The Children's Hospital of Colorado in the United States recently successfully completed the hospital's first combined heart and liver transplant for a child. The difficult 16-hour operation gave 11-year-old girl Gracie Greenlaw a new life. This rare case also marks a key step for the hospital in the field of complex multi-organ transplantation. Only 38 children in the United States have previously received sequential or combined heart and liver transplants.
Children's Hospital Colorado stated that this operation is an important milestone for the hospital's pediatric transplant program. The operation relies on the close collaboration of 25 multidisciplinary teams and dozens of experts, covering multiple specialties such as cardiac surgery, liver transplant surgery, cardiology, hepatology, anesthesia, and critical care medicine. Dr. Megan Adams, surgical director of the Pediatric Liver Transplant and Kidney Transplant Surgery Program, said that it is the continuous accumulation and inter-specialty collaboration over the years that has given the hospital the ability to perform such complex multi-organ transplants, thereby providing hope for more children with critical and complex diseases.
Gracie was diagnosed at birth with hypoplastic left heart syndrome, a severe congenital heart malformation in which only one ventricle pumps blood effectively. Before she was three years old, she had undergone three major heart surgeries: Norwood's, Glenn's and Fontaine's to reconstruct blood flow pathways and maintain systemic circulation. With the improvement of surgical and perioperative management, more and more such children can survive into adolescence or even adulthood. However, long-term cardiac function compensation and circulatory changes will also bring continuous burden to the liver and other organs, and some children will eventually develop abnormal liver function or even liver failure.
In order to deal with this risk of long-term complications, Children's Hospital Colorado established the Fontaine multidisciplinary clinic in 2016 under the framework of the single ventricle project to provide full follow-up management for patients with single ventricles such as left heart hypoplasia, tricuspid atresia, and unbalanced atrioventricular channel. Under the joint management of cardiologist Dr. Katherine Simpson and hepatologist Dr. Dania Brigham, Gracie's heart and liver function were monitored and evaluated in a long-term and systematic manner. As time went by, the medical team judged that it was difficult to fundamentally improve her prognosis by relying solely on drugs and conventional intervention. Combined heart and liver transplantation would be her best option to achieve a better long-term quality of life.
Before establishing the direction of transplantation, Gracie had repeatedly struggled with plastic bronchitis for many years. This disease can form thick protein-like "emboli" in the airways, seriously affecting breathing. Over the past year, her respiratory symptoms have worsened, and her liver function indicators have worsened significantly, suggesting a gradual loss of liver compensatory capacity. After evaluation, the medical team decided to apply for a combined heart and liver organ transplant for her, and in April she was officially placed on the waiting list for a dual organ transplant.
Focusing on this operation, the hospital's large team composed of the Department of Surgery, Cardiology, Hepatology, Anesthesia, and Intensive Care held many meetings to review possible blood volume fluctuations, electrolyte balance changes, coagulation, perfusion and other risks that may occur during the surgical steps. Compared with single-organ transplantation, heart and liver replacement are performed sequentially in the same operation, requiring the team to achieve an extremely delicate balance between time window, organ preservation, and the patient's overall condition.
Less than a month after she was put on the waiting list, a suitable donor organ became available - a relay for life made possible by a family who chose organ donation despite their overwhelming grief. Since the heart can only survive outside the body for a limited time, the surgical team first performed a heart transplant. Dr. Matthew Stone, surgical director of the Pediatric Heart Transplantation Program, and congenital heart surgeon Emily Downs were the surgeons. It took about nine hours to complete the heart replacement and related reconstruction.
At the same time, the liver from the same donor was connected to a TransMedics organ maintenance system. This "ex vivo life support pump" simulates the blood flow and metabolic environment of the human liver to help the organ maintain stable function during the waiting period. After the heart transplant was successfully completed, Dr. Adams and transplant surgeon Kendra Kangzen took over and performed the liver transplant, which lasted about seven hours. Throughout the process, the anesthesia team continued to fine-tune the hemodynamic and metabolic status to ensure Gracie's stability during the long operation.
The surgery was successful. More than a month after surgery, Gracie was successfully discharged from the Cardiac Progression Care Unit. It has been about seven months since the surgery. She still needs to return to the hospital for monthly check-ups, but she has been able to return to school and play with her dog at home, gradually returning to a near-normal daily life. Doctors predict that, like all pediatric heart transplant patients, she may need another heart transplant at some stage in her future life, but the transplanted liver is expected to stay with her throughout her life.
Duncan Wilcox, chief of surgery at Children's Hospital Colorado, said that this case epitomizes the hospital's professional strength and full care capabilities in the diagnosis and treatment of complex childhood diseases and organ transplantation. As a leading pediatric medical institution in Colorado and the entire Rocky Mountain region, the hospital hopes to build on this foundation and further carry out more difficult multi-organ transplants to provide more complex and critically ill children with opportunities to survive and improve their quality of life.