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. For all patients, survival mimics that for liver transplantation Outcomes in Fontan patients with or without cirrhosis are not necessarily different in those who receive heart transplantation alone.S3.14.3-5, Multicenter data gathering on patients con- sidered for multiorgan transplantation are needed to inform future recommendations for these therapies. 3.15. Palliative Care Recommendation for Palliative Care Referenced studies that support the recommendation are summarized in Online Data Supplement 24. COR LOE Recommendation IIa B-NR Discussion of end-of-life issues and advance directives can be beneficial for patients with ACHD or their surrogates.S3.15-1 S3.15-3 Recommendation-Specific Supportive Text 1. Patients with ACHD sometimes have significant morbidities not amenable to effective medical or surgical treatment and may be best managed using the consultative expertise of palliative care special- ists. Accurate predictions of prognosis in ACHD are difficult, and patients commonly receive aggressive treatments during their terminal admission.S3.15-4 There is a discrepancy between patient-reported in- terest in discussing advance directives and physician- reported discussions, with more patients interested in such discussions than recognized by providers.S3.15-1, Early discussion of advance planning is favored by nearly twice as many patients as physicians.S3.15-3 Early discussion of end-of-life issues is consistent with patient-centered care and patient satisfaction and can facilitate palliative care. Although discuss- ing end-of-life options would seem appropriate for all patients, there are circumstances (eg, cultural or cognitive) when those conversations may not be appropriate. Similarly, although the goal is not to wait to discuss end-of-life until death is imminent, such discussion may not have the same benefit for young patients who are clinically well with low-risk disease. 