Combined Living Donor Liver Transplantation With Coronary Artery Bypass Grafting: Possible but not Without a Struggle

Abstract

Background

A combined liver transplant (LT) and coronary artery bypass grafting (CABG) may sometimes be needed for patients with decompensated cirrhosis who also have significant coronary artery disease (CAD). However, such a procedure is associated with significant morbidity and mortality.

Methods

From May 2012 to August 2020, eight patients with significant coronary artery disease (CAD) underwent combined off pump CABG (OPCAB) and living donor liver transplantation (LDLT) at our center. We analyzed patient demographics, preoperative clinical findings, operative details, and postoperative outcomes.

Results

Mean recipient age and body mass index were 59 ± 6 years and 26 ± 3kg/m², respectively. The model for end-stage liver disease (MELD) score was 20. Four patients each had hypertension and diabetes. Mean total duration of the surgery was 982 ± 117 min, with 598 ± 89 min for living donor liver transplantation (LDLT). The mean volume of packed red blood cell transfusion was 2500ml. The duration of the ventilatory support (median 49 h post-surgery), and the median intensive care unit and hospital stay (8 and 18 days, respectively). Two patients died during the postoperative period due to sepsis with multiorgan failure No recipient had evidence of acute coronary syndrome, stress cardiomyopathy; none required interventional hemodynamic support. Four patients developed atrial arrhythmia's in the post-operative period, all were managed successfully with medical management.

Conclusion

Combined CABG and LDLT is feasible but poses significant challenges. Careful preprocedure planning, and meticulous intra- and post-operative management involving a multidisciplinary team of LT Surgeons and anesthetists, hepatologists, cardiologists, and cardiac surgeons is required to ensure optimal outcomes in these patients.