Simultaneos Heart – Liver transplantation
1. Preoperative Planning & Coordination
•Multidisciplinary alignment (cardiac surgery, transplant hepatology, anesthesia, perfusion)
•Donor organ assessment and synchronized timing of procurement
•Hemodynamic optimization and coagulation planning
•blood products (massive transfusion readiness)
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2. Surgical Exposure
•Median sternotomy + laparotomy (simultaneous or staged)
•Establish invasive monitoring (TEE, PA catheter, arterial lines)
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3. Cardiopulmonary Bypass (CPB) Initiation
•Aortic and bicaval cannulation
•Full CPB support with systemic anticoagulation
•Cooling if required (center-dependent strategy)
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4. Native Heart Explantation
•Transection of great vessels
•Removal of diseased heart while preserving left atrial cuff
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5. Donor Heart Implantation
•Sequential anastomoses (bicaval preferred):
•Left atrium
•IVC → SVC
•Pulmonary artery
•Aorta
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6. Cardiac Reperfusion & Stabilization
•Aortic unclamping and reperfusion
•De-airing and rhythm restoration
•Gradual weaning from CPB
•Critical checkpoint:
•Stable MAP
•Adequate RV function
•inotropes/vasopressors
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7. Transition Phase (Key SHLT Moment)
•Ensure cardiac graft stability before abdominal phase
•Reverse or titrate anticoagulation cautiously
•Optimize volume status to prevent hepatic congestion
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8. Native Liver Hepatectomy
•Mobilization of liver
•hepatic artery, portal vein, bile duct
•IVC management:
•Piggyback (preferred) → preserves venous return
•Standard IVC replacement (if needed)
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9. Liver Graft Implantation
•Venous anastomosis (hepatic veins/IVC)
•Portal vein anastomosis
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10. Portal Reperfusion (High-Risk Phase)
•Controlled reperfusion
•Watch for post-reperfusion syndrome:
•Hypotension
•Hyperkalemia
•Acidosis
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11. Arterial & Biliary Reconstruction
•Hepatic artery anastomosis
•Biliary reconstruction:
•Duct-to-duct (preferred)
•Roux-en-Y (if indicated)
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12. Hemostasis & Closure
•Aggressive correction of coagulopathy
•Drain placement
•Chest and abdomen closure (staged if needed)
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13. Postoperative Management (ICU)
•Integrated cardiac + hepatic support
•RV dysfunction
•Primary graft dysfunction (heart/liver)
•Coagulopathy & bleeding
•Early immunosuppression strategy coordination
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Key Technical Pearls
•Heart-first strategy → ensures stable perfusion for liver graft
•Avoid RV overload during liver phase
•Tight control of volume + electrolytes during reperfusion
•Continuous communication between teams is critical
Dr.Sam Zeraatian Nejad Davani, Cardiovascular and Transplant surgeon. Advanced Fellow of Thoracic Organs Transplantation Chicago Illinois.