By Hendra Lukman 
Children’s Hospital Colorado (Children’s Colorado) has successfully performed its first-ever dual heart and liver transplant, a groundbreaking achievement for its Pediatric Transplant Program and a testament to years of dedicated preparation and interdisciplinary collaboration. This complex life-saving procedure, involving dozens of specialists across 25 multidisciplinary care teams, marks a significant advancement in the hospital’s capacity to treat children with the most severe and life-threatening organ failures. Nationwide, such dual transplants are exceedingly rare, with only 38 pediatric patients having undergone this procedure previously.
The successful completion of this intricate surgery underscores Children’s Colorado’s commitment to providing advanced, comprehensive care for young patients facing critical medical challenges. Dr. Megan Adams, surgical director of the Pediatric Liver Transplant and Kidney Transplant Programs, 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," 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 Journey of Preparation and Resilience
The path to this monumental achievement was paved with years of meticulous planning, specialized training, and unwavering dedication from the medical staff at Children’s Colorado. The hospital’s leadership recognized the growing need for advanced transplant capabilities, particularly for patients with complex congenital conditions that can impact multiple organ systems. This foresight allowed for the development of robust multidisciplinary teams capable of tackling procedures of unprecedented complexity.
The story of 11-year-old Gracie Greenlaw, the recipient of this historic transplant, highlights the critical importance of this forward-thinking approach. Gracie was born with hypoplastic left heart syndrome (HLHS), a severe congenital heart defect characterized by the underdevelopment of the left side of the heart. This condition necessitates extensive medical interventions from infancy. Gracie underwent three major open-heart surgeries—the Norwood, the Glenn, and the Fontan procedures—before the age of three, each designed to reroute blood flow and enable her single functioning ventricle to sustain circulation. While these Fontan-type circulations are life-saving, they are known to place significant long-term strain on the liver, often leading to progressive liver damage and eventual failure.
The Fontan Multidisciplinary Clinic: A Model of Integrated Care
In recognition of the complex and evolving needs of patients with single-ventricle physiology, Children’s Colorado established the Fontan Multidisciplinary Clinic in 2016. This clinic operates under the umbrella of the hospital’s Single Ventricle Program, a specialized initiative dedicated to providing comprehensive, coordinated care for children diagnosed with HLHS and other conditions affecting a single pumping chamber of the heart. Conditions such as tricuspid atresia and unbalanced common atrioventricular canal also fall under the purview of this program. The clinic’s philosophy centers on a "whole-patient" approach, ensuring that every aspect of a child’s health, from cardiac function to liver health and beyond, is meticulously monitored and managed by a cohesive team of experts.
Through the Fontan Multidisciplinary Clinic, Gracie received continuous and vigilant monitoring of both her cardiac and hepatic systems. This integrated care model brought together specialists from various disciplines, including Dr. Kathleen Simpson, a leading cardiologist, and Dr. Dania Brigham, a respected hepatologist. Their collaborative efforts were instrumental in managing Gracie’s condition over the years, ensuring she could live as full and typical a life as possible, while also preparing her for the eventual necessity of a transplant.
Dr. Simpson elaborated on the long-term implications of the Fontan circulation: "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 proactive approach exemplifies the clinic’s mission: to optimize a patient’s health and well-being for as long as possible while strategically planning for future interventions.
Escalating Health Challenges and the Decision for Dual Transplant
As Gracie grew, she began to experience escalating health issues directly related to the long-term effects of her congenital heart disease. One significant complication was plastic bronchitis, a rare and serious condition characterized by the formation of thick, proteinaceous casts in the airways, obstructing breathing. Over the past year, Gracie’s symptoms of plastic bronchitis worsened considerably, coinciding with the emergence of clear signs of liver failure. This confluence of critical organ dysfunction presented a stark reality: a dual heart and liver transplant was no longer a future possibility but an immediate necessity for her survival and for the prospect of a significantly improved quality of life.
The medical team at Children’s Colorado made the difficult but necessary decision to place Gracie on the national transplant waitlist in April. This decision triggered an intensive period of preparation, not only for Gracie and her family but also for the extensive medical team.
Orchestrating a Complex Surgical Endeavor
The prospect of a dual heart and liver transplant demands an extraordinary level of coordination and expertise. Specialists from surgery, cardiology, hepatology, anesthesiology, critical care, and numerous other subspecialties convened regularly for months leading up to Gracie’s placement on the waitlist. These meetings were crucial for meticulously planning every facet of the operation, from donor organ procurement and preservation to the precise surgical techniques required for transplanting two vital organs simultaneously. Key considerations included managing the significant differences in blood volume requirements between the two organs, the complexities of immunosuppression protocols for dual transplants, and the intricate management of electrolytes and hemodynamics during such a prolonged and demanding procedure.
The hospital’s investment in cutting-edge technology and specialized equipment played a pivotal role in this preparation. The utilization of advanced organ preservation systems was identified as a critical component for ensuring the viability of donor organs, particularly the liver, which has a more limited window of viability outside the body compared to the heart.
A Precisely Timed 16-Hour Surgical Marathon
The opportunity for Gracie’s life-saving transplant arose less than a month after she was placed on the waitlist, a testament to the urgency of her condition and the generosity of a donor family. The availability of compatible donor organs is a complex logistical challenge, and in this instance, the timing allowed for the commencement of the procedure.
The surgical team, led by Dr. Matthew Stone, surgical director of the Pediatric Heart Transplant Program, and congenital heart surgeon Dr. Emily Downs, initiated the operation with the heart transplant. This phase of the procedure lasted approximately nine hours. During this critical time, the donor liver was not idle. It was meticulously maintained on a TransMedics Organ Care System, a sophisticated piece of medical technology designed to replicate the physiological environment of the human body, thereby preserving the organ’s function and viability for an extended period. This innovative system provided the cardiac surgical team with the necessary time to complete their complex work without compromising the integrity of the liver.
Once the heart transplant was successfully concluded, the surgical focus shifted to the liver. Dr. Adams and transplant surgeon Dr. Kendra Conzen took the lead for the liver transplant, a procedure that spanned an additional seven hours. The entire 16-hour surgical marathon demanded unwavering precision, seamless communication, and constant vigilance from every member of the multidisciplinary team. The anesthesiology department played a critical role throughout, ensuring Gracie’s physiological stability and optimizing her condition for the demands of each stage of the transplant.
The Road to Recovery and a Renewed Future
The success of this unprecedented dual organ transplant was evident in Gracie’s remarkable recovery. Following the surgery, she spent just over a month in the cardiac progress care unit, a testament to the advanced post-operative care provided by Children’s Colorado’s specialized teams. Seven months after the transplant, Gracie has made a triumphant return to her daily life. She continues to attend regular monthly follow-up appointments, a standard practice for transplant recipients, but has successfully reintegrated into her school environment and is back at home, enjoying the companionship of her beloved dogs.
While the transplanted liver is expected to provide Gracie with a lifetime of improved health, her medical team anticipates that, like most pediatric heart transplant recipients, she will likely require a second heart transplant later in life. This prospect, however, is tempered by the immense success of the current procedure and the significant improvement in her overall health and quality of life.
A Benchmark for Pediatric Transplant Care
The accomplishment at Children’s Colorado represents more than just a single successful surgery; it signifies a major leap forward in the hospital’s capabilities and its position as a leader in pediatric transplant care. Dr. Duncan Wilcox, Surgeon in Chief at Children’s Colorado, articulated 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," 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 dual heart and liver transplant not only offers a renewed future for Gracie Greenlaw but also sets a new benchmark for what is possible in pediatric medicine. It highlights the critical role of specialized, multidisciplinary care teams, advanced medical technology, and a commitment to innovation in addressing the most challenging health conditions faced by children. The success of this procedure is expected to pave the way for more children across the region to access life-saving dual organ transplants, offering them the opportunity for healthier, longer, and happier lives. The event underscores the vital importance of organ donation and the profound impact it has on transforming lives.
