Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Department of Anesthesiology, Mayo Clinic Florida, Jacksonville, Florida, USA.
Liver Transpl. 2023 Jun 1;29(6):591-597. doi: 10.1097/LVT.0000000000000079. Epub 2023 Feb 7.
We conducted a web-based survey to characterize liver transplant (LT) evaluation and listing practices for patients being evaluated for combined heart-liver transplantation (CHLT), with a specific emphasis on patients with congenital heart disease (CHD), around transplant centers in North America. Very few protocols for liver evaluation and listing in patients undergoing combined heart-liver transplantation are published, and no guidelines currently exist on this topic. A subject of intense debate in the transplant community is the decision of which patients with CHD and liver disease benefit from CHLT compared with heart transplantation. A focus group from the American Society of Transplantation Liver-Intestine Community of Practice Education Subcommittee developed a web-based survey that included questions (1) respondee demographic information; (2) LT evaluation practices in CHLT; (3) liver organ listing practices in CHLT, and (4) 4 clinical vignettes with case-based scenarios in CHLT liver listings among CHD patients who underwent Fontan palliation. The survey was distributed to medical and surgical LT program directors of 47 centers that had completed at least 1 CHLT up to July 2021 in the US and the University of Toronto, Canada. The survey had an excellent 83% response rate (87% for centers that completed at least 1 CHLT in the past 5 y). Total 66.7% used transjugular liver biopsy with HVPG measurements, 30% used percutaneous liver biopsy with no consensus on the use of a fibrosis staging system, 95% mandated contrasted cross-sectional imaging, and 65% upper endoscopy. The following isolated findings evaluation mandated CHLT listing: isolated elevated HVPG (61.5%); the presence of portosystemic collaterals on imaging (67.5%); the endoscopic presence of esophageal or gastric varices (75%), and the presence of HCC (80%), whereas the majority of centers did not feel that the presence of isolated splenomegaly (100%), thrombocytopenia (81.6%), endoscopic findings of portal hypertensive gastropathy (66.7%), or highly sensitized patients (84.6%) justified CHLT. In our survey of North American centers that had performed at least 1 CHLT in the past 5 years, we observed heterogeneity in practices for both evaluation and listing protocols in these patients.
我们进行了一项基于网络的调查，以描述北美的肝移植（LT）评估和列单实践，重点关注接受心脏-肝脏联合移植（CHLT）评估的患者，尤其是患有先天性心脏病（CHD）的患者。在接受联合心脏-肝脏移植的患者中，很少有关于肝脏评估和列单的方案被发表，目前也没有关于这个主题的指南。在移植界，一个激烈争论的话题是决定哪些患有 CHD 和肝脏疾病的患者从 CHLT 中受益，而不是心脏移植。美国移植协会肝脏-肠道实践教育小组委员会的一个焦点小组开发了一个基于网络的调查，其中包括问题 (1) 应答者的人口统计学信息；(2) CHLT 中的 LT 评估实践；(3) CHLT 中的肝脏器官列单实践；(4) 在接受 Fontan 姑息治疗的 CHD 患者中，4 个基于案例的 CHLT 肝脏列单的临床案例。该调查分发给了美国和加拿大的 47 个中心的医疗和外科 LT 项目主任，这些中心在 2021 年 7 月之前至少完成了 1 例 CHLT。调查的回应率非常高，达到了 83%（在过去 5 年内至少完成了 1 例 CHLT 的中心的回应率为 87%）。66.7%的中心使用经颈静脉肝活检和 HVPG 测量，30%的中心使用经皮肝活检，但在纤维化分期系统的使用上没有共识，95%的中心要求进行对比横断面成像，65%的中心进行上消化道内镜检查。以下孤立的发现评估需要 CHLT 列单：孤立性 HVPG 升高（61.5%）；影像学上存在门体侧支循环（67.5%）；内镜下存在食管或胃静脉曲张（75%）和 HCC（80%），而大多数中心认为孤立性脾肿大（100%）、血小板减少症（81.6%）、内镜下门静脉高压性胃病（66.7%）或高度致敏患者（84.6%）不应该作为 CHLT 的理由。在我们对过去 5 年内至少完成了 1 例 CHLT 的北美的中心的调查中，我们观察到这些患者的评估和列单方案存在异质性。
