*Purpose: There is minimal data describing combined thoracic-liver transplants (tx) with normothermic machine perfusion (NMP) used for liver preservation as the thoracic tx is done. We report a series of 2 patients where NMP was used to mitigate injury from extended liver preservation time.

*Methods: We reviewed two cases of combined thoracic-liver tx performed at our center, one heart-liver-kidney (HLK) (148 days f/u) and one lung-liver (LL) (20 days f/u). In both cases, the liver was preserved using NMP with the TransMedics OCS Liver device with FDA approval for compassionate use. The protocol for the ongoing clinical trial in liver preservation was used in both cases with one exception. In the LL case, an arterial reconstruction was done prior to NMP.

*Results: The HLK recipient is a 48 yo M with non-ischemic cardiomyopathy and resultant hepatic and renal failure. The LL recipient is a 49 yo F with autoimmune hepatitis and bronchiectasis with pulmonary htn. The HLK donor was a brain dead (TBI) 41 yo M, BMI 32 with normal LFT and INR. The LL donor was a brain dead (TBI) 46 yo F, BMI 20 with normal LFT and INR. The total NMP time was 5h 16m for the HLK and 6h 56 m for the LL. The total time from clamp to portal reperfusion was 8h 17 m in the HLK and 9h 29m in the LL. Initial, peak, trough and final lactate on pump were 6.2, 6.2, 0.5, 1.1 and 1.8, 3.4, 1.1, 2.2 mmol/L for the HLK and LL, respectively. The HLK required high dose vasopressors (VP) following heart tx but did not experience any additional events upon liver reperfusion. The LL did not require VP and did not have any post-reperfusion events. For the HLK, ALT and AST peaked at 2369 and 3929 IU/L immediately post tx and steadily decreased to normal. Lactate was 10.4 mmol/L following the liver tx and decreased to normal within 48 hours. TB peaked at 7.5 mg/dL on POD 6 and steadily decreased to normal. INR peaked at 2.4 following the liver tx and decreased to < 1.5 within 72 hours. Despite the course being complicated with extended high VP requirement, acute cellular rejection (ACR) of the heart, multiple resistant infections and resultant renal allograft failure, liver function remains normal. For the LL, ALT and AST peaked at 128 and 300 IU/L immediately post tx and steadily decreased. There was a biopsy proven mild ACR 10 d post tx with elevation of transaminases at that time. Lactate was 3.9 mmol/L following the LL and decreased to normal within 12 hours. TB peaked at 9.1 mg/dL on POD 1 and was 1.3 by POD 5. INR peaked at 1.5 following the liver tx and has remained normal. Despite the mild liver ACR, function remains normal.

*Conclusions: Liver NMP is an option for multi-organ tx with planned extended liver ischemia time. NMP may decrease risk of reperfusion syndrome in liver tx alone patients with marginal cardiopulmonary function, which may expand donor selection. Also, NMP may be useful in cases where there is extended ischemia time when the intended recipient becomes too ill to proceed with tx and a backup recipient must be prepared.

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