COMBINED HEART AND LIVER TRANSPLANTATION: Edited by Juliet Emamaullee and Eugene DePasqualeConsiderations and experience driving expansion of combined heart–liver transplantationGong, Timothya,b,c; Hall, Shelleya,b,cAuthor Information aCenter for Advanced Heart and Lung Disease, Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center bDivision of Cardiology, Department of Advanced Heart Failure, Mechanical Support, and Transplant, Baylor Heart and Vascular Hospital, Dallas cTexas A&M University College of Medicine, Bryan, Texas, USA Correspondence to Timothy Gong, MD, Center for Advanced Heart and Lung Disease, Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, 3410 Worth Street, Suite 250, Dallas, TX 75246, USA. Tel: +1 214 820 6856; fax: +1 214 820 1474; e-mail: email@example.com Current Opinion in Organ Transplantation: October 2020 - Volume 25 - Issue 5 - p 496-500 doi: 10.1097/MOT.0000000000000804 Buy Metrics Abstract Purpose of review Heart transplantation concomitant with a liver transplant may be warranted when end-stage heart failure results in irreversible liver failure. Previously reported outcomes have been excellent yet the specific immunoprotective role of the liver allograft is not known. We review the current literature about the immunologic benefit for combined heart and liver transplantation (CHLT). Recent findings The total number of combined heart and liver transplants continues to increase and accounts for approximately 25 cases per year. Familial amyloid polyneuropathy with cardiac cirrhosis is the most common indication for CHLT while adult congenital heart disease (CHD) with associated cirrhosis is increasing in frequency. The majority of recent registry data suggest a statistically equivalent to modestly improved survival advantage for CHLT compared with isolated heart transplantation. Direct mechanisms accounting for this survival advantage are not proven, but combined heart and liver transplants experience lower rates of acute cardiac rejection and cardiac allograft vasculopathy (CAV). Summary Combined heart and liver transplants remain a small percentage of the total heart transplants worldwide, but the majority of recent literature confirms the safety and viability of this option for patients with end-stage heart and liver disease. Equivalent to modestly improved survival outcomes, lower rates of acute cardiac rejection and CAV warrant further investigation into the liver allograft's immunoprotective effect on the transplanted heart. The key mechanisms of tolerogenicity have important implications for surgical technique and immunosuppression requirements. Future directions include development of criteria for heart–liver transplant candidacy and identification of equitable allocation protocols. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.