First-reported case of successful sequential coronary artery bypass grafting with combined bilateral lung-liver transplantation

Timeline.

Central Message.

Concomitant VA ECMO-supported CABG, bilateral lung transplantation, and liver transplantation is feasible in a carefully selected patients.

Historically, combined lung-liver transplantation has been reserved for patients with end-stage pulmonary and hepatic disease who would not survive single-organ transplantation alone.¹ Given the complexity of this approach, it is primarily performed at high-volume centers by surgeons with substantial expertise in thoracic and abdominal transplantation. The addition of a coronary artery bypass grafting (CABG) to a lung or liver transplantation further increases procedural complexity, prolonging operative time, heightening coagulopathy risk, and increasing hemodynamic instability.^2,3 To the best of our knowledge, this case report presents the first successful case of a concomitant combined CABG, double-lung transplant, and liver transplant in the literature.

Case Description

Institutional review board approval was not required for this case report. The patient provided informed written consent for the publication of their study data.

Preoperative Assessment

A 62-year-old woman with interstitial lung disease and metabolic-associated steatohepatitis cirrhosis presented to the lung transplant clinic for pretransplant evaluation after several weeks of progressive, acute-on-chronic dyspnea (Figure 1). At the time of hospital admission, the patient required 30 L/min and 55% supplemental oxygen via Optiflow (Fisher & Paykel), corresponding to an inspired oxygen fraction (Fio₂) of 55%. Baseline oxygen saturation on this regimen was 92% to 94%. The patient demonstrated desaturation with ambulation, with oxygen saturation decreasing to 90% on 50 L/100% Fio₂. Given concurrent portal hypertension with gastroesophageal varices, portal gastropathy, and splenomegaly (16.8 cm), the liver transplant team was consulted for potential combined lung-liver transplantation.

Figure 1.

Timeline illustrating key events before, during, and after surgery.

Further preoperative cardiac evaluation revealed a moderate ostial left anterior descending (LAD) calcified stenosis (50%-60%) nonischemic by diastolic hyperemia-free ratio and intravascular ultrasonography and a moderate-to-severe mid-LAD calcified stenosis (60%-70%) ischemic by diastolic hyperemia-free ratio (Table 1). The anatomy of the LAD lesions was deemed very high risk for percutaneous coronary intervention. The patient's chest dimensions were normal (Figure E1); therefore, a lung transplantation through a sternotomy was considered feasible. After extensive multidisciplinary discussion, the patient was approved for combined CABG, bilateral lung transplantation, and orthotopic liver transplantation.

Table 1.

Baseline clinical and diagnostic variables for transplant evaluation

Clinical or diagnostic variable	Value
Age, y	62
Weight, kg	63
BMI, kg/m2	23.2
Listing parameters
MELD-Na	6
Serum creatinine, mg/dL	0.77
Serum sodium, mmol/L	139
Total bilirubin, mg/dL	0.4
INR	1.0
Lung diagnosis	Myositis-associated interstitial lung disease
Liver diagnosis	MASH cirrhosis
LV ejection fraction	61%
Right heart catheter	PAP 12/5/0
Left heart catheter	Moderate ostial LAD calcified stenosis (50%-60%) nonischemic by DFR and IVUS
	Moderate to severe mid-LAD calcified stenosis (60%-70%) ischemic by DFR
CI, L/min/m2	2.70
FEV1, L, n (%)	1.6 (67%)
FVC, L, n (%)	1.7 (59%)
DLCO	20%
6-min walk test, ft	433
Use of oxygen	High-flow nasal cannula at 10 L/min
Carotid vessel status	Right: CCA no stenosis, ICA <50% stenosis, ECA no stenosis
	Left: CCA no stenosis, ICA <50% stenosis, ECA no stenosis
Esophagus evaluation	Normal EGD, esophagram with small type I sliding hiatal hernia with nonobstructive Schatzki ring
	Mild portal hypertensive gastropathy
Mammography	DCIS s/p partial mastectomy >5 y previously
Colonoscopy	One hyperplastic polyp
PRAs	Class I and II PRA negative

BMI, Body mass index; MELD, Model for End-Stage Liver Disease; INR, international normalized ratio; MASH, metabolic dysfunction-associated steatohepatitis; LV, left ventricle; PAP, pulmonary artery pressure; LAD, left anterior descending; DFR, diastolic hyperemia-free ratio; IVUS, intravascular ultrasonography; CI, cardiac index; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; DLCO, diffusion capacity of the lungs for carbon monoxide; CCA, common carotid artery; ICA, internal carotid artery; ECA, external carotid artery; EGD, esophagogastroduodenoscopy; DCSI, ductal carcinoma in situ; PRA, panel reactive antibody.

Figure E1.

Standing a/p and lateral radiographs as well as a computed tomography image highlighting the chest dimensions of the patient.

Donor Information

The lungs and liver were procured from a donation after brain death donor. The arterial oxygen tension to Fio₂ ratio before procurement was 489 mm Hg. Prerecovery aspartate transferase, alanine aminotransferase, and alkaline phosphatase levels were 55 U/L, 15 U/L, and 112 U/L, respectively. Both organs were procured in a standard manner. The lungs were preserved using a 10 °C cooler (Traferox Technologies) and the liver using a normothermic machine perfusion (OCS Liver; Transmedics).

Intraoperative Sequence

CABG without cardiopulmonary bypass

A median sternotomy was performed and the left internal mammary artery was harvested as a pedicle. After administration of 10,000 IU of heparin, central venoarterial (VA) extracorporeal membrane oxygenation (ECMO) was initiated with a 21-Fr Soft-Flow (MC3; Medtronic) aortic cannula and a percutaneously placed right femoral vein 25-Fr Bio-Medicus (Medtronic) drainage cannula. The left internal mammary artery was anastomosed to the mid-LAD, bypassing the stenotic lesions in a beating heart fashion. Hemostasis was carefully ensured before proceeding.

Bilateral lung transplantation

We initially decided to follow a liver-first approach to minimize the risk for transfusion-related acute lung injury to the newly implanted lung; however, logistical delays in donor liver transport (which remained on normothermic machine perfusion pump) necessitated proceeding with the bilateral lung transplantation first. Lung transplantation was performed through the median sternotomy, maintaining VA-ECMO flow at approximately 80% of the cardiac output to facilitate controlled reperfusion of the lungs. After both lungs were reperfused, the patient's chest was packed with gauze.

Orthotopic liver transplantation

The donor liver was implanted in a standard manner using piggyback technique and duct-to-duct anastomosis over a stent. The patient's abdomen was closed, VA-ECMO was weaned, the patient was decannulated, and after meticulous hemostasis, the sternotomy was closed.

The estimated blood loss of the operation was 1000 mL. The patient received 7 units of packed red blood cells, 4 units of platelets, 8 units of fresh-frozen plasma, and 3 units of cryoprecipitate. Total operating room time was 13 hours and 12 minutes. For the left lung, a total preservation time of 14 hours and 12 minutes was recorded (warm ischemic time [WIT], 42 minutes), for the right lung, preservation time was 15 hours and 52 minutes (WIT, 56 minutes), and for the liver graft 19 hours and 12 minutes (WIT, 22 minutes).

Postoperative course

Primary graft functions of both transplanted organs were excellent, with the liver clearing lactate immediately; on pressure control mode with 60% Fio₂, peak pressure of 22, positive end-expiratory pressure of 8, and tidal volume of 398 cc a with an arterial oxygen tension of 204 mm Hg was measured upon arrival in the intensive care unit. The patient was extubated on postoperative day 1. On postoperative day 2, she developed hypoactive delirium and a tracheostomy was placed, primarily for airway protection. She was also found to have bile-tinged drainage from her abdominal drain. The patient returned to the operating room for re-exploration, which revealed a leak from the recipient cystic duct stump. The remaining postoperative course was uncomplicated. The patient remained in the intensive care unit for a total of 18 days and was discharged home on postoperative day 25. Upon discharge, the patient was on room air and had normal liver function tests.

Discussion

To the best of our knowledge, this is the first reported case of a combined sequential VA-ECMO−supported beating-heart CABG followed by lung and liver transplantation. Traditionally, solid-organ transplantation has been reserved for patients with failure of a single organ system, with exceptions made for well-established dual organ procedures such as heart-lung, heart-kidney, and lung-liver transplantation. However, the selection of candidates for multiorgan transplantation remains a critical determinant of success because of the significant physiological burden and heightened perioperative risks associated with these complex procedures.

At our lung transplant center, bilateral lung transplantation is generally preferred over single-lung transplantation. On the basis of our institutional experience, this approach does not substantially increase perioperative mortality or compromise postoperative recovery while providing the long-term benefits of improved graft function and durability. From a technical standpoint, both lung and liver transplantation were considered relatively straightforward in this patient. The presence of significant LAD stenosis necessitated coronary revascularization before lung transplantation, as untreated coronary artery disease is a major risk factor for perioperative cardiac events.⁴ Given the patient's cirrhosis and interstitial lung disease, a VA-ECMO−supported CABG was selected to avoid the proinflammatory and coagulopathic effects of cardiopulmonary bypass. Because of the superior rates of early and long-term patency of internal mammary coronary grafts, we chose a sternotomy and in situ mammary harvest, rather than vein conduit via a clamshell thoracotomy exposure, which would be at greater risk of early conduit occlusion in the face of expected resuscitation of coagulopathy during liver transplantation Maintaining VA-ECMO support during liver transplantation also facilitated lung allograft protection.

Our institution's standard approach in combined lung-liver transplantation is to transplant the liver first, because this strategy reduces pulmonary vascular resistance and optimizes metabolic function before lung implantation. A liver-first approach is supported by 2 primary factors: (1) with advancements in preservation techniques, lung allografts have an ischemic tolerance of up to 24 hours, allowing for a safe delay before transplantation⁵ and (2) the risk of transfusion-related acute lung injury is reduced, as patients are not exposed to excessive intraoperative transfusions before lung implantation.

Unfortunately, because of logistical constraints, the surgical team had to proceed with double-lung transplantation after the CABG. Although unconventional, this surgical sequence proved feasible, reinforcing the need for individualized organ sequencing strategies in multiorgan transplantation and flexible intraoperative decision-making. Modern innovations in organ preservation and machine perfusion techniques that safely extend organ preservation time were essential to the success of this multispecialty lung and liver transplant and will increase access to multiorgan transplantation.

Conclusions

This case report highlights the feasibility of sequential VA-ECMO−supported CABG, bilateral lung transplantation, and liver transplantation in a carefully selected patient. A multidisciplinary approach enabled successful graft function and patient rapid recovery.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.