Additionally, it is advisable to con- sider options for transplantation or ventricular assist de- vice as a backup before other high-risk surgery is pursued. See Online Data Supplement 23 for referenced studies. 3.14.3. Multiorgan Transplant Recognizing the vulnerability of many organ systems in patients with CHD, multiorgan transplantation is often considered, although infrequently performed. Multi- organ transplantation requires a multidisciplinary and comprehensive approach with thoughtful planning and communication among practitioners. Multiorgan transplantation may be performed as se- quential operations or as a single operation. Typically, simultaneous multiorgan procedure in patients with CHD will be heart-lung transplantation for conditions that result in irreversible pulmonary hypertension such as Eisenmenger syndrome.S3.14.3-1,S3.14.3-2 Fewer than 100 heart-lung transplants are performed internationally each year, with a median survival of 3.3 years and 10-year survival of 32%.S3.14.3-3 Survival is worse for heart-lung recipients than single-organ heart or lung recipients pos- sibly, in part, because of longer wait times.S3.14.3-4 CLINICAL STATEMENTS AND GUIDELINES The occurrence of simultaneous heart-liver trans- plantation is an option in patients with severe right-sid- ed HF and in single ventricle patients after Fontan palli- ation. Given the recognized vulnerability of the liver to injury in Fontan patients and the fact that heart alone transplantation outcomes have been poor in patients with concomitant liver dysfunction, transplant centers may favor heart-liver transplantation in those with cir- rhosis, but this policy is not universal. Fewer than 15 such procedures are performed annually in the United States, and approximately 20% of patients are referred because of underlying CHD.S3.14.3-5,S3.14.3-6 Consequently, experience with these procedures is limited,S3.14.3-5,S3.14.3-7 and heterogeneity makes generalizability difficult. Data are insufficient to support recommendations. 