Expanding access and rising complexity: Contemporary early outcomes in heart-liver transplantation for adult congenital heart disease.

Abstract

Adoption of the 6-tier US heart allocation policy in October 2018 coincided with increasing use of combined heart-liver transplantation (CHLT) and more adults with congenital heart disease (ACHD) candidates. The impact of early outcomes is uncertain, however. We retrospectively analyzed adult CHLTs recorded in the United Network for Organ Sharing (UNOS) database between January 1, 2000, and July 1, 2025, excluding retransplantation and multiorgan cases. Two eras were defined: premodern (2000-2018) and modern (2019-2025). Cox models for 1-year mortality included era, ACHD status, and an era × ACHD interaction, adjusted for primary analysis covariates. Era-stratified survival also compared CHLT with orthotopic heart transplantation (OHT) for ACHD. Among 602 recipients (premodern era, 247; modern era, 355), annual CHLT volume tripled and the ACHD share rose from 20.6% to 50.7% from the premodern era to the modern era. Modern recipients were younger and of greater acuity; procurement distance and cold ischemic time increased (192 nautical miles vs 47 nautical miles and 3.7 hours vs 2.9 hours), and the use of donation after circulatory death hearts began. Unadjusted 30-day and 1-year mortality were higher post-2019, while conditional survival beyond 30 days was similar in the 2 eras. Adjusted analyses showed an era × ACHD association with higher 1-year mortality (hazard ratio [HR], 3.21; 95% confidence interval [CI], 1.08-9.50); longer cardiac cold ischemic time was associated with increased risk (per hour HR, 1.32; 95% CI, 1.14-1.54). In ACHD patients, survival after OHT improved in the modern era but survival after CHLT declined, yielding a ∼20-point 1-year gap. Post-2018 expansion broadened CHLT access for ACHD. The early perioperative signal aligns with ACHD OHT complexity and may be amplified in dual-organ CHLT, particularly as longer travel and ischemia accompany expanded accessibility, supporting earlier referral and physiologically aligned exception pathways.