Combined Heart-Kidney Transplantation After Total Artificial Heart Insertion A. Ruzzaa, L.S.C. Czerb,*, K.A. Ihnkena, M. Sasevicha, A. Trentoa, D. Ramzya, F. Esmailiana, J. Moriguchib, J. Kobashigawab, and F. Arabiaa a
Cedars-Sinai Heart Institute, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California, United States; and bCedars-Sinai Heart Institute, Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California, United States
ABSTRACT We present the first single-center report of 2 consecutive cases of combined heart and kidney transplantation after insertion of a total artificial heart (TAH). Both patients had advanced heart failure and developed dialysis-dependent renal failure after implantation of the TAH. The 2 patients underwent successful heart and kidney transplantation, with restoration of normal heart and kidney function. On the basis of this limited experience, we consider TAH a safe and feasible option for bridging carefully selected patients with heart and kidney failure to combined heart and kidney transplantation. Recent FDA approval of the Freedom driver may allow outpatient management at substantial cost savings. The TAH, by virtue of its capability of providing pulsatile flow at 6 to 10 L/min, may be the mechanical circulatory support device most likely to recover patients with marginal renal function and advanced heart failure.
R
ENAL failure is considered a contraindication for heart transplantation (HTx) or mechanical circulatory support [1e3]. Yet, end-stage cardiac and renal failure may coexist, and this population of patients is expected to grow as transplant waiting lists increase due to the shortage of donor organs. Mechanical circulatory support for end-stage heart failure includes the pneumatically driven, biventricular, pulsatile, total artificial heart (TAH) (Syncardia Inc, Tucson, Ariz., United States), approved by the Food and Drug Administration as a bridge to HTx. A total of 54 combined heart and kidney transplants (HKTx) were performed at Cedars Sinai Medical Center in Los Angeles from June 1992 to November 2013. To our knowledge, this represents the largest single-center experience with HKTx since the initial description of the combined procedure in 1978 [1]. We present the first single-center report of 2 consecutive cases of combined HKTx after TAH insertion. Both patients had advanced heart failure and developed dialysis-dependent renal failure after implantation of the TAH. Both patients underwent successful heart and kidney transplantation, with restoration of normal heart and kidney function. Case 1. A 55-year-old woman with history of rhythmrelated cardiac arrest 30 years prior was placed on amiodarone for 1.5 years, but discontinued its use due to thyroid toxicity. A pacemaker-cardioverter-defibrillator 0041-1345/14 http://dx.doi.org/10.1016/j.transproceed.2014.09.106
210
was inserted, and she had seven subsequent defibrillator implant procedures. Furthermore, her history was characterized by constrictive pericarditis with restrictive physiology pattern, for which she underwent pericardial stripping complicated by phrenic nerve injury. She also had right heart failure, 2 partially successful ablations, and 2 cardiac arrests requiring cardiopulmonary resuscitation. The patient was referred to Cedars-Sinai Medical Center. She arrived with progressive decline in her functional status and had abdominal swelling, fatigue, as well as renal dysfunction. Admission serum creatinine level was 1.6e1.8 mg/ dL with an estimated GFR of 30e59 mL/min (CKD stage 3). She was diuresed, and placed on milrinone, dopamine, and dobutamine infusions. The blood pressure was 82/50 mmHg, central venous pressure 26 mmHg, pulmonary arterial pressure (PA) 36/24 mmHg (mean 29), and cardiac output (CO) by thermodilution 3.2 L/min with a cardiac index (CI) of 1.96 while on inotropic support. The patient continued to decline hemodynamically, developed cardiogenic shock, and became anuric. She was
*Address correspondence to Lawrence S.C. Czer, MD, Medical Director, Heart Transplantation Program, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Suite A3100, Los Angeles, CA 90048. E-mail: [email protected] ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
Transplantation Proceedings, 47, 210e212 (2015)
TRANSPLANT AFTER ARTIFICIAL HEART INSERTION
urgently brought to the operating room for TAH placement. A redo sternotomy with lysis of previous adhesions required 90 minutes. Ascending aortic and bicaval cannulations were performed and the patient was placed on cardiopulmonary bypass (CPB). The resected native heart showed extensive fibrinous pericarditis, myocardial fibrosis, and areas of ossification. The atrial connections, as well as the pulmonary and aortic anastomoses to the outflow cannulae, were prepared. The TAH was connected to the atria and to the outflow grafts, the crossclamp was released, the TAH was de-aired, and the patient came off CPB. The patient’s chest was left open to prevent tamponade and was closed on the second postoperative day. The patient was hemodynamically stable but anuric and required hemodialysis. She remained anuric, was placed on the waiting list for combined HKTx, and remained in the hospital. A compatible double-organ donor became available on day 148 in the hospital, and the patient had a combined heart and kidney transplant. There were very dense mediastinal adhesions requiring almost 2 hours to lyse and the patient was placed on CPB. Heart transplantation was performed using bicaval anastomoses [4e7]. CPB time was 170 minutes, total ischemic time 163 minutes, and crossclamp time 132 minutes. Kidney transplantation was performed by a separate surgical team after a period of hemodynamic stabilization. Postoperative immunosuppression consisted of anti-thymocyte globulin (ATG), followed by maintenance therapy with tacrolimus, mycophenolate mofetil, and prednisone [8e10]. The patient was extubated on postoperative day 1, and she was discharged in good condition on day 15 after combined HKTx. Endomyocardial biopsy on days 15 and 30 post-transplantation showed no evidence of cellular rejection or antibody-mediated rejection (AMR). On day 45 post-transplant, the biopsy showed mild acute cellular rejection (grade 1A-1R) and no evidence of AMR [10]. A Doppler echocardiogram showed normal left and right ventricular function. Renal function returned to normal. Case 2. A 56-year-old man with history of dilated idiopathic cardiomyopathy, LVEF 25%, atrial fibrillation, biventricular pacemaker-cardioverter-defibrillator insertion, hypertension, hyperlipidemia, and diabetes mellitus developed decompensated heart failure. Admission creatinine was 1.8e2.6 mg/dL, with a measured creatinine clearance of 36 mL/min (CKD stage 3). He was evaluated for heart transplantation and was placed on the heart transplant waiting list. He required inotropic support. Because of hemodynamic deterioration despite inotropic support, a TAH was placed. He subsequently had mediastinal exploration for bleeding. The patient became anuric and required hemodialysis. He continued to be anuric, was placed on the waiting list for combined HKTx, and remained in the hospital. On day 123, the patient underwent combined HKTx. Total CPB time was 180 minutes, cross-clamp time 162 minutes. Postoperative immunosuppression consisted of ATG, followed by maintenance therapy with tacrolimus, mycophenolate mofetil, and prednisone [8e10]. The patient
211
experienced right ventricular dysfunction postoperatively requiring inotropic support and hemodialysis for 10 days before recovering heart and renal function. He was discharged after 2 weeks. At 1 and 2 weeks after the transplant, endomyocardial biopsies were negative for cellular rejection and for AMR. LVEF on echocardiogram at 2 weeks was 57% and right heart catheterization revealed PA 33/12, with CO 7.06 L/min and CI 3.24. DISCUSSION
This report represents the first 2 consecutive cases of successful combined HKTx after TAH insertion from a single center. HKTx after TAH has been reported previously only twice in single case reports from different institutions [11,12]. The TAH has been implanted in more than 1,250 patients worldwide [3]. The longest time on TAH support has been 1374 days. The device was approved as bridge to heart transplantation and in selected cases may be used as destination therapy. The TAH has been applied in patients with severe biventricular failure after LVAD insertion and with allograft failure after HTx. Preoperative renal failure is considered a relative contraindication to TAH insertion [3]. VAD insertion is also contraindicated in patients with renal failure or with concomitant end-stage heart and kidney failure awaiting transplant [2]. The cardiorenal syndrome is a low-output state associated with end-stage cardiac and renal failure. Combined cardiac and renal failure is difficult to manage medically. Both patients in the current report had evidence of CKD (stage 3) upon admission, as well as advanced heart failure, and subsequently developed dialysis-dependent renal failure. We previously published our analysis of 30 consecutive patients who underwent combined HKTx at our institution, demonstrating excellent short- and long-term survival comparable with that after HTx alone, with low rates of cellular and AMR [8,13]. Furthermore, we evaluated the use of VAD as a bridge to combined HKTx in 6 consecutive patients with endstage heart and kidney failure [14]. Combined HKTx had excellent outcomes, suggesting that it is safe to perform HKTx in patients with combined heart and kidney failure who are bridged to transplant with a VAD. Now we report our experience using the TAH as bridge to combined HKTx in patients with concomitant heart and kidney failure awaiting transplant. On the basis of this limited experience, we consider TAH a safe and feasible option for bridging carefully selected patients with heart and kidney failure to combined HKTx. The patients in the current report waited in the hospital (>120 days) for the combined transplant, since they did not qualify for the SynCardia Freedom driver trial due to hemodialysis dependence. Recent FDA approval of the Freedom driver may allow outpatient management at substantial cost savings. The TAH, by virtue of its capability of providing pulsatile flow at 6e10 L/min, may be the mechanical circulatory support device most likely to recover patients with marginal renal function and advanced heart failure.
212
ACKNOWLEDGMENTS Francisco Arabia, MD, is a consultant to SynCardia. Jon Kobashigawa, MD, has received honoraria and/or research grants from XDx Inc., Novartis Pharmaceuticals Inc., Cylex, and Genzyme Corp.
REFERENCES [1] Norman JC, Brook MI, Cooley DA, Klima T, Kahan BD, et al. Total support of the circulation of a patient with postcardiotomy stone-heart syndrome by a partial artificial heart (ALVAD) for 5 days followed by heart and kidney transplantation. Lancet 1978;1:1125e7. [2] Kaltenmaier B, Pommer W, Kaufmann F, Hennig E, Molzahn M, Hetzer R. Outcome of patients with ventricular assist devices and acute renal failure requiring renal replacement therapy. ASAIO J 2000;46:330e3. [3] Copeland JG. SynCardia total artificial heart: update and future. Tex Heart Inst J 2013;40:587e8. [4] Trento A, Czer LS, Blanche C. Surgical techniques for cardiac transplantation. Semin Thorac Cardiovasc Surg 1996;8:126e32. [5] Trento A, Takkenberg JM, Czer LS, Blanche C, Nessim S, et al. Clinical experience with one hundred consecutive patients undergoing orthotopic heart transplantation with bicaval and pulmonary venous anastomoses. J Thorac Cardiovasc Surg 1996;112: 1496e502. [6] Blanche C, Nessim S, Quartel A, Takkenberg JJ, Aleksic I, et al. Heart transplantation with bicaval and pulmonary venous anastomoses. A hemodynamic analysis of the first 117 patients. J Cardiovasc Surg 1997;38:561e6.
RUZZA, CZER, IHNKEN ET AL [7] Aleksic I, Freimark D, Blanche C, Czer LS, Trento A. Does total orthotopic heart transplantation offer improved hemodynamics during cellular rejection events? Transplant Proc 2003;35: 1532e5. [8] Czer LS, Ruzza A, Vespignani R, Jordan S, De Robertis MA, et al. Survival and allograft rejection rates after combined heart and kidney transplantation in comparison with heart transplantation alone. Transplant Proc 2011;43:3869e76. [9] Goland S, Czer LS, Coleman B, De Robertis MA, Mirocha J, Zivari K, et al. Induction therapy with thymoglobulin after heart transplantation: impact of therapy duration on lymphocyte depletion and recovery, rejection, and cytomegalovirus infection rates. J Heart Lung Transplant 2008;27:1115e21. [10] Czer LS, Phan A, Ruzza A, Rafiei M, Setareh-Shenas S, Caceres M, et al. Antithymocyte globulin induction therapy adjusted for immunologic risk after heart transplantation. Transplant Proc 2013;45:2393e8. [11] Jaroszewski DE, Pierce CC, Staley LL, Wong R, Scott RR, Steidley EE, et al. Simultaneous heart and kidney transplantation after bridging with the CardioWest total artificial heart. Ann Thorac Surg 2009;88:1324e6. [12] Hansen AJ, Copeland JG. Combined heart-kidney transplant after CardioWest total artificial heart bridge. J Heart Lung Transplant 2010;29:1193e5. [13] Ruzza A, Czer LS, Trento A, Esmailian F. Combined heart and kidney transplantation: what is the appropriate surgical sequence? Interact Cardiovasc Thorac Surg 2013;17:416e8. [14] Yanagida R, Czer LS, Ruzza A, Schwarz ER, Simsir SA, Jordan SC, et al. Use of ventricular assist device as bridge to simultaneous heart and kidney transplantation in patients with cardiac and renal failure. Transplant Proc 2013;45:2378e83.
Cedars-Sinai Heart Institute, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California, United States; and bCedars-Sinai Heart Institute, Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California, United States
ABSTRACT We present the first single-center report of 2 consecutive cases of combined heart and kidney transplantation after insertion of a total artificial heart (TAH). Both patients had advanced heart failure and developed dialysis-dependent renal failure after implantation of the TAH. The 2 patients underwent successful heart and kidney transplantation, with restoration of normal heart and kidney function. On the basis of this limited experience, we consider TAH a safe and feasible option for bridging carefully selected patients with heart and kidney failure to combined heart and kidney transplantation. Recent FDA approval of the Freedom driver may allow outpatient management at substantial cost savings. The TAH, by virtue of its capability of providing pulsatile flow at 6 to 10 L/min, may be the mechanical circulatory support device most likely to recover patients with marginal renal function and advanced heart failure.
R
ENAL failure is considered a contraindication for heart transplantation (HTx) or mechanical circulatory support [1e3]. Yet, end-stage cardiac and renal failure may coexist, and this population of patients is expected to grow as transplant waiting lists increase due to the shortage of donor organs. Mechanical circulatory support for end-stage heart failure includes the pneumatically driven, biventricular, pulsatile, total artificial heart (TAH) (Syncardia Inc, Tucson, Ariz., United States), approved by the Food and Drug Administration as a bridge to HTx. A total of 54 combined heart and kidney transplants (HKTx) were performed at Cedars Sinai Medical Center in Los Angeles from June 1992 to November 2013. To our knowledge, this represents the largest single-center experience with HKTx since the initial description of the combined procedure in 1978 [1]. We present the first single-center report of 2 consecutive cases of combined HKTx after TAH insertion. Both patients had advanced heart failure and developed dialysis-dependent renal failure after implantation of the TAH. Both patients underwent successful heart and kidney transplantation, with restoration of normal heart and kidney function. Case 1. A 55-year-old woman with history of rhythmrelated cardiac arrest 30 years prior was placed on amiodarone for 1.5 years, but discontinued its use due to thyroid toxicity. A pacemaker-cardioverter-defibrillator 0041-1345/14 http://dx.doi.org/10.1016/j.transproceed.2014.09.106
210
was inserted, and she had seven subsequent defibrillator implant procedures. Furthermore, her history was characterized by constrictive pericarditis with restrictive physiology pattern, for which she underwent pericardial stripping complicated by phrenic nerve injury. She also had right heart failure, 2 partially successful ablations, and 2 cardiac arrests requiring cardiopulmonary resuscitation. The patient was referred to Cedars-Sinai Medical Center. She arrived with progressive decline in her functional status and had abdominal swelling, fatigue, as well as renal dysfunction. Admission serum creatinine level was 1.6e1.8 mg/ dL with an estimated GFR of 30e59 mL/min (CKD stage 3). She was diuresed, and placed on milrinone, dopamine, and dobutamine infusions. The blood pressure was 82/50 mmHg, central venous pressure 26 mmHg, pulmonary arterial pressure (PA) 36/24 mmHg (mean 29), and cardiac output (CO) by thermodilution 3.2 L/min with a cardiac index (CI) of 1.96 while on inotropic support. The patient continued to decline hemodynamically, developed cardiogenic shock, and became anuric. She was
*Address correspondence to Lawrence S.C. Czer, MD, Medical Director, Heart Transplantation Program, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Suite A3100, Los Angeles, CA 90048. E-mail: [email protected] ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
Transplantation Proceedings, 47, 210e212 (2015)
TRANSPLANT AFTER ARTIFICIAL HEART INSERTION
urgently brought to the operating room for TAH placement. A redo sternotomy with lysis of previous adhesions required 90 minutes. Ascending aortic and bicaval cannulations were performed and the patient was placed on cardiopulmonary bypass (CPB). The resected native heart showed extensive fibrinous pericarditis, myocardial fibrosis, and areas of ossification. The atrial connections, as well as the pulmonary and aortic anastomoses to the outflow cannulae, were prepared. The TAH was connected to the atria and to the outflow grafts, the crossclamp was released, the TAH was de-aired, and the patient came off CPB. The patient’s chest was left open to prevent tamponade and was closed on the second postoperative day. The patient was hemodynamically stable but anuric and required hemodialysis. She remained anuric, was placed on the waiting list for combined HKTx, and remained in the hospital. A compatible double-organ donor became available on day 148 in the hospital, and the patient had a combined heart and kidney transplant. There were very dense mediastinal adhesions requiring almost 2 hours to lyse and the patient was placed on CPB. Heart transplantation was performed using bicaval anastomoses [4e7]. CPB time was 170 minutes, total ischemic time 163 minutes, and crossclamp time 132 minutes. Kidney transplantation was performed by a separate surgical team after a period of hemodynamic stabilization. Postoperative immunosuppression consisted of anti-thymocyte globulin (ATG), followed by maintenance therapy with tacrolimus, mycophenolate mofetil, and prednisone [8e10]. The patient was extubated on postoperative day 1, and she was discharged in good condition on day 15 after combined HKTx. Endomyocardial biopsy on days 15 and 30 post-transplantation showed no evidence of cellular rejection or antibody-mediated rejection (AMR). On day 45 post-transplant, the biopsy showed mild acute cellular rejection (grade 1A-1R) and no evidence of AMR [10]. A Doppler echocardiogram showed normal left and right ventricular function. Renal function returned to normal. Case 2. A 56-year-old man with history of dilated idiopathic cardiomyopathy, LVEF 25%, atrial fibrillation, biventricular pacemaker-cardioverter-defibrillator insertion, hypertension, hyperlipidemia, and diabetes mellitus developed decompensated heart failure. Admission creatinine was 1.8e2.6 mg/dL, with a measured creatinine clearance of 36 mL/min (CKD stage 3). He was evaluated for heart transplantation and was placed on the heart transplant waiting list. He required inotropic support. Because of hemodynamic deterioration despite inotropic support, a TAH was placed. He subsequently had mediastinal exploration for bleeding. The patient became anuric and required hemodialysis. He continued to be anuric, was placed on the waiting list for combined HKTx, and remained in the hospital. On day 123, the patient underwent combined HKTx. Total CPB time was 180 minutes, cross-clamp time 162 minutes. Postoperative immunosuppression consisted of ATG, followed by maintenance therapy with tacrolimus, mycophenolate mofetil, and prednisone [8e10]. The patient
211
experienced right ventricular dysfunction postoperatively requiring inotropic support and hemodialysis for 10 days before recovering heart and renal function. He was discharged after 2 weeks. At 1 and 2 weeks after the transplant, endomyocardial biopsies were negative for cellular rejection and for AMR. LVEF on echocardiogram at 2 weeks was 57% and right heart catheterization revealed PA 33/12, with CO 7.06 L/min and CI 3.24. DISCUSSION
This report represents the first 2 consecutive cases of successful combined HKTx after TAH insertion from a single center. HKTx after TAH has been reported previously only twice in single case reports from different institutions [11,12]. The TAH has been implanted in more than 1,250 patients worldwide [3]. The longest time on TAH support has been 1374 days. The device was approved as bridge to heart transplantation and in selected cases may be used as destination therapy. The TAH has been applied in patients with severe biventricular failure after LVAD insertion and with allograft failure after HTx. Preoperative renal failure is considered a relative contraindication to TAH insertion [3]. VAD insertion is also contraindicated in patients with renal failure or with concomitant end-stage heart and kidney failure awaiting transplant [2]. The cardiorenal syndrome is a low-output state associated with end-stage cardiac and renal failure. Combined cardiac and renal failure is difficult to manage medically. Both patients in the current report had evidence of CKD (stage 3) upon admission, as well as advanced heart failure, and subsequently developed dialysis-dependent renal failure. We previously published our analysis of 30 consecutive patients who underwent combined HKTx at our institution, demonstrating excellent short- and long-term survival comparable with that after HTx alone, with low rates of cellular and AMR [8,13]. Furthermore, we evaluated the use of VAD as a bridge to combined HKTx in 6 consecutive patients with endstage heart and kidney failure [14]. Combined HKTx had excellent outcomes, suggesting that it is safe to perform HKTx in patients with combined heart and kidney failure who are bridged to transplant with a VAD. Now we report our experience using the TAH as bridge to combined HKTx in patients with concomitant heart and kidney failure awaiting transplant. On the basis of this limited experience, we consider TAH a safe and feasible option for bridging carefully selected patients with heart and kidney failure to combined HKTx. The patients in the current report waited in the hospital (>120 days) for the combined transplant, since they did not qualify for the SynCardia Freedom driver trial due to hemodialysis dependence. Recent FDA approval of the Freedom driver may allow outpatient management at substantial cost savings. The TAH, by virtue of its capability of providing pulsatile flow at 6e10 L/min, may be the mechanical circulatory support device most likely to recover patients with marginal renal function and advanced heart failure.
212
ACKNOWLEDGMENTS Francisco Arabia, MD, is a consultant to SynCardia. Jon Kobashigawa, MD, has received honoraria and/or research grants from XDx Inc., Novartis Pharmaceuticals Inc., Cylex, and Genzyme Corp.
REFERENCES [1] Norman JC, Brook MI, Cooley DA, Klima T, Kahan BD, et al. Total support of the circulation of a patient with postcardiotomy stone-heart syndrome by a partial artificial heart (ALVAD) for 5 days followed by heart and kidney transplantation. Lancet 1978;1:1125e7. [2] Kaltenmaier B, Pommer W, Kaufmann F, Hennig E, Molzahn M, Hetzer R. Outcome of patients with ventricular assist devices and acute renal failure requiring renal replacement therapy. ASAIO J 2000;46:330e3. [3] Copeland JG. SynCardia total artificial heart: update and future. Tex Heart Inst J 2013;40:587e8. [4] Trento A, Czer LS, Blanche C. Surgical techniques for cardiac transplantation. Semin Thorac Cardiovasc Surg 1996;8:126e32. [5] Trento A, Takkenberg JM, Czer LS, Blanche C, Nessim S, et al. Clinical experience with one hundred consecutive patients undergoing orthotopic heart transplantation with bicaval and pulmonary venous anastomoses. J Thorac Cardiovasc Surg 1996;112: 1496e502. [6] Blanche C, Nessim S, Quartel A, Takkenberg JJ, Aleksic I, et al. Heart transplantation with bicaval and pulmonary venous anastomoses. A hemodynamic analysis of the first 117 patients. J Cardiovasc Surg 1997;38:561e6.
RUZZA, CZER, IHNKEN ET AL [7] Aleksic I, Freimark D, Blanche C, Czer LS, Trento A. Does total orthotopic heart transplantation offer improved hemodynamics during cellular rejection events? Transplant Proc 2003;35: 1532e5. [8] Czer LS, Ruzza A, Vespignani R, Jordan S, De Robertis MA, et al. Survival and allograft rejection rates after combined heart and kidney transplantation in comparison with heart transplantation alone. Transplant Proc 2011;43:3869e76. [9] Goland S, Czer LS, Coleman B, De Robertis MA, Mirocha J, Zivari K, et al. Induction therapy with thymoglobulin after heart transplantation: impact of therapy duration on lymphocyte depletion and recovery, rejection, and cytomegalovirus infection rates. J Heart Lung Transplant 2008;27:1115e21. [10] Czer LS, Phan A, Ruzza A, Rafiei M, Setareh-Shenas S, Caceres M, et al. Antithymocyte globulin induction therapy adjusted for immunologic risk after heart transplantation. Transplant Proc 2013;45:2393e8. [11] Jaroszewski DE, Pierce CC, Staley LL, Wong R, Scott RR, Steidley EE, et al. Simultaneous heart and kidney transplantation after bridging with the CardioWest total artificial heart. Ann Thorac Surg 2009;88:1324e6. [12] Hansen AJ, Copeland JG. Combined heart-kidney transplant after CardioWest total artificial heart bridge. J Heart Lung Transplant 2010;29:1193e5. [13] Ruzza A, Czer LS, Trento A, Esmailian F. Combined heart and kidney transplantation: what is the appropriate surgical sequence? Interact Cardiovasc Thorac Surg 2013;17:416e8. [14] Yanagida R, Czer LS, Ruzza A, Schwarz ER, Simsir SA, Jordan SC, et al. Use of ventricular assist device as bridge to simultaneous heart and kidney transplantation in patients with cardiac and renal failure. Transplant Proc 2013;45:2378e83.
