Combining liver transplantation and coronary artery bypass grafting can be safe and effective

One-year mortality rates are comparable to those from liver transplantation alone

Improvements in surgical techniques have made orthotopic liver transplantation (OLT) a viable option for older patients who may also have cardiovascular disease, but poor cardiovascular health may keep transplant candidates from receiving a new organ.
Some such patients can safely undergo angioplasty to correct their heart conditions first, however, those requiring coronary artery bypass grafting (CABG) can experience a rapid decline in liver function during the procedure. To address this dilemma, in rare instances, doctors have performed CABG in conjunction with OLT.

Researchers led by Alan Koffron, M.D. of Northwestern University, recently studied five patients’ experiences with this combined procedure and concluded it can be both safe and effective, with one-year mortality rates similar to those reported for liver transplantation alone. The authors suggest that patients receiving CABG-OLT benefit from multidisciplinary preoperative evaluation, coordination between cardiac and transplant surgeons, careful graft selection, and use of sapheno-atrial veno-veno bypass.

Their findings are published in the November 2004 issue of Liver Transplantation, the official journal of the American Association for the Study of Liver Diseases (AASLD) and the International Liver Transplantation Society (ILTS). The journal is published on behalf of the societies by John Wiley & Sons, Inc., and is available online via Wiley InterScience.

The researchers retrospectively reviewed the medical records of five patients who underwent combined CABG-OLT. They ranged in age from 54 to 66 years old and four of the five patients were male. All of the patients had end-stage liver disease, as well as significant three vessel coronary atherosclerotic disease with preserved left ventricular function. The patients were evaluated by a team including surgery, hepatology, cardiology and anesthesiology before being listed for a transplant. When a liver became available, the patient was brought to the operating room. The cardiac surgery was performed first, except in patients with hepatocellular carcinoma (to ensure that the cancer had not spread,) then, the liver transplant. The combined procedure lasted an average of nearly 14 hours.

All of the patients survived the surgery, although one died five months later from complications of severe recurrent hepatitis C infection. Other patients experienced post-operative complications including pericardial effusion that required re-operation, cardiac arrest, acute rejection, and pneumonia. Patient stays in the intensive care unit ranged from 2 to 40 days (the mean was 10 days). Four of the five patients were discharged home while one patient required a brief in patient rehabilitation stay. “In this series,” the authors report, “combined OLT-CABG appears to be a safe and effective approach to patients with severe coronary artery disease and end-stage liver disease.” Several technical features of the combined procedure contributed to the positive results observed including careful donor selection, keeping the chest wound open during the liver transplant to inspect for hemostasis, and monitoring patients post-operatively using ultrasonography.

“The one-year mortality rates are comparable with OLT alone and, in general, ICU stay and hospital length of stay do not appear to be prolonged,” the authors conclude. “CABG-OLT should be offered to patients with severe coronary artery disease who would otherwise be denied OLT due to their cardiac risk factors.”