Simultaneous Heart-Kidney Transplantation During Mechanical Circulatory Support in a Patient with Bilateral Iliac Artery Stenosis

A 54-year-old male patient was admitted to the emergency room due to cardiac arrest.He had history of coronary artery bypass surgery 3 years ago.Despite the surgery and optimal medical treatment for heart failure, the left ventricular ejection fraction (LVEF) remained less than 35%, and implantable cardioverter-defibrillator was inserted 2 years before admission.Also, he was on hemodialysis for chronic kidney failure and had severe stenosis with heavy calcification of bilateral lower extremity arteries.Six months ago, elective heart and kidney transplantation was discouraged by multi-disciplinary team discussion due to the concern of vascular risk related to the heavy calcification on lower extremity arteries.At the time of admission, he was on pulseless state, and an electrocardiogram (EKG) showed pulseless electrical activity.Thus, cardiopulmonary resuscitation (CPR) was performed, but there was no return of spontaneous circulation.Therefore, extracorporeal membrane oxygenation (ECMO) was inserted at the same time as CPR was performed.Coronary angiography showed significant stenosis at proximal right coronary artery (RCA) and a stent was deployed successfully.Despite revascularization of RCA, his LVEF was not recovered.Since the ECMO weaning process was not successful, we decided to perform simultaneous heart-kidney transplantation.After 2 weeks, appropriate donor was matched, and successful heart and kidney transplantation was performed with the meticulous management of calcified arteries.After the surgery, both heart and kidney remained normal function.He was transferred to the general ward on the third day, and discharged on the 45th day after the operation.To date, he is on stable follow-up at an outpatient clinic.This case showed successful simultaneous heart-kidney transplantation during ECMO in a patient with very high vascular risk and both heart-kidney dysfunction.Patients with multiple comorbidities require systematic management and multi-dimensional cooperation with flexible decision making according to the encountering situation.