Does Liver Surface Nodularity by Non-Invasive Testing Suggesting Cirrhosis Contraindicate Heart Transplant?

Purpose The criteria for combined heart-liver transplant (HLiTx) has not been well established. Liver cirrhosis in a heart failure patient would require consideration for HLiTx. Investigators have used non-invasive testing (NIT) such as abdominal ultrasound and CT scans to assess for liver surface nodularity which suggests cirrhosis. Biopsies are then performed to assess for liver disease. However, pathology findings can be heterogeneous and, therefore, the biopsy may not be reliable to exclude cirrhosis due to sampling error. It is not known whether abnormal NIT suggesting cirrhosis alone renders poor outcome if heart alone transplant (HATx) proceeds. Methods Between 2012 and 2017, we identified 24 patients with an abnormal NIT demonstrating liver surface nodularity suggestive of cirrhosis but with liver biopsies showing no cirrhosis by pathology. Of these 24 patients, most patients had mild-moderate fibrosis with 3 patients who had severe 3-4+ fibrosis. Study endpoints included 3-year survival, freedom from non-fatal major adverse cardiac events (NF-MACE: MI, CHF, PCI, ICD implant, stroke), and freedom from cardiac allograft vasculopathy (CAV, defined by stenosis ≥30%). Freedom from 1-year rejection [acute cellular rejection (ACR), antibody-mediated rejection (AMR)] was also recorded. We compared these 24 patients to patients who underwent HATx without liver disease (n=523) during this same time period. Results Patients who had liver nodularity with HTx had similar 3-year survival, freedom from NF-MACE, and freedom from CAV compared to control patients who had HATx without liver disease. Furthermore, 1-year freedom from rejection was similar between study groups (see table). The 3 patients with 3-4+ fibrosis on liver biopsy had similar outcomes to the rest of the study group. Conclusion In our single center experience, surface nodularity suggesting cirrhosis by NIT but with no evidence of biopsy-proven cirrhosis does not appear to be a contraindication to proceed with HATx.