Heart-liver transplantation using the en bloc technique: A single-center experience over two decades

Background: Combined heart-liver transplantation (CHLT) is a definitive therapy reserved for patients with concomitant heart failure and advanced liver disease. A limited number of centers perform CHLT, and even fewer use the en bloc implantation technique. Here we review clinical outcomes and immunoprotective effects following CHLT and describe our institution's more than two decades of experience in performing the en bloc technique. Methods: All patients who underwent CHLT at our institution between January 2003 and July 2023 were identified. Recipient and donor characteristics, operative details, and clinical outcomes were assessed. Kaplan-Meier analysis was performed to evaluate survival following CHLT. Results: A total of 20 patients underwent CHLT using the en bloc technique at our institution between January 2003 and July 2023. At a median follow-up of 3.8 years for patients who survived the perioperative period (n 1/4 18), estimated survival was 94% at 1 year and 75% at 5 years. There was 100% freedom from acute moderate rejection, acute severe rejection, and chronic rejection in all patients. No patients required retransplantation due to rejection. Conclusions: CHLT is a definitive therapy reserved for patients with multiorgan dysfunction. At our institution, the en bloc technique is the preferred operative approach, as it minimizes cardiac insult, requires fewer anastomoses, minimizes cold ischemia time, and allows for rapid correction of coagulopathy. Overall survival for this cohort is excellent. Episodes of acute rejection were rare, providing further support for the idea that the liver may serve an immunoprotective role in multiorgan transplantation. (J Thorac Cardiovasc Surg 2025;169:1254-62)