| When it comes to a combined heart-liver transplant, success demands more than innate judgment and consummate surgical skill. It takes passion, the kind that rejects the very word “impossible,” the kind that challenges the unknown, and vigorously tackles being first, being best. |
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| Just a year ago, 15 members representing two transplant teams at Maryland performed the first such surgery in the state, and only the 53rd to be done in the country. The patient, a 33-year-old man, would have faced certain death had he not received both a new heart and new liver. He had been referred to Bartley Griffith, MD, chief of cardiac surgery, and director of cardiac transplantation, who had assisted in the world’s first few heart-liver transplants. “The clinical team in transplantation at this university is world-class and more than capable of performing the tricky double transplant,” Griffith says. |
Benjamin Philosophe, MD, associate professor of surgery and chief of the transplant team explains, “The transplanted heart has to be strong enough to withstand the stress of the liver transplant. It takes an incredible amount of coordination among team members. There is no way of knowing when a donor with both a healthy heart and liver will be available; so the team has to be ready at all times.”
After the two organs have been removed from the donor, the heart transplant begins. Finally, the liver is transplanted. From beginning to end, the entire procedure can take almost 24 hours. Because the patient is on a heart-lung machine during the surgery, blood thinners are used. This sets up a high risk of excessive bleeding. Luis Campos, MD, assistant professor of surgery and the team member who performed the liver transplant in that first combined procedure, recalls, “It was like sailing in uncharted waters.”
Campos and the team proved to be more than competent sailors, however, since the surgery was successfully completed with only minimal blood loss and little variation in blood pressure. The patient was released from the medical center in two weeks time, and has been able to resume a healthy lifestyle. Less than a week later, the transplant teams were called into action for a repeat performance of the same surgery, this time for a patient suffering from amyloidosis, a disease in which a protein forms in the liver and destroys both the liver and the heart.
Surgeons who comprise the school’s transplant teams are leading the field with some of the most difficult procedures—from simultaneous pancreas-kidney transplants to “domino” liver surgeries involving a deceased donor and two recipients, plus advanced procedures for lung and cardiac transplantation. Added to that is extensive research including pre-clinical studies offering new hope for facial and other composite tissue transplants.
Quality of Life Decisions
Most people with Type 1 diabetes become diabetic at an early age and face a lifetime requirement of insulin. After living with the disease for 20 years, 40 percent of patients suffer kidney failure and need dialysis. Many will require a transplant. Today, depending on the severity of their disease, patients have a choice. They may opt for a kidney transplant and be placed on a waiting list, or they can search for a living donor.
Stephen T. Bartlett, MD, professor and chair, department of surgery, reports that following a combined pancreas-kidney transplant, patients return home in about seven days, off dialysis and their kidney failure cured. He says studies on the impact of kidney transplantation report dramatically improved quality of life. “This is one of the most gratifying parts of my work, seeing the changes in a patient’s life” Bartlett says. “I have seen grown men cry from the emotion of having a lifelong disease cured. No longer do they face the personal investment in self care, managing their diabetes, or having to submit to the rigors and limitations of dialysis.”
For many, however, there is an even better option—a laparoscopic living donor transplant. Having performed more than 1,200 of these procedures since 1995, the team is the unqualified world leader in the surgery that minimizes the medical trauma for donors, and benefits patients by negating the necessity of waiting for a deceased donor kidney. The living donor need not be a relative. Even age doesn’t disqualify a donor. Philosophe points out one recent donor was 74 years old. “We look at the overall condition of the kidney donor, not just their age,” he says.
Historically, patients requiring transplantation hesitate to ask a family member or friend to donate an organ because of the discomfort and possible lengthy recuperative time. However, the living kidney donor has the organ removed laparoscopically through several small incisions. No muscle is split, meaning that healing is fast, and the donor can leave the hospital within
24 hours.
Some patients will require more than a kidney transplant however. In spite of rigid self management of their disease and care by an endocrinologist, they have serious secondary complications that may include retinopathy leading to blindness or loss of muscle control. For them, transplanting both the kidney and pancreas simultaneously is possible. In cases in which a living kidney donor is available, either simultaneous or separate living donor kidney and deceased donor pancreas transplants can be performed with equal success rates. A highly complicated surgery, pancreas-kidney transplantation is one which Maryland’s transplant team has performed successfully more than 750 times. “The diabetic patient may present with many complications,” Bartlett says. “For instance, diabetics often have hardening of the arteries or vascular issues. Then there are hazards of the surgery itself—risk of infection or bleeding.”
The surgeon who was the first to perform successful pancreas-kidney transplants in both Maryland and California qualifies these challenges by adding, “None of this makes the procedure impossible however—just technically demanding.”
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The Domino Effect
In this age of technological and scientific breakthroughs, milestones often are complacently placed in the context of inevitability, the expected consequence of having solved earlier medical puzzles that pave the way for even more extraordinary discoveries. Few can remain complacent, however, when considering the significance of one liver from a deceased donor playing a central role in saving the lives of two patients.
That’s what happens through a relatively new sequential or “domino” liver transplant in which a liver from a deceased donor is transplanted to cure a life-threatening genetic disease in one patient, and that patient’s liver is transplanted to another person suffering liver failure.
Philosophe explains that familial amyloidosis is a disease that gradually causes paralysis throughout the body. “The only curative treatment is a transplant,” he says. “This disease is caused by an abnormal protein produced by the liver that gets deposited in tissue over many years.” He reports that the damage is done gradually, and that the disease doesn’t manifest itself for at least 30 years. In the meantime, the liver is normal in every other way. So an older been transplanted in an adjacent surgery suite puts singular meaning to the phrase “new lease on life.”
“This procedure is a complicated one,” Philosophe says “Surgeons have to cut the connecting blood vessels from the first patient in a way that provides enough length to attach the liver received from the deceased donor, while making sure the vessels from that patient’s liver are long enough to attach during the second transplant.”
Even liver transplant patients today benefit from the availability of a procedure using living donors. True, one can’t live without a liver, but people do well without a portion of their native liver. Part of the living donor’s organ, generally the right lobe, is transplanted with the result that it—and the part retained by the donor—are regenerated in both donor and recipient
Cutting Edge Research
Bartlett, along with Rolf N. Barth, MD, assistant professor of surgery, and Eduardo Rodriguez, MD, associate professor of surgery, and chief of plastic and reconstructive surgery at the R Adams Cowley Shock Trauma Center, have developed a pre-clinical model for transplanting composite tissue allografts. The plan calls for using tissue of skin, muscle, and bone in facial transplants for the military wounded, trauma victims, and those who have undergone oncologic resections that destroy part of the face.
The idea for the research originated when Bartlett received a request for grant applications from the U.S. Department of Defense, seeking innovative strategies for treating military injuries. The team received the grant and additional subsequent funding for this much needed area of investigation. “There are people who have devastating facial injuries for which there are no adequate solutions,” Barth reports. “Some have had dozens of surgeries without regaining their normal appearance. If we can transplant them with a segment of missing tissue—whether it be for the face, limb or chest wall—we may be able to restore their deformity and their self esteem in one operation.”
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“Every defect in every patient will be different,” he says. “Each detail must be carefully worked out so that we know, through appropriate scans and clinical examination, just what is needed, and what we’ll have to harvest in order to correct the defect.”
Commenting on the imminence of clinical trials, he says the team is very close but adds, “This isn’t a race, and we don’t care whether or not we are the first in the U.S. to do this. What we care about is doing it right, while being able to predict the outcome.”
Heart and Lung
Statistics alone tell a dramatic story of the medical school’s cardiothoracic program headed by Griffith. During the year 2007, 15 lung transplants were performed—11 of them double lobe transplants. There were 30 heart transplants, one heart-kidney and two heart-liver transplants. While no patient that year required the highly delicate procedure to transplant both heart and lung simultaneously, the team is one of relatively few to successfully perform that operation.
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Griffith is regarded internationally for his work, including being the first to save the life of a woman with a recurring heart tumor by removing both of her heart’s upper chambers, then reconstructing them with animal and human donor tissue. The patient’s heart was removed from her chest for five hours before being reimplanted. The cardiac team is being funded by the National Institutes of Health for the study of pig organs for use in human transplants. In addition, they are conducting a trial to evaluate a perfusion machine to maintain the donor heart in a fresh state that actually allows it to beat in the machine. The heart goes through a difficult time when the brain dies and the pituitary gland and central areas of the brain send signals to the body, resulting in heart damage. Griffith, who is co-director of a national trial to test the device, explains, “We’re tricking the heart into thinking it is still in the body while we control all the factors.”
The plan is to get the heart out of the post-brain dead environment in order to restore its function. In its own studies, the team has investigated the device in the laboratory on hearts that were rejected for transplants. Results were promising, Griffith says, though not yet conclusive enough for actual use in transplantation.
Griffith recently authored an article in the New England Journal of Medicine that describes the team’s development of a means of combating organ rejection in lung transplants.
“Early chronic rejection is the biggest obstacle to lung transplantation,” he says. “Immuno-suppressant drugs generally are administered orally, but the lung is available to us through breathing. So we developed an aerosol medication and used it in high concentrations, getting it directly to where it was most needed. We were able to do this without influencing the otherwise toxic side effects of the drug.”
The Core of Success
What does it take to become a transplant surgeon, particularly on a team recognized for pioneering achievement? Bartlett says, “You can’t be daunted by complications. You have to anticipate them and be prepared at all times. A transplant surgeon needs an enormous amount of determination. There are critical decisions to be made—before, during and after the surgery. Those decisions, even though they aren’t made in a vacuum but with the help of colleagues, often are the toughest part.”
He doesn’t mention the almost indefinable passion—the intense dedication that is reflected in the approach these surgeons take in their work—the denial of failure, and the optimism that guides every successful transplant. Oddly enough, there is a certain reserve as well, a disinclination to boast. Maybe that’s understandable. There isn’t much time for boasting in the day of a transplant team