Walking the Tightrope: A Center's Experience with Simultaneous Heart-liver-kidney Transplantation

Background Fewer than 25 simultaneous heart-liver-kidney transplants (SHLKTxs) have been performed in the U.S. This highly complex operation was performed nine times by only four centers from 2018 to 2019. However, one institution, the University of Chicago Medical Center (UCMC), is responsible for two-thirds of all SHLKTxs performed in that period. There is a paucity of literature regarding the logistics and infrastructure of performing SHKLTxs. The development of a standardized, effective protocol would improve outcomes in the high-risk patients who undergo this operation. We assessed the unique strategies that this center employs to successfully perform a high volume of SHLKTxs to understand possible programmatic procedures. Methods We reviewed the logistical methods and infrastructure of the UCMC concerning the process of SHLKTx, spanning the stages from patient selection to operating room (OR) management. Additionally, we attempted to identify areas of future improvement. Results The UCMC employs strict patient selection criteria, as potential candidates must meet the listing criteria for each organ independently. The severity of illness, however, must also indicate the potential for a successful outcome, and the age limit for candidates is typically 60 years. Donor selection and organ allocation are critical to ensure that all organs are received from the same donor, which can require negotiation when the procurement is not in a local area. The technically challenging surgery requires the transplant teams to move quickly in order to minimize ischemic time for the heart and prevent reperfusion injury in the liver, while the kidney is perfused. Due to the risk of these events, the transplant team recommends the use of mechanical support, such as extra-corporeal membrane oxygenation (ECMO). The key element of the UCMC's success was found to be the team's ability to procure and achieve success with organs that many other centers would turn down. The team is willing to accept undersized hearts, travel further distances, use DCD organs, and transplant Hepatitis C seropositive non-viremic (HCV Ab+/NAT-) livers to an HCV seronegative recipient in pursuit of an expeditious and successful SHLKTx. The combined efforts of a skilled, multidisciplinary team are also essential. The various teams see the patients together in a structured rounding schedule, and the operation itself consists of three distinct phases with choreographed and planned handoffs. Areas identified for future improvement included standardizing the approach used in the OR, particularly team transfer and timing. Conclusion The UCMC owes its established track record of successful SHLKTxs to the internal infrastructure of its program. In particular, its willingness to accept organs that other centers refuse allows it to perform a high volume of expeditious and successful SHLKTxs. Future steps include protocolizing OR management along with identifying parameters that allow for a structured system of team transfer.