July 01, 2025
Highly sensitized patients who need a heart transplant now have a chance to successfully receive a donor organ and add years to their lives.
Patients who are highly sensitized have elevated antibody levels that can cause the immune system to reject a transplanted organ. Sensitization often occurs due to blood transfusions, pregnancies, ventricular assist devices and previous transplants. In these cases, a patient may only match with less than 5% of the donor population.
Faced with these odds, transplant specialists at Mayo Clinic in Florida recently found a solution for a highly sensitized patient on a left ventricular assist device (LVAD) who needed a heart transplant and whose health continued to deteriorate after desensitization therapies failed.
The solution — an enterprise-first procedure known as heart-after-liver domino transplant, also known as HALT-D — became only the second such transplant surgery performed in the country involving a patient on LVAD support. It also built on an innovative surgical approach pioneered at the Mayo Clinic in Minnesota.
The reverse transplant procedure that opened doors
Since 2011, transplant surgeons at Mayo Clinic have performed a reverse dual heart-liver transplant procedure called heart-after-liver transplant, also known as HALT, in patients who need both a heart and a liver — and who fit other criteria for candidacy.
With HALT, instead of transplanting the heart first and then the liver, transplant surgeons follow a sequence where the liver is transplanted first and then the heart.
In 2021, a research team led by Sudhir S. Kushwaha, M.D., a cardiologist at Mayo Clinic in Minnesota, found that performing this reverse transplant significantly lowered rejection rates for highly sensitized patients with elevated antibody levels.
The researchers found that transplanting the liver first decreases a patient's donor-specific alloantibody (DSA) levels, helping to avoid negative immunological responses and lowering the patient's rejection risk.
"The heart is very sensitive, whereas the liver appears to tolerate exposure to high levels of circulating antibodies," Dr. Kushwaha said at the time. "If we put the heart in first, we know the circulating antibodies will attack the heart."
The HALT-D procedure
When they couldn't find any other options for their heart transplant patient on LVAD support, Parag C. Patel, M.D., a transplant cardiologist at Mayo Clinic in Florida, set to work searching for solutions. He looked at Dr. Kushwaha's study in the Journal of the American College of Cardiology and to more recent research published in The Journal of Heart and Lung Transplantation investigating the efficacy of a combined heart-after-liver transplant with domino for sensitized patients with a healthy liver.
In heart-after-liver transplant with domino liver transplant, also known as HALT-D, a patient receives two donor organs — a liver and then a heart — to prevent the likelihood the body will reject a donor heart. At the same time, the patient donates their own liver to another patient, making each patient an organ recipient and an organ donor within the same day.
Dr. Patel knew his patient had a functioning liver, so he discussed the possibility of HALT-D for the patient with a multidisciplinary team. This team included abdominal transplant surgeons; hepatologists; cardiothoracic surgeons; transplant cardiologists; transplant and cardiac anesthesiologists; transplant and cardiovascular critical care; and members of the human leukocyte antigen (HLA) lab, as well as others from the high-risk liver committee, pharmacy, perfusion and lab medicine.
"Although we hadn't performed HALT-D on a patient on LVAD support before, we knew this could be a path forward," says Dr. Patel.
To help the patient's new liver absorb antibodies as effectively as possible, the surgical team used plasmapheresis during the transplant to clear the patient's blood of as many antibodies as possible. The team also gave the patient eculizumab to suppress the immune system so it wouldn't create any additional antibodies. Afterward, team members monitored the patient's antibodies to make sure they didn't increase and administered immunosuppression medications.
The patient tolerated the procedure well and is now almost ready to get back to her normal life.
"We were very excited by HALT-D's success with this patient," says Dr. Patel. "This is a true innovation that will create opportunities for other patients who were previously not transplant candidates."
Future opportunities with HALT-D
The follow-up for people who undergo HALT-D is about the same as it is for a patient with a heart transplant, Dr. Patel says. The only difference is the heightened monitoring of antibodies in HALT-D patients.
"Unlike other transplant patients, we're watching for antibodies daily initially, then weekly, then monthly, at least for the first six months," he says. "If at that point they demonstrate stability, we can be relatively confident."
Dr. Patel and his team noticed that the patient's antibodies were reduced within hours of the liver transplant — and they stayed reduced.
"This gives us hope that this type of therapy would allow for better longevity compared to traditional therapies for desensitization," he says.
The experience also has led to a domino effect across the other Mayo Clinic sites: "Each institution has learned from these results and is now finding opportunities to help patients who didn't have options before," says Dr. Patel.
While most transplant centers don't take on heart-liver transplants or even dual transplants at all, Mayo Clinic transplant surgeons are willing to see these patients with complex needs because of their expertise and team approach to care.
For more information
Daly RC, et al. Heart-after-liver transplantation attenuates rejection of cardiac allografts in sensitized patients. Journal of the American College of Cardiology. 2021;77:1331.
Lin S, et al. Heart after liver transplantation with domino for a highly sensitized patient. The Journal of Heart and Lung Transplantation. 2023;42:1632.
Refer a patient to Mayo Clinic.