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Highlights and insights from recent Cleveland Clinic experience
Dual-organ heart transplantations have been offered at Cleveland Clinic for the past 25 years. In many cases, the need for a multiorgan heart transplant comes about initially because of heart failure, with other organs secondarily deteriorating owing to low cardiac output. Other patients have primary pathologies that simultaneously involve the heart as well as other organs.
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“We are seeing a median survival of about 10 years for dual-transplant patients, and many patients from the longest-running programs (heart-lung and heart-kidney) have now survived more than 15 years,” notes cardiothoracic surgeon Michael Tong, MD, MBA, Director of Cardiac Transplantation and Mechanical Circulatory Support at Cleveland Clinic. “This is remarkable, considering how ill these patients were before transplantation.”
In recent years, the number of dual-organ heart transplants performed at Cleveland Clinic has increased dramatically, as reflected in the graph below (Figure). This increase is due to a combination of factors:
“Although we have increased our number of dual-organ heart transplants substantially in recent years, we have done so in a very careful and measured way,” Dr. Tong notes.
The oldest dual-organ program at Cleveland Clinic – heart-lung transplantation – started in 1991, and 44 such transplants had been performed as of mid-2024.
Heart-kidney transplantation followed a year later, with the number of cases, especially in recent years, far surpassing those of other dual transplants (58 cumulative cases as of mid-2024).
Heart-liver transplantation, the newest program, started in 2006, with 18 such cases completed through mid-2024.
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“The trend is a significant recent increase in the number of patients to whom we offer dual-organ transplantation,” Dr. Tong observes. “Previously some of these patients may not have been a candidate for any operation, but now we would consider them for multiorgan transplantation.”
Many patients in need of a heart transplant have cardiorenal syndrome and sometimes acute renal failure. For those who undergo a heart transplant alone, some have full recovery of their kidneys, while others must remain on dialysis afterward, which leads to a survival disadvantage. “Because it is difficult to predict renal recovery preoperatively,” Dr. Tong notes, “we traditionally erred on offering dual-organ transplant to patients with both cardiac and renal failure even though some of the kidneys may have recovered.”
However, this policy changed at Cleveland Clinic starting in June 2023 — consistent with a broader national shift — with the goal of avoiding overtreatment and unnecessary use of donor organs. With the current “safety net” protocol, patients with both cardiac and renal failure undergo heart transplantation alone. After 60 days, if the kidneys fail to recover, the patient can get high-priority listing for kidney transplant.
Another important development has been the emergence of new organ preservation machines that can keep a kidney perfused and viable for at least 48 hours after procurement. This has fundamentally changed the workflow for the heart-kidney program, Dr. Tong explains. Before, back-to-back heart transplantation and kidney transplantation were required, regardless of whether the patient was bleeding or hemodynamically unstable, making it less likely that the transplanted kidney would function well immediately after transplant.
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New perfusion pumps provide valuable time: After heart transplant, the patient has time to recover in the ICU. If needed, bleeding can be brought under control and the patient can undergo dialysis for 24 to 36 hours to ensure an optimal metabolic state before the kidney transplant.
“Since the new system was instituted, we have been performing the kidney transplant in more stable patients, and we often see immediate recovery of the transplanted kidney with immediate urine production,” Dr. Tong says.
With its large referral base of complex patients, Cleveland Clinic has been able to gain expertise in dual-organ transplantation for special populations. For example, it has become one of the largest transplantation programs in the world for patients with amyloidosis.
Patients with a failing Fontan circulation also make up another unique patient group and often require either heart-kidney or heart-liver transplantation. Mortality is typically 15% to 30% acutely after transplant, about five to 10 times the rate for a typical heart transplant.
“In my opinion, there’s no harder operation than a heart transplant or dual-organ transplant for failing Fontan patients,” says Dr. Tong. “But if we do it successfully, these patients’ long-term survival is as good as — if not better than — that of almost any other heart transplant population.”
Dr. Tong emphasizes that a successful outcome for each dual-organ transplant patient requires close collaboration between at least two surgical specialties — heart surgery and liver/kidney/lung transplantation— and, in the setting of a failing Fontan or other congenital heart conditions, with congenital heart surgery specialists as well.
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The collaboration extends to medical colleagues too, such as heart failure and cardiac transplant cardiologist Sanjeeb Bhattacharya, MD. “Dual-organ transplant has become increasingly important, especially in special populations such as those with complex adult congenital heart disease (ACHD),” Dr. Bhattacharya says. “These are incredibly sick patients who have lived with their cardiac disease their entire lives, leading to multiorgan dysfunction requiring multiorgan treatment and transplant. Providing transplant options for these complex ACHD patients leads to better survival and quality of life. This could not be done without a dedicated multiorgan team approach across our various specialties.”
Dr. Tong concurs. “I attribute our high success rates to our exceptional multidisciplinary collaborative culture,” he concludes.
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