Introduction: Combined heart and liver transplantation (CHLT) is a highly complex treatment option for pediatric patients with single ventricle physiology palliated with a Fontan procedure, which requires extensive surgical planning and multidisciplinary management. Our aim was to describe two different surgical approaches to CHLT. 
Methods: Description of differing surgical strategies employed during the CHLT of two failing Fontan patients (13 and 17-year-old) with bridging fibrosis on the Congestive Hepatic Fibrosis Scoring System. 
Results: In patient 1 both the heart and liver were transplanted under cardiopulmonary bypass (CPB) with a liver cold ischemia time (CIT) of 200 minutes. The liver was implanted with caval replacement. After completing both transplants, CPB was converted to a closed extracorporeal circuit (CEC).
In patient 2, CPB was converted to CEC after completing cardiac implantation and successfully reverting anticoagulation. Meanwhile, the liver graft was treated with hypothermic oxygenated perfusion (HOPE) during 282 minutes and was implanted with a 2-hour CIT and almost normal coagulation values using a piggy-back anastomosis. Patient 2 required less extracorporeal support, blood product transfusions and had a shorter ICU stay. 
Conclusion: Pediatric CHLT are a surgical challenge that require multidisciplinary involvement and can be performed following different surgical schemes.