After several years as a patient of transplant hepatologist Bonike Oloruntoba-Sanders, MD, at Duke Health, a 47-year-old man with cirrhosis faced acute decompensation warranting transplant evaluation. During his evaluation, he was found to have profound mitral valve regurgitation, a complication of a prior episode of endocarditis. With profound mitral valve regurgitation that two minimally invasive procedures failed to address, the patient would not have been a candidate for a liver transplant.
“Often, heart disease eliminates a patient as a candidate for transplant because of the level of risk,” says Oloruntoba. The patient would not receive cardiac clearance for a transplant while at the same time advanced liver disease precluded heart surgery.
“These patients are not suited for a major surgical procedure,” agrees liver transplant surgeon Aparna S. Rege, MD. “No one would perform heart valve replacement on a decompensated liver patient because the outcome would be poor for the patient, possibly fatal.”
How did the transplant team treat this critically ill patient?
Rege and Oloruntoba-Sanders considered a combined procedure to address both the valve disease and liver disease in a single surgery, the first procedure of its kind at Duke. “There are very few centers that will do combined cardiac surgery and liver transplant,” says Rege.
They consulted with heart surgeon Jacob N. Schroder, MD, director of the Duke Heart Transplant Program. “With our history of heart/liver transplants, we’re very comfortable working with the liver transplant team and coming up with a safe plan to do both procedures,” says Schroder.
For the combined procedure, the patient was put on cardiopulmonary bypass for open mitral valve replacement. After the successful replacement, the team closed the chest and transitioned the patient to extracorporeal membrane oxygenation (ECMO) to perform the liver transplant. Both surgeries were successful, and the patient is doing well.
“Our program is truly multidisciplinary,” says Oloruntoba-Sanders. “Our surgeons, hepatologists, and social workers are all striving for the best outcome, and that relationship helps us work with surgeons in other divisions.”
“We work very collaboratively not only within our specialty but also with other specialties,” Rege agrees.
“We’re very willing to have these conversations,” Schroder concurs.
Rege cites Duke’s efforts to broaden the donor pool and advance transplant procedures as additional highlights of the program. “We have a lot of innovative programs and procedures being performed at Duke,” she says. “We cater to the patient’s needs on a case-by-case basis.”
Recent research has shown that patients with a Model for End-stage Liver Disease (MELD) score of 11-12 may also benefit from transplant, as opposed to the previous cutoff of 15. “For any patient with liver disease, consider referral,” Oloruntoba-Sanders concludes. “We’re always happy to review cases.”