*Purpose: Combined heart-liver transplants (CHLTx) have been shown to have good short-term outcomes in those with end-stage heart and liver disease: we conducted a comprehensive review of the largest single-center cohort of CHLTx focusing on long-term survival and function of both heart and liver grafts.

*Methods: From 1992 to 2019, 47 CHLTx were performed at our center. Patients were matched in a 1:1 ratio with similar isolated heart transplant (IHTx) recipients on the basis of age, gender, pre-operative comorbidities and heart transplant indication. Overall survival, graft survival, graft function, and biopsy-proven rejection episodes were assessed.

*Results: The most common indication for CHLTx was familial amyloidosis (30 patients, 64%) followed by congenital heart disease with concomitant liver failure (7 patients, 15%). Mean follow-up time was 75 ± 57 months. Survival at 1, 5, 10 and 15 years was similar (94%, 88%, 66% and 44% respectively for CHLTx and 93%, 76%, 59% and 25% for IHTx, p = 0.493). Cardiac function was comparable: the mean EF at 10 years and at last follow-up was 63% and 62% respectively in CHTX and 62% and 60% for IHTx (p = 0.942 and p = 0.379). Freedom from T cell-mediated rejection at last follow-up was greater in CHLTx patients (44% versus 9% in IHTx, p < 0.001) and treatment for rejection was lower in the CHLTx cohort (p = 0.01). The burden of Coronary Artery Vasculopathy was lesser in the CHLTx patients (15% and 29% at 1 and 5 years respectively, 40% and 53% for IHTx patients).

*Conclusions: CHLTx offers comparable survival outcomes and inferior rates of graft rejection compared to IHTx. This study highlights the excellent long-term results for CHLTx patients. In an era of limited organ availability, our outcomes support CHLTx as a robust treatment option for those with amyloidosis or end-stage heart and liver disease.

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