2023 FSA Podium and Poster Abstracts

S002: COMBINED LUNG AND LIVER TRANSPLANTATION, A CASE REPORT
Hayden Dohnalek, MD; Brandon Lopez, MD; Jennifer Bromwell, DO; Miguel Rovira, MD; Greg Janelle, MD; University of Florida College of Medicine

Introduction/Background: The combined liver-lung transplant is a rare but emerging procedure. It is offered to patients with end stage lung disease who would not be expected to survive transplantation in the setting of coexisting liver disease. Guidelines suggest considering this procedure in patients who meet criteria for lung transplant listing in the setting of biopsy-proven end-stage liver disease [3]. We report a case of liver-lung transplantation at our institution in a patient with hepatopulmonary syndrome (HPS) in the setting of alcoholic cirrhosis.

Methods: The patient is a 67-year-old male who presented with hematemesis and SOB. Medical history included COPD, type II diabetes, obstructive sleep apnea and alcohol abuse. Subsequent workup revealed esophageal varices, cirrhosis and HPS. Following work-up at our facility, the patient was deemed a candidate for combined orthotopic liver and bilateral orthotopic lung transplantation. MELD score at the time of organ allocation was 25.

Results: The patient presented to the OR hemodynamically stable on 10L high flow nasal cannula and inhaled epoprostenol. Induction of anesthesia was performed with propofol, fentanyl and rocuronium. A left-sided double lumen ETT was placed for lung isolation. Arterial access was obtained, and an introducer was placed in the left IJ with a pulmonary artery catheter. Central access was also obtained in the right IJ to facilitate access for vv-ECMO if needed.

Liver transplantation was performed first with lung transplantation performed second. Methylprednisolone, mycophenolate and basiliximab were used for induction of immunosuppression. The liver transplant proceeded uneventfully, with reperfusion at 225 minutes of cold ischemic time and 299 minutes post-incision. Coagulopathy was corrected prior to reperfusion of the donor lungs and guided with point-of-care testing including thromboelastography and Quantra TM . During lung transplantation, the patient experienced multiple episodes of supraventricular tachycardia related to hilar exposure requiring internal electrical cardioversion. Inhaled nitric oxide was started in response to pulmonary hypertension (mPAP>40mmHg) following clamping of the left pulmonary artery, allowing the case to be completed without ECMO. The right and left lungs were reperfused at 457 and 621 minutes of ischemic time, respectively. Total products included 4 units of pRBC, 3u FFP, 1u of platelets, and 2 pooled units of cryoprecipitate. The patient was brought to the ICU after skin closure; the total operative time was 14 hours.

Discussion / Conclusion: The number of reported liver-lung transplants is <100 [3]. Liver-lung transplant for HPS is a rare indication and is poorly reported in the literature. The order in which each transplant occurs has important considerations. Historically, given the shorter tolerated ischemia time of lung grafts, lung transplant was performed first. However, advocates of the liver-first method have emerged with several hypothesized benefits. By exposing native lungs to liver reperfusion, associated injury can be avoided in the transplanted lungs. Correction of coagulopathy occurs prior to reperfusion of transplanted lungs and avoid fluid shift associated with transfusion. Additionally, less cold ischemia time in the liver can result in less biliary stricture. While more research is needed to compare the two methods, liver-first offers a potentially safer liver-lung transplantation.