cardiopulmonary bypass (CPB) to per- forming the HTx first on CPB followed by the liver transplanta- tion after separation from CPB and heparin reversal. A veno- venous bypass was also used to enable a bloodless field for the liver transplantation surgeons; however, this method does not confer any haemodynamic protection to the newly transplanted heart [3]. Other studies have also used right ventricular assist device (RVAD), if needed, post-transplantation [4]. Technique Recently, we performed 3 combined transplantations using planned rather than ‘crash’ RVAD in order to protect the newly transplanted heart from high-dose inotropic support and facilitate a haemodynamically stable and bloodless liver implantation during inferior vena cava clamping and liver reperfusion. We have trans- planted 3 patients [with no predispositions to right ventricle (RV) dysfunction] in this manner: (1) a 60-year-old female with a history of familial amyloidosis who suffered from extensive liver disease and restrictive cardiomyopathy, (2) a 57-year-old male with a past medical history of alcohol-related cirrhosis and non-ischaemic (re- lated to alcohol) cardiomyopathy (patient abstained from alcohol 2 years prior to transplantation) and (3) a 58-year-old male with fa- milial transthyretin amyloidosis presenting with end stage heart failure due to extensive amyloid infiltration of the heart; patients preoperative characteristics are described in Table 1. The proce- dure starts with a standard bicaval HTx. Once completed, the pa- tient is separated from CPB, decannulated and protamine is administrated. Once the patient is deemed to be stable and hae- mostasis is achieved, 5000 units of heparin are given intravenously and an extracorporeal RVAD is placed. RVAD configuration is de- scribed in Fig. 1. Attention must be paid to not volume overload the left ventricle (LV). The mid-line position of the interventricular septum and the interatrial septum on TEE is reassuring for ade- quate filling of the LV. Inotropic support may still be required for adequate functioning of the LV. Once the liver transplantation is completed, the RVAD is weaned with attention to the central Table 1: Preoperative patient characteristics Preoperative variables Patient 1 Patient 2 Patient 3 Cardiac index 1.76 1.7 1.7 MELD score 15 23 25 PVR Data not available 4.9 1.8 INR 1.4 1.3 1.4 Cardiac ischaemic time (min) 135 175 160 Liver ischaemic time (min) 494 488 433 INR: international normalized ratio; MELD: model for end-stage liver dis- ease; PVR: pulmonary vascular resistance. CASE REPORT VC The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Interactive CardioVascular and Thoracic Surgery 29 (2019) 969–970 CASE REPORT – ADULT CARDIAC doi:10.1093/icvts/ivz183 Advance Access publication 30 July 2019 Downloaded from https://academic.oup.com/icvts/article/29/6/969/5540948 by guest on 16 September 2023