Comment on: Detection and Management of HLA Sensitization in Candidates for Adult Heart Transplantation

Dear Editors, We read with interest the manuscript “Detection and management of HLA sensitization in candidates for adult heart transplantation”1DeFilippis EM Kransdorf EP Jaiswal A et al.Detection and management of HLA sensitization in candidates for adult heart transplantation.J Heart Lung Transplant. 2022; (Published online December 27)https://doi.org/10.1016/j.healun.2022.12.019Abstract Full Text Full Text PDF Scopus (1) Google Scholar by DeFillippis and colleagues. The manuscript presents a concise and pertinent state of the art review regarding a practical clinical approach to the sensitized heart transplant recipient. A burgeoning area of interest of our group which was not discussed, however, is the utility of heart after liver transplantation as a modality to provide profound immunologic protection. Daly et. al recently published a small, retrospective single institutional study (n=7) of patients with high allosensitization who underwent combined heart after liver transplant (HALT). In their subset of patients, the median PRA was 77%, all had positive prospective pre-operative T-cell crossmatch. Following HALT, retrospective cross match was negative in all patients, DSA levels were insignificant, and no patients experienced greater than 1R rejection over a median follow-up period of 48 months2Daly RC Rosenbaum AN Dearani JA et al.Heart-After-Liver Transplantation Attenuates Rejection of Cardiac Allografts in Sensitized Patients.J Am Coll Cardiol. 2021; 77: 1331-1340https://doi.org/10.1016/j.jacc.2021.01.013Crossref Scopus (9) Google Scholar. These results, albeit in a small, highly selected patient population, are highly encouraging as we continue to encounter increasing numbers of sensitized patients who would benefit from heart transplantation. As a specialty we are moving rapidly towards embracing expanded donor criteria, innovation, machine perfusion, and surgical advances. The field is in a position where we can offer heart transplantation to patients who may otherwise have been denied. Specifically, HALT may be a very helpful modality to address the unique challenges associated in adults with congenital heart disease (ACHD) which we have seen represented in a growing population within our end stage heart failure patients. Recognizing that ACHD patients have higher rates of sensitization compared to non-congenital heart disease recipients, in addition to the added complexity of Fontan physiology, multiple sternal re-entries, and aortopulmonary collaterals, with an increased risk of bleeding, HALT may provide the ability to address multiple challenging variables in this difficult patient population. The management and capacity to move highly sensitized patients to transplant is improving. Further investigation into the utility of HALT as a strategy is warranted.