Locations:
Search IconSearch

Advances and Dilemmas in Multiorgan Heart Transplantation

Highlights and insights from recent Cleveland Clinic experience

abdominal organs within the human body

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.

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

“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.”

A substantial rise in volumes

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:

  • Increased collaboration among the transplant teams for the various organs involved
  • Learned experience, which allows surgeons to operate on more complex patients
  • Availability of organ preservation systems that enable longer organ viability after procurement
bar graph showing transplant volumes over time
Figure. Cleveland Clinic’s dual-organ heart transplant volume growth over recent five-year intervals.

“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.

Advertisement

“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.”

Heart-kidney transplant poses important dilemmas

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.

Advertisement

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.

Special patient populations

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.”

Multidisciplinary collaboration is key

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.

Advertisement

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.

Advertisement

Related Articles

William Carey, MD, with patient
December 12, 2024/Digestive/Research
Hearts From Donors Infected with Hepatitis C Are Safe for Transplant, Study Shows

Findings show no increased risk in long-term outcomes

Physician caring for infant on exam table
July 9, 2024/Pediatrics/Cardiology
More Questions Remain About the Role of Statins in Pediatric Heart Transplant

Large registry study explores association between statin use and long-term outcomes

woman doctor in white coat
Meet Dr. Amanda Vest, New Section Head of Heart Failure and Transplant Cardiology

Eminent clinician-researcher brings special expertise in nutritional interventions for heart failure

stylized heart and lungs with text overlay
Vital Statistics From Cleveland Clinic in Heart Failure and Electrophysiology

Recent volume and outcomes data in two major realms of cardiovascular care

22-CHP-3075509-CQD-650×450-Amdani
September 26, 2023/Pediatrics/Cardiology
A New Metric for Donor-Recipient Size Matching in Pediatric Heart Transplantation?

Findings from more than 7,500 donor-recipient pairs

illustration of heart and lungs with text
Vital Stats From Our Heart Failure and Electrophysiology Programs

Our latest volume and outcomes data in two key subspecialty areas

22-CHP-3480260 CQD Amdani-Race and Socioeconomic
April 6, 2023/Pediatrics/Cardiology
Digging Deeper into Racial and Socioeconomic Disparities in Pediatric Heart Transplant

More scientific evidence is needed to guide these challenging, complex decisions

Ad