By Hendra Lukman 
Children’s Hospital Colorado (Children’s Colorado) has successfully performed its first-ever dual heart and liver transplant, a complex and life-saving procedure that represents a significant advancement for the hospital’s Pediatric Transplant Program and a beacon of hope for critically ill children. This groundbreaking operation, involving dozens of specialists across 25 multidisciplinary care teams, underscores the hospital’s commitment to providing advanced medical care for the most challenging pediatric cases. Nationwide, this intricate procedure is exceptionally rare, with only 38 pediatric patients having previously undergone such a combined transplant.
The successful execution of this dual organ transplant is a testament to years of meticulous planning, interdisciplinary collaboration, and unwavering dedication from the medical staff at Children’s Colorado. Dr. Megan Adams, surgical director of the Pediatric Liver Transplant and Kidney Transplant Programs, expressed immense pride in the achievement. "Performing Children’s Colorado’s first-ever heart and liver dual organ transplant is an amazing accomplishment for our Pediatric Transplant Program," Dr. Adams 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."
A History of Comprehensive Care for Complex Conditions
The journey leading to this historic transplant began years ago, with Children’s Colorado proactively preparing for the possibility of performing such a complex dual organ procedure. This foresight involved extensive coordination among a diverse group of specialists, including cardiac surgeons, hepatologists, cardiologists, anesthesiologists, transplant coordinators, nurses, and numerous other allied health professionals. The strong backing from hospital leadership was also crucial, ensuring that the necessary resources and infrastructure were in place to support such an undertaking when a patient critically needed it.
The recipient of this pioneering transplant was 11-year-old Gracie Greenlaw, a young patient who has faced significant health challenges since birth. Gracie was born with hypoplastic left heart syndrome (HLHS), a severe congenital heart defect characterized by an underdeveloped left ventricle, the heart’s main pumping chamber. HLHS is one of the most serious congenital heart defects, affecting approximately 1 in 4,000 newborns. Children born with HLHS require immediate and extensive medical intervention.
Before her third birthday, Gracie underwent a series of three highly complex palliative surgeries designed to reroute blood flow and compensate for the underdeveloped left side of her heart. These included the Norwood procedure, the Glenn shunt, and the Fontan procedure. While these life-saving surgeries have dramatically improved survival rates for children with HLHS, enabling many to live into adulthood, they can also lead to serious long-term complications. One of the most significant of these complications is the increased risk of liver damage and eventual liver failure, a condition known as Fontan-associated liver disease (FALD).
The Fontan Multidisciplinary Clinic: A Model for Integrated Care
Recognizing the unique and multifaceted needs of patients with single ventricle physiology, Children’s Colorado established the Fontan Multidisciplinary Clinic in 2016. This clinic is an integral part of the hospital’s comprehensive Single Ventricle Program, which is dedicated to providing coordinated, holistic care for children diagnosed with HLHS and other conditions involving a single functioning ventricle, such as tricuspid atresia and unbalanced common atrioventricular canal.
The Fontan clinic brings together a dedicated team of specialists who work collaboratively to monitor and manage the complex interplay of cardiac and non-cardiac issues that can arise in these patients. Through this integrated approach, Gracie received continuous, specialized monitoring and treatment for both her heart and liver conditions. Key members of her care team included Dr. Kathleen Simpson, a leading cardiologist, and Dr. Dania Brigham, a renowned hepatologist. Their collaborative efforts ensured that Gracie’s health was managed proactively, anticipating potential complications and intervening as necessary.
"The Fontan is a lifesaving surgery, but the longer someone lives after the procedure, there is an increased chance of developing comorbidities," explained Dr. Simpson. "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 sentiment highlights the careful balance medical professionals must strike when managing chronic, complex conditions, weighing the benefits and risks of aggressive interventions against the goal of maintaining a good quality of life.
The Escalation of Illness and the Decision for Dual Transplant
Over the years, Gracie managed a chronic condition known as plastic bronchitis, a rare and serious complication associated with Fontan circulation. This condition involves the buildup of thick, protein-rich material in the airways, leading to respiratory distress and impaired lung function. In the past year, Gracie’s symptoms associated with plastic bronchitis significantly worsened, and concurrently, her liver began to show clear signs of failure. These developments indicated that her existing medical management was no longer sufficient, and a more definitive solution was required to preserve her life and improve her long-term prognosis.
After extensive evaluation and discussion among her multidisciplinary care team, the decision was made that a dual heart and liver transplant was the most viable option to address her life-threatening conditions and provide her with a chance at a healthy future. Gracie was subsequently placed on the national transplant waitlist in April, marking the beginning of a tense period of anticipation for her and her family.
Meticulous Preparation for an Unprecedented Procedure
The prospect of a dual heart and liver transplant triggered an intensive period of preparation at Children’s Colorado. Dozens of specialists from various departments convened regularly for detailed planning sessions. These meetings were critical for meticulously outlining every aspect of the complex surgical undertaking. The team addressed numerous logistical and medical challenges inherent in transplanting two vital organs simultaneously. Key considerations included managing significant differences in blood volume requirements between the heart and liver during the procedure, precise electrolyte balance, and the intricate coordination of surgical teams working in tandem. The hospital’s commitment to innovation and its advanced infrastructure were vital in facilitating this level of preparation for such a rare event.
A 16-Hour Marathon of Surgical Precision
The moment of truth arrived less than a month after Gracie was placed on the transplant waitlist. Compatible donor organs became available, a scenario made possible by the selfless generosity of another family’s decision to donate organs. Given the critical time sensitivity of organ transplantation, particularly for the heart, the surgical team prioritized the heart transplant.
The intricate heart transplant surgery was led by Dr. Matthew Stone, surgical director of the Pediatric Heart Transplant Program, and Dr. Emily Downs, a congenital heart surgeon. This phase of the operation lasted approximately nine hours. During this demanding procedure, a specialized device known as the TransMedics Organ Care System played a pivotal role. This advanced technology was used to maintain the donor liver in a near-physiological state, effectively replicating normal liver function outside the body. This innovative approach ensured the viability of the donor liver and provided the heart surgical team with the necessary time to complete their work without compromising the liver’s quality.
Following the successful completion of the heart transplant, the surgical focus shifted to the liver. Dr. Adams and Dr. Kendra Conzen, a transplant surgeon, led the seven-hour liver transplant procedure. The seamless transition between the two complex surgeries, along with the meticulous management of Gracie’s overall health and physiological stability, required constant and exceptionally close coordination with the anesthesiology teams. Their expertise was paramount in safeguarding Gracie’s well-being throughout the marathon 16-hour operation.
Recovery and a Renewed Promise of Life
The highly complex dual organ transplant was a resounding success. Gracie’s recovery journey began in the cardiac progressive care unit, where she remained for just over a month. This intensive period of monitoring and rehabilitation was crucial for her initial healing and adaptation to her new organs.
Seven months post-transplant, Gracie has demonstrated remarkable progress. While she continues to attend monthly follow-up appointments to ensure her long-term health and monitor the function of her transplanted organs, she has been able to resume a more normal childhood. She has returned to school, reconnecting with her studies and peers, and has joyfully returned home to be with her beloved dogs. This return to everyday life is the ultimate measure of success for such a life-altering procedure.
It is important to note that, as with most pediatric heart transplant recipients, Gracie will likely require a subsequent heart transplant later in her life, as the lifespan of a transplanted heart can be variable. However, the transplanted liver is expected to provide her with a healthy and functional organ for the remainder of her lifetime, significantly improving her long-term outlook and quality of life.
A New Era in Pediatric Transplant Care
The successful dual heart and liver transplant at Children’s Colorado is more than just a medical achievement; it signifies a new era in the hospital’s capacity to treat children with the most complex and life-threatening illnesses. Dr. Duncan Wilcox, Surgeon in Chief at Children’s Colorado, emphasized the significance of this milestone. "This procedure showcases the expertise, talent, and level of care Children’s Colorado provides to our patients, including those with complex medical needs," Dr. Wilcox stated. "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."
This achievement positions Children’s Colorado at the forefront of pediatric transplant innovation, not only within its seven-state service region but also on a national level. The experience gained from this groundbreaking surgery will undoubtedly inform future protocols and enhance the hospital’s ability to offer such complex interventions to other children facing similar critical conditions. The success serves as a powerful reminder of the critical importance of organ donation and the profound impact it has on transforming lives.
