Background
First combined orthotopic heart and liver transplant (CHLT) performed in San Diego and the first time an Impella 5.0 (Abiomed) micro-axial cardiac assist device has been used as a bridge to transplant.
Case Description
58 year old male with non ischemic cardiomyopathy (LVEF 16%) from both alcohol abuse and mismatched bicuspid aortic bio-prosthetic valve, automatic implantable cardioverter defibrillator (AICD), treated Hepatitis C virus infection, hypothyroidism, hypertension, ex-heavy drinker and smoker admitted for progressively worsening congestive heart failure refractory to maximal medical management. Hospital course complicated by acute kidney injury and atrioventricular node ablation for atrial fibrillation; eventually needing placement of Impella 5.0 cardiac assist device via his right axillary artery while awaiting work up for heart transplant which revealed liver cirrhosis (MELD 10). Listed 1A status for a combined heart and liver transplant (CHLT) with suitable organs procured after 155 days with 50 days of Impella 5.0 cardiac support as a bridge to transplant.
Anesthesia setup included balanced anesthetic with focus on large bore access lines (9Fr right internal jugular introducer catheter x2), hemodynamic monitoring with transesophageal echocardiogram (TEE), right radial arterial line, left femoral arterial line as well as cell saver and cardiopulmonary bypass (CPB) machine. CPB was initiated with Impella 5.0 device explanted before orthotopic heart transplant performed. Dobutamine 5mcg/kg/min was utilized to attenuate transplanted right heart dysfunction with norepiphrine 5mcg/kg/min infusions to maintain right sided coronary perfusion pressures. Serial thromboelastograms (TEGs) after coming off bypass were used to ensure adequate coagulation parameters before liver transplant could be contemplated. The preferred surgical liver transplant technique was the "piggy back" method without veno-veno bypass which involves partial clamping of the inferior vena cava preserving flow. Chest left open during the orthoptic liver transplant to monitor bleeding. Transfusion totals included 12 units packed red blood cells, 11 units of fresh frozen plasma, 4 pooled units of platelets, cell saver 675ml and albumin 900ml. Majority of blood loss occurred during liver transplant an-hepatic stage with right heart strain on TEE noted during the reperfusion stage. Patient was transferred intubated, ventilated, supported with dobutamine infusions along with inhaled nitric oxide to the dedicated transplant/ICU team after a prolonged but uncomplicated 11 hour surgical course with CPB time 150mins and donor ischemia time 116mins.
Postoperative course complicated by acute on chronic right subdural hematoma managed conservatively before discharge home a month after his CHLT.
Discussion
Only 18 combined orthoptic heart-liver transplants were performed in the United states in 2016 including this case. This case however is the first to use an Impella 5.0 (Abiomed) as a bridge to combined heart-liver transplant. The Impella’s placement is markedly less invasive than the current FDA approved ventricular assist devices (VAD) which need surgery with cardiac bypass support but do necessitate inpatient status.The major anesthetic challenges in this case relate to preparation for massive transfusion requirements, assessing coagulation status, managing multiple surgical teams and optimizing transplanted right heart function coming off bypass and especially during reperfusion of the newly transplanted liver.
