The Use of Normothermic Machine Perfusion for Staged Combined Heart-Liver Transplant.

For patients with cardiac cirrhosis, combined heart-liver transplant (CHLT) has been increasingly performed with improving outcomes. The standard heart-then-liver approach may increase ischemic times and postreperfusion syndrome (PRS) risk. Achieving adequate hemodynamic stability may also pose a challenge. To mitigate these risks, we assessed the use of liver normothermic machine perfusion (NMP) in a staged CHLT. A 63-year-old male patient with diabetes, coronary artery disease, and NYHA Class III systolic heart failure presented to our center in cardiogenic shock. Subsequent liver biopsy found end-stage cirrhosis. He was bridged with an Impella 5.5 until a dual heart-liver donor became available. A standard heart transplant via redo sternotomy was performed on cardiopulmonary bypass (CPB). The chest was packed but left open in anticipation of the liver transplant. The liver was placed on NMP using the Organ Care System (TransMedics) with hepatic arterial and portal venous flows set at 350 and 0.8 mL/min, respectively. He received a staged liver transplant using the standard 'piggyback' technique, 8 h after the heart transplant. There was minimal PRS and bleeding. Total time on NMP was 16.4 h. The chest and abdomen were closed at the end of the liver transplant. The postoperative course was complicated by acute renal failure requiring temporary hemodialysis. He was eventually discharged home, is now off dialysis, and continues to do well. The NMP keeps the liver in an active metabolic state, allowing us to transplant the heart and establish optimal hemostasis to decrease blood product transfusion. This also allows time for proper postoperative fluid resuscitation and lactic acidosis clearance and helps achieve better hemodynamic stability with decreased inotrope/vasopressor doses. Additionally, the liver NMP is effective in minimizing complications related to PRS. A staged approach to CHLT using the NMP should be considered in such high-risk patients.