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Heart-Liver Surgery May Help Patients Excluded from Transplant List


Ernest House needed a liver transplant. But a heart condition was keeping him off the transplant list. 

“I would have died,” he says. “There’s no doubt about that. My body was failing.”

A former college football quarterback, House had always strived to stay active. That didn’t change when he reached his golden years.

In 2018, at age 65, he was at the gym by 6 every morning, worked full-time, and traveled regularly with his wife to cheer on his grandchildren at their many sporting events.

But that year, a searing pain in his back drove him to seek medical advice. 

“I was in terrible pain,” says House, a business owner from London, KY. 

After 2 years of searching for answers, tests finally revealed the source of his suffering: His liver was irreversibly diseased. (House had been diagnosed with nonalcoholic fatty liver disease in his late 20s.) 

At the Cleveland Clinic, specialists discovered damage in another organ: his heart. There was a major blockage in House’s right coronary artery. 

There was a clear treatment path for each condition: Transplant surgery for the liver and heart surgery for the blockage. But having both conditions together presented a life-threatening problem: House’s heart was too weak for him to have a liver transplant. And his liver was too damaged for him to have heart surgery. 

Could a rare and innovative dual organ procedure offer a way out? 

Patients with heart and liver problems are extremely challenging to treat, says Michael Zhen-Yu Tong, MD, a cardiac surgeon at Cleveland Clinic and director of cardiac transplantation and mechanical circulatory support. 

For someone with a coronary blockage, the stress of a liver transplant can cause a heart attack on the operating table, he says. For someone with a diseased liver, cardiac surgery can cause blood clotting problems or critically low blood pressure that could kill them. 

“These patients are in a therapeutic blind spot,” Tong says. “We just don’t have any treatments for them that would be effective when we only operate in our own silos. This is where we essentially came together and said, ‘Hey, there’s clearly an unmet need here. How can we work together to help these patients?’” 

House was lucky enough to land at one of the few institutions (Cleveland Clinic) in the country that perform combined cardiac surgery and liver transplant (CS + LT), a complex procedure where patients have both operations just hours apart. 

House made a good candidate for the procedure because he was under 70, his other organs were healthy, and he was healthy and active, says Tong. 

When a liver became available in 2020, House had the nearly 12-hour dual procedure. 

First, the cardio-thoracic surgery team did heart surgery, leaving House’s chest open. Then, the liver transplant team removed his liver and replaced it with a healthy transplant. Surgeons then closed his belly, checked his chest for bleeding, and closed his chest. 

It’s “very common” for patients to be deemed ineligible for a liver transplant due to heart disease, says Ali Zarrinpar, MD, PhD, a liver transplant surgeon and a professor in the University of Florida Division of Transplantation and Hepatobiliary Surgery in Gainesville, FL. 

About 2% of U.S. adults have been diagnosed with liver disease. Coronary artery disease or heart valve problems are estimated to happen in up to 30% of patients with end-stage liver disease. 

That’s not surprising when you consider that close to 6% of adults have been diagnosed with heart disease. (That goes up to around 18% after age 65.) It’s the leading cause of death for men, women, and most racial and ethnic groups. Heart disease can even lead to liver disease, particularly in patients with longstanding heart failure from congenital heart disease, says Zarrinpar.

Surgeons at Cleveland Clinic have been refining the combined cardiac surgery and liver transplant procedure since 2018. Researchers recently published a study highlighting the unique surgical approach and describing the method used to select patients for the combined treatment. 

“Not every patient – even though they may have both heart and liver disease – are good candidates,” Tong says. “We have to make sure that the patient can tolerate such a major operation. Sometimes patients can be very frail and debilitated, or they may have other organs that may not be functioning as well, such as [diseased] kidneys or lungs.”

At Cleveland Clinic, all prospective candidates for the unique surgery must have end-stage liver disease and cardiac dysfunction. Each is first evaluated independently by the cardiac surgery, cardiology, hepatology, and liver transplant teams. After that, a liver transplant subcommittee with all four teams present continues to review each case on a biweekly basis. The committee generally excludes patients who are either too healthy or too sick to qualify for the procedure. 

Thirty-one patients had the combined surgery at Cleveland Clinic between 2005 and 2021. Patient survival rates were 74% a year later, and 55% five years after the procedure, the analysis found. Patient outcomes varied depending on their age and medical conditions. 

For example, patients who were older than 60, had kidney dysfunction, or who were on dialysis before the transplant had lower 5-year survival, the study found. Where heart blockages were the main problem, outcomes were worse, in comparison to cases where valve repairs or replacements were the main problem. 

Koji Hashimoto, MD, PhD, director of liver transplantation at the Cleveland Clinic Main Campus, says some patients who underwent the combined surgery had comparable 1- and 5-year survival rates to patients in the general population having liver transplants. 

In general, survival rates for patients having a liver transplant alone are 86% a year later and 72% at 5 years, according to the National Institute of Diabetes and Digestive and Kidney Diseases. 

Success rates for the combined procedure are encouraging, say Cleveland Clinic surgeons, and they plan to continue performing the dual surgeries. 

“Now we’ve not only shown proof of concept, but we’ve shown this is a procedure that’s repeatable, and that we can get good outcomes in a wide range of patients,” Tong says. 

“As we collect more data [and] as we’re able to offer this to more patients, we may be able to refine what type of patients will have the greatest benefit, and what type of patients may struggle from this operation.”

While the combined surgery may give more patients the chance for a new liver, it also raises questions about the best use of scarce organs. 

In 2021, nearly 12,000 adult candidates were on the liver waiting list, and another 13,000 were added before the end of the year, according to the Health Resources and Services Administration. About 1,100 people died waiting.   

Given the scarcity of donor livers, it’s a difficult decision to give these organs to patients who need more complex operations because they have higher medical and surgical risks, says Zarrinpar. 

“This issue is challenging because it raises important questions about how to share limited resources fairly while also trying to save as many lives as possible,” he says. 

After a successful surgery, House spent the next 6 months recovering. He describes the road back to health as “long and lonely.” The pandemic had just started, and his large family couldn’t visit. The months were filled with tests to ensure his new liver was working properly and waiting for his heart to heal from surgery. Eventually, House was moved to a rehabilitation center where he received occupational therapy and worked on strengthening his muscles, he says.

His wife, Kim, finally saw her husband again at the rehabilitation center after 4 months apart. 

“I was shocked by his appearance,” she says. “He had lost over 100 pounds, had a beard, his hair was shaggy, and he was very weak and frail. He was a shell of the man I had last seen.” 

Today, House, 69, is back to his healthy, active self. He continues to work full-time at his business, a company that provides support and services to adults with developmental disabilities. The grandfather of nine still exercises five times a week, and his heart and new liver are going strong, he says. 

“I don’t expect to slow down,” House says. “I have projects at various stages that will keep me busy for years to come. My goal is to keep moving forward. I feel lucky and blessed to be alive.”



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