By Hendra Lukman 
Children’s Hospital Colorado (Children’s Colorado) has achieved a monumental milestone in pediatric medicine, successfully performing its first-ever dual heart and liver transplant. This complex and life-saving procedure represents a significant advancement for the hospital’s renowned Pediatric Transplant Program and underscores its commitment to providing cutting-edge care for children with the most severe and life-threatening illnesses. The groundbreaking surgery involved an intricate collaboration among dozens of specialists, meticulously organized across 25 multidisciplinary care teams, highlighting the hospital’s exceptional capacity for coordinated, high-acuity interventions. Nationwide, this rare and challenging procedure has been performed on only 38 pediatric patients previously, underscoring the rarity and complexity of this achievement.
Dr. Megan Adams, surgical director of the Pediatric Liver Transplant and Kidney Transplant Programs at Children’s Colorado, expressed immense pride in the accomplishment. "Performing Children’s Colorado’s first-ever heart and liver dual organ transplant is an amazing accomplishment for our Pediatric Transplant Program," she stated. "Thanks to years of dedication and a team committed to being the trusted leaders in pediatric transplant across our seven-state region, we’re grateful to provide this level of care to even more kids who need complex organ transplants to treat life-threatening illnesses and help them live healthy and happy lives." Her remarks emphasize the sustained effort and strategic development that preceded this success, positioning Children’s Colorado as a vital resource for complex transplant needs in its expansive service area.
Years of Strategic Preparation Culminate in a Life-Saving Intervention
The successful dual transplant was not an isolated event but the culmination of years of meticulous planning, specialized training, and institutional commitment. Children’s Colorado had been strategically preparing its infrastructure and personnel for the possibility of performing such a complex dual organ transplant for an extended period. This foresight involved fostering deep collaboration among specialists from various critical fields, including cardiothoracic surgery, hepatology, cardiology, anesthesiology, critical care, and immunology, among others. The strong backing from hospital leadership provided the necessary resources and support to build a team capable of executing such a high-stakes procedure. This integrated approach ensured that when 11-year-old Gracie Greenlaw and her family urgently needed this life-saving intervention, the hospital was not only prepared but poised for success.
Gracie’s journey to this historic transplant began at birth, marked by a diagnosis of hypoplastic left heart syndrome (HLHS). This severe congenital heart defect means that the left side of her heart was underdeveloped, with only one functioning pumping chamber to support the entire circulatory system. From infancy, Gracie underwent a series of three complex palliative surgeries – the Norwood procedure, the Glenn shunt, and the Fontan procedure – designed to reroute blood flow and enable her heart to circulate blood more effectively. While advancements in pediatric cardiology have significantly improved the survival rates for children born with HLHS, allowing many to reach adulthood, the condition and its intricate surgical treatments can unfortunately lead to serious long-term complications. Among these, progressive liver damage and eventual liver failure are significant concerns for individuals with Fontan circulation, due to the chronic venous congestion and elevated pressures experienced by the liver.
Addressing the Long-Term Sequelae of Single Ventricle Physiology
Recognizing the complex and evolving medical needs of patients with single ventricle physiology, Children’s Colorado established the Fontan Multidisciplinary Clinic in 2016. This specialized clinic, an integral part of the hospital’s comprehensive Single Ventricle Program, was specifically designed to provide coordinated, holistic care for children diagnosed with HLHS and other conditions characterized by a single functional ventricle, such as tricuspid atresia and unbalanced atrioventricular canal defects. The clinic’s model emphasizes a team-based approach, bringing together pediatric cardiologists, cardiac surgeons, hepatologists, nephrologists, pulmonologists, gastroenterologists, dietitians, social workers, and child life specialists. This integrated care model ensures that every aspect of a patient’s health is continuously monitored and managed, anticipating potential complications and intervening proactively.
Through the Fontan Multidisciplinary Clinic, Gracie received ongoing, specialized monitoring and treatment for both her cardiac condition and the developing liver issues. Her dedicated care team, which included leading experts such as cardiologist Dr. Kathleen Simpson and hepatologist Dr. Dania Brigham, worked in close concert to manage her complex health status. Their collaborative efforts aimed to maintain Gracie’s health and quality of life for as long as possible, making informed decisions about when a transplant would become the optimal treatment pathway.
Dr. Simpson elaborated on the challenges inherent in long-term Fontan circulation management: "The Fontan is a lifesaving surgery, but the longer someone lives after the procedure, there is an increased chance of developing comorbidities. Our care team worked to keep her healthy and living a typical day-to-day life as long as possible before we determined a dual organ transplant would give her the best long-term quality of life." This statement highlights the careful balancing act involved in managing such complex congenital conditions, where the goal is not just survival, but sustained well-being and a high quality of life.
The Road to a Complex Dual Organ Transplant: A Race Against Time
The progression of Gracie’s condition eventually necessitated a more aggressive intervention. Over the years, she had lived with plastic bronchitis, a serious complication associated with Fontan circulation that causes the formation of thick, protein-rich casts within the airways, leading to significant respiratory distress. In the past year, Gracie’s symptoms of plastic bronchitis began to worsen, and concurrently, signs of progressive liver failure became increasingly evident. This dual deterioration presented a critical juncture for her medical team. After thorough evaluation and extensive consultation, the consensus was that a dual heart and liver transplant was the most viable option to provide Gracie with a chance at a healthy future. She was subsequently placed on the national transplant waitlist in April.
The preparation for a dual organ transplant is a monumental undertaking, far more intricate than a single organ transplant. For Gracie’s case, dozens of highly specialized physicians and surgeons convened regularly in the months leading up to her listing and continued to meet frequently as her condition warranted. These planning sessions were dedicated to meticulously strategizing every facet of the potential surgery. Key considerations included the precise timing of organ procurement, the logistical challenges of coordinating two separate organ implantations, the management of significant blood volume shifts, and the critical need for precise electrolyte and hemodynamic management throughout the prolonged operative period. The potential for immunological rejection of two different organs also necessitated careful pre-transplant conditioning and post-transplant immunosuppression protocols.
A Precisely Orchestrated 16-Hour Surgical Marathon
The window for organ transplantation is notoriously short, with donor hearts having a limited viability period of typically four to six hours outside the body. Gracie’s medical team was acutely aware of this critical time constraint. Less than a month after being placed on the transplant waitlist, compatible donor organs became available, a testament to the generosity of another family’s decision to donate life. The surgical team, prioritizing the heart transplant due to its stringent time sensitivity, commenced the operation with this procedure. Dr. Matthew Stone, surgical director of the Pediatric Heart Transplant Program, and congenital heart surgeon Dr. Emily Downs, led this initial, highly demanding nine-hour phase of the surgery.
While the cardiac team worked diligently on Gracie’s new heart, the donor liver was not idle. It was meticulously preserved and actively supported using a TransMedics Organ Care System (OCS). This state-of-the-art technology is designed to mimic the physiological environment of the human body, perfusing the donor liver with a nutrient-rich solution and allowing it to continue functioning outside the body. The OCS technology proved invaluable, preserving the liver’s viability and function, thereby providing the heart surgeons with the necessary time to complete their complex work without compromising the liver transplant’s feasibility.
Following the successful completion of the heart transplant, Dr. Adams and transplant surgeon Dr. Kendra Conzen took the lead for the liver transplant, which subsequently took an additional seven hours to perform. This phase involved the intricate dissection, removal of the diseased liver, and meticulous implantation of the donor organ, including the complex reattachment of the hepatic artery, portal vein, hepatic veins, and bile duct. Throughout the entire 16-hour surgical marathon, constant, vigilant communication and close coordination with the anesthesiology teams were paramount. These teams were responsible for maintaining Gracie’s physiological stability, managing anesthesia, monitoring vital signs, and ensuring the optimal conditions for both surgical teams. The successful execution of this dual transplant is a profound testament to the seamless teamwork and advanced surgical capabilities present at Children’s Colorado.
Recovery and a Renewed Future
The complex surgery proved successful, and Gracie began her long road to recovery. She transitioned from the intensive cardiac progress care unit just over a month after the procedure, a significant milestone indicating her stabilization and progress. Seven months post-transplant, Gracie continues to attend regular monthly follow-up appointments, a standard practice for transplant recipients to monitor for any signs of rejection or complications and to adjust immunosuppression medications. However, the most encouraging development is her return to a more normal life. She has resumed attending school, reconnecting with her peers and her education, and has returned home to her beloved dogs, a symbol of her regained health and vitality.
As with all pediatric heart transplant recipients, Gracie’s medical team anticipates that she will likely require another heart transplant later in life. The lifespan of transplanted hearts, while improving with medical advancements, is generally not indefinite. However, the prognosis for her transplanted liver is considerably more optimistic. The liver is known for its remarkable regenerative capacity, and a successful transplant is generally expected to last for the remainder of a recipient’s lifetime. This dual outcome offers a profound sense of relief and hope for Gracie and her family.
Dr. Duncan Wilcox, Surgeon in Chief at Children’s Colorado, highlighted the broader significance of this achievement: "This procedure showcases the expertise, talent and level of care Children’s Colorado provides to our patients, including those with complex medical needs," he remarked. "As the top-ranked pediatric hospital in Colorado and the Rocky Mountain region, we are proud of our leading-edge transplant care and look forward to supporting more patients who need dual organ transplants in the future." His statement not only celebrates the immediate success but also looks forward, reinforcing the hospital’s dedication to advancing transplant medicine and serving as a beacon of hope for children facing life-threatening organ failure across the region.
The success of this first dual heart and liver transplant at Children’s Colorado is more than just a medical achievement; it represents a tangible extension of hope and a testament to the power of specialized care and collaborative medicine. It underscores the critical role that advanced pediatric transplant centers play in offering second chances at life for children facing the most formidable health challenges. The hospital’s investment in multidisciplinary teams, advanced technology, and years of dedicated preparation has now positioned it to offer this extraordinary level of care, ensuring that more children like Gracie can look forward to healthy, fulfilling lives.
