Introduction

No standardized criteria currently exists for which patients should be listed for pediatric combined heart liver transplant (cHLT) versus heart transplant (HT). We aimed to correlate pre-transplant markers with intraoperative findings of cirrhosis to better predict which patients go on to recieve cHLT.

Methods

Twenty-two patients with Fontan failure listed for cHLT were included in this retrospective study (2006-2023). Patients listed for cHLT have an intra-operative exam at the time of donor offer. Patients with the intra-operative finding of cirrhosis undergo cHLT, otherwise the liver is reallocated. Fifteen patients underwent cHLT and 7 received HT alone.

Results

There was no significant differences between the cHLT and HT alone groups across demographics (including age and time out from Fontan), labwork (LFTs, platelet count, albumin, INR), and imaging (elastography and nodular liver appearance). All patients found to have intra-operative cirrhosis who underwent cHLT had either: 

1. Stage 2 or greater fibrosis AND 2 or more signs of portal hypertension (splenomegaly, varices, and/or ascites) OR

2. Stage 2 or greater hepatic fibrosis AND polysplenia/asplenia AND varices AND ascites 

No patient who underwent HT alone met any of the above criteria. No calculated score was predictive of cHLT (including APRI, FIB4, and MELDXI). No patient with stage 1 fibrosis underwent cHLT and all patients with stage 4 fibrosis underwent cHLT.

Conclusion

Based on our center's experience, we utilize the above refined criteria to decide which patients to list for cHLT. Ongoing collaborative studies and registries are essential to better stratify which patients would benefit from cHLT versus HT alone.