Ernest House needed a liver transplant. But a heart condition kept him off the transplant list.

“I would have died,” he says. “No doubt about that. “My body was failing.”

House, a former college football quarterback, had always made a point of staying active. That didn’t change when he reached his golden years.

In 2018, at age 65, he was going to the gym every morning at 6, working full time, and traveling regularly with his wife to cheer on his grandchildren at their many sporting events.

But that year, a stabbing pain in his back led him to seek medical attention.

“I was in terrible pain,” says House, a business owner from London, KY.

After two years of searching for answers, tests finally revealed the source of his suffering: his liver was irreversibly diseased. (House had been diagnosed with nonalcoholic fatty liver disease when she was in her twenties.)

At the Cleveland Clinic, specialists discovered damage to another organ: his heart. There was a significant blockage in House’s right coronary artery.

Patients with heart and liver problems are extremely difficult to treat, says Dr. Michael Zhen-Yu Tong, a cardiac surgeon at the Cleveland Clinic and director of heart transplantation and mechanical circulatory support.

For someone with a coronary blockage, the stress of a liver transplant can cause a heart attack on the operating table, he says. For someone with a diseased liver, heart surgery can cause blood clotting problems or critically low blood pressure that could kill them.

“These patients are in a therapeutic blind spot,” Tong says. “We just don’t have any treatments for them that are effective when we’re just operating in our own silos. This is where we essentially came together and said, ‘Hey, there’s clearly an unmet need here.’ How can we work together to help these patients?’”

House was fortunate to land at one of the few institutions (Cleveland Clinic) in the country that perform a combination of heart surgery and liver transplant (CS + LT), a complex procedure in which patients undergo both operations with few hours apart.

House was a good candidate for the procedure because he was under 70, his other organs were healthy, and he was healthy and active, Tong says.

When a liver became available in 2020, House underwent a nearly 12-hour dual procedure.

First, the cardiothoracic surgery team performed heart surgery, leaving House’s chest open. The liver transplant team then removed his liver and replaced it with a healthy transplant. Surgeons then closed his belly, examined his chest for bleeding, and closed his chest.

It is “very common” for patients to be deemed ineligible for a liver transplant due to heart disease, says Ali Zarrinpar, MD, PhD, a liver transplant surgeon and professor in the Division of Transplantation and Hepatobiliary Surgery at the University of Florida in Gainesville, FL. .

About 2% of American adults have been diagnosed with liver disease. Coronary artery disease or heart valve problems are estimated to occur in up to 30% of patients with end-stage liver disease.

That is not surprising if we consider that about 6% of adults have been diagnosed with heart disease. (That amounts to around 18% after age 65.) It is the leading cause of death among men, women, and most racial and ethnic groups. Heart disease can even lead to liver disease, especially in patients with chronic heart failure due to congenital heart disease, Zarrinpar says.

Surgeons at the Cleveland Clinic have been perfecting the combined heart surgery and liver transplant procedure since 2018. Researchers recently published a study highlighting the unique surgical approach and describing the method used to select patients for combination treatment.

“Not all patients, even those with heart and liver disease, are good candidates,” Tong says. “We have to make sure the patient can tolerate such an important operation. Sometimes patients may be very frail and weakened, or may have other organs that are not working as well, such as [diseased] kidneys or lungs.”

At Cleveland Clinic, all potential candidates for this unique surgery must have end-stage liver disease and cardiac dysfunction. Each is first evaluated independently by the cardiac surgery, cardiology, hepatology and liver transplant teams. After that, a liver transplant subcommittee with all four teams present continues to review each case biweekly. The committee generally excludes patients who are too healthy or too sick to qualify for the procedure.

Thirty-one patients underwent the combined surgery at the Cleveland Clinic between 2005 and 2021. Patient survival rates were 74 percent one year later and 55 percent five years after the procedure, the analysis found. Patient outcomes varied depending on their age and medical conditions.

For example, patients over age 60, with kidney dysfunction, or who were on dialysis before transplant had lower five-year survival, the study found. When heart blockages were the main problem, outcomes were worse, compared with cases in which valve repairs or replacements were the main problem.

Koji Hashimoto, MD, PhD, director of liver transplantation at Cleveland Clinic’s main campus, says some patients who underwent the combined surgery had 1- and 5-year survival rates comparable to patients in the population. general who underwent liver transplants.

Overall, survival rates for patients who receive only a liver transplant are 86% one year later and 72% at 5 years, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

While combined surgery may give more patients the opportunity to get a new liver, it also raises questions about the best use of scarce organs.

In 2021, almost 12,000 adult candidates were on the liver waiting list and another 13,000 were added before the end of the year. according to the Health Resources and Services Administration. Around 1,100 people died waiting.

Given the shortage of donor livers, it is a difficult decision to donate these organs to patients who need more complex operations because they have higher medical and surgical risks, Zarrinpar says.

“This issue is challenging because it raises important questions about how to share limited resources fairly while trying to save as many lives as possible,” he says.

After a successful surgery, House spent the next 6 months recovering. He describes the road back to health as “long and lonely.” The pandemic had just begun and his large family could not visit him. The months were filled with tests to make sure his new liver was working properly and waiting for his heart to heal from the surgery. Eventually, House was moved to a rehabilitation center where he received occupational therapy and worked to strengthen his muscles, he says.

His wife, Kim, finally saw her husband again at the rehab center after 4 months apart.

“I was surprised by its appearance,” he says. “She had lost more than 100 pounds, she had a beard, her hair was shaggy and she was very weak and fragile. She was a shadow of the man she had last seen.”

Today, House, 69, is healthy and active again. He continues to work full time in his business, a company that provides support and services to adults with developmental disabilities. The grandfather of nine still exercises five times a week and his heart and new liver are strong, he says.

“I don’t expect to slow down,” House says. “I have projects in various stages that will keep me busy for years to come. My goal is to continue moving forward. “I feel lucky and blessed to be alive.”