Clinical Outcomes of Adult Fontan-Associated Liver Disease and Combined Heart-Liver Transplantation

Matthew J. Lewis, Leigh C. Reardon, Jamil Aboulhosn, Christiane Haeffele, Sharon Chen, Yuli Kim, Stephanie Fuller, Lisa Forbess, Laith Alshawabkeh, Marcus A. Urey, Wendy M. Book, Fred Rodriguez, Jonathan N. Menachem, Daniel E. Clark, Anne Marie Valente, Matthew Carazo, Alexander Egbe, Heidi M. Connolly, Eric V. Krieger, Jilian AngiuloAri Cedars, Jong Ko, Roni M. Jacobsen, Michael G. Earing, Jonathan W. Cramer, Peter Ermis, Christopher Broda, Natalia Nugaeva, Heather Ross, Jordan D. Awerbach, Richard A. Krasuski, Marlon Rosenbaum

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


Background: The impact of Fontan-associated liver disease (FALD) on post-transplant mortality and indications for combined heart-liver transplant (CHLT) in adult Fontan patients remains unknown. Objectives: The purpose of this study was to assess the impact of FALD on post-transplant outcomes and compare HT vs CHLT in adult Fontan patients. Methods: We performed a retrospective-cohort study of adult Fontan patients who underwent HT or CHLT across 15 centers. Inclusion criteria were as follows: 1) Fontan; 2) HT/CHLT referral; and 3) age ≥16 years at referral. Pretransplant FALD score was calculated using the following: 1) cirrhosis; 2) varices; 3) splenomegaly; or 4) ≥2 paracenteses. Results: A total of 131 patients (91 HT and 40 CHLT) were included. CHLT recipients were more likely to be older (P = 0.016), have a lower hemoglobin (P = 0.025), require ≥2 diuretic agents pretransplant (P = 0.051), or be transplanted in more recent decades (P = 0.001). Postmatching, CHLT demonstrated a trend toward improved survival at 1 year (93% vs 74%; P = 0.097) and improved survival at 5 years (86% vs 52%; P = 0.041) compared with HT alone. In patients with a FALD score ≥2, CHLT was associated with improved survival (1 year: 85% vs 62%; P = 0.044; 5 years: 77% vs 42%; P = 0.019). In a model with transplant decade and FALD score, CHLT was associated with improved survival (HR: 0.33; P = 0.044) and increasing FALD score was associated with worse survival (FALD score: 2 [HR: 14.6; P = 0.015], 3 [HR: 22.2; P = 0.007], and 4 [HR: 27.8; P = 0.011]). Conclusions: Higher FALD scores were associated with post-transplant mortality. Although prospective confirmation of our findings is necessary, compared with HT alone, CHLT recipients were older with higher FALD scores, but had similar survival overall and superior survival in patients with a FALD score ≥2.

Original languageEnglish (US)
Pages (from-to)2149-2160
Number of pages12
JournalJournal of the American College of Cardiology
Issue number22
StatePublished - Jun 6 2023


  • Fontan-associated liver disease
  • adult Fontan
  • combined heart-liver transplant
  • heart transplant

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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