By Hendra Lukman 
Children’s Hospital Colorado has marked a significant medical milestone with the successful completion of its first-ever dual heart and liver transplant in a pediatric patient. This complex and rare procedure, involving an intricate orchestration of over two dozen specialists across 25 multidisciplinary care teams, represents a new frontier in advanced organ transplantation for the Denver-based institution. The achievement places Children’s Colorado among a select group of pediatric medical centers capable of performing such life-saving interventions. Nationwide, only 38 pediatric patients have previously undergone this combined heart and liver transplantation, underscoring the rarity and technical difficulty of the surgery.
The groundbreaking operation was performed on 11-year-old Gracie Greenlaw, who has navigated a lifelong battle with a severe congenital heart defect. Her journey highlights the evolving capabilities of pediatric transplant programs and the profound impact of integrated, multi-specialty care on patient outcomes.
A Decade of Preparation Culminates in a Life-Saving Intervention
The successful dual transplant was not an isolated event but the culmination of years of dedicated preparation, strategic planning, and unwavering commitment by the medical staff at Children’s Colorado. The hospital’s Pediatric Transplant Program has been meticulously building its expertise and infrastructure to address the most complex cases, including those requiring multiple organ replacements.
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," 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."
This sentiment was echoed by Dr. Duncan Wilcox, Surgeon in Chief at Children’s Colorado, who emphasized the hospital’s role as a leading pediatric medical center. "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 commented. "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."
The Complexities of Congenital Heart Disease and its Cascading Effects
Gracie Greenlaw’s medical journey began at birth with hypoplastic left heart syndrome (HLHS), a severe congenital heart defect characterized by the underdevelopment of the left side of the heart. This condition means the left ventricle, the heart’s main pumping chamber, is too small to effectively pump blood to the body.
From a young age, Gracie underwent a series of life-altering surgeries to reroute blood flow and compensate for the underdeveloped left ventricle. These included the Norwood procedure, the Glenn shunt, and the Fontan procedure – complex palliative surgeries designed to allow blood to bypass the non-functional left side of the heart. While these interventions have dramatically improved survival rates for children with HLHS, enabling many to live into adulthood, they can also lead to significant long-term complications. One of the most serious of these is liver damage and, in some cases, liver failure, often referred to as Fontan-associated liver disease (FALD).
Integrated Care: The Fontan Multidisciplinary Clinic
Recognizing the unique and multifaceted needs of patients with single ventricle physiology, Children’s Colorado established the Fontan Multidisciplinary Clinic in 2016. This specialized clinic, a key component of the hospital’s Single Ventricle Program, offers comprehensive, coordinated care for children with HLHS and other single ventricle conditions such as tricuspid atresia and unbalanced common atrioventricular canal.
The clinic’s approach centers on a holistic view of the patient, bringing together a dedicated team of specialists from various disciplines, including cardiology, hepatology, pulmonology, nephrology, nutrition, social work, and child life services. This integrated model ensures that every aspect of the patient’s health is meticulously monitored and managed.
For Gracie, this meant continuous, expert oversight of both her cardiac and hepatic conditions. Cardiologist Dr. Kathleen Simpson and hepatologist Dr. Dania Brigham were integral members of her care team, working collaboratively to manage her complex health status for years. Their combined expertise was crucial in monitoring Gracie’s progress and identifying the optimal time for intervention.
Dr. Simpson explained the delicate balance involved in managing patients post-Fontan: "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."
The Escalation of Symptoms and the Decision for Dual Transplant
Over the past year, Gracie’s health began to decline, presenting new and urgent challenges. She experienced worsening symptoms of plastic bronchitis, a rare but serious complication of Fontan circulation where protein-rich fluid builds up in the airways, obstructing breathing. Concurrently, signs of progressive liver failure became apparent. These developments signaled that her current medical management was no longer sufficient and that a more aggressive intervention was necessary.
After careful evaluation and extensive discussions among her multidisciplinary team, the decision was made to place Gracie on the transplant waitlist for both a new heart and a new liver. This critical step was taken in April, initiating a period of intense anticipation and preparation.
Orchestrating a Complex Surgical Endeavor
The prospect of a dual heart and liver transplant demanded extraordinary planning and coordination. Dozens of specialists convened regularly to meticulously map out every detail of the procedure. Key considerations included managing the significant differences in blood volume requirements between the two organs, ensuring precise electrolyte balance throughout the lengthy surgery, and synchronizing the timing of the organ implantations.
The surgical team had to be prepared for a range of potential complications, from anesthetic challenges to post-operative recovery protocols. The successful execution of such a procedure hinges on seamless communication and an unwavering trust among all members of the surgical and medical staff.
The 16-Hour Surgical Marathon
The call for compatible donor organs arrived less than a month after Gracie was placed on the waitlist, a testament to the urgency of her condition and the generosity of a donor family. The availability of both organs presented a narrow window for transplantation, given the limited viability of donor hearts outside the body.
The surgical process commenced with the heart transplant, a procedure that typically takes between six to nine hours. Dr. Matthew Stone, Surgical Director of the Pediatric Heart Transplant Program, and congenital heart surgeon Dr. Emily Downs spearheaded this critical phase, leading a team of cardiac specialists through the intricate process of implanting the new heart.
While the cardiac team was engaged in the heart transplant, the donor liver was placed on a specialized piece of technology known as the TransMedics Organ Care System (OCS). This innovative device is designed to keep the donor liver functioning in a near-physiological state outside the body, mimicking the conditions within a living organism. The OCS technology played a vital role in preserving the liver’s viability, providing the heart surgeons with the necessary time to complete their work without compromising the subsequent liver transplant.
Following the completion of the heart transplant, Dr. Adams and transplant surgeon Dr. Kendra Conzen took charge of the liver transplantation. This second phase of the dual organ transplant added another seven hours to the surgical marathon. Throughout the entire 16-hour operation, the anesthesiology team maintained constant vigilance, ensuring Gracie’s physiological stability and protecting her vital organs. The successful coordination of these two distinct yet interconnected surgical teams was paramount to the overall outcome.
A Promising Recovery and a Return to Life
The complex surgery proved successful, marking a triumphant moment for Gracie and her medical team. Following the operation, Gracie was transferred to the cardiac progress care unit for intensive monitoring and recovery. Just over a month later, she was discharged from the unit, a significant step forward in her healing journey.
Seven months post-transplant, Gracie has shown remarkable resilience and progress. While she continues to attend regular monthly follow-up appointments to monitor her recovery and ensure the long-term success of the transplants, she has been able to resume a more normal life. She has returned to school, reintegrating into her educational environment, and has joyfully reunited with her beloved dogs at home.
The medical team anticipates that Gracie’s transplanted liver is expected to function for the remainder of her life. However, as is common with pediatric heart transplant recipients, it is acknowledged that she will likely require a subsequent heart transplant later in life, given the complexities of managing a transplanted heart in a growing child.
Broader Implications for Pediatric Transplant Care
The successful dual heart and liver transplant at Children’s Colorado has far-reaching implications for the field of pediatric organ transplantation. It demonstrates the hospital’s advanced capabilities in managing extremely complex cases that require a high degree of multidisciplinary collaboration and surgical expertise.
This achievement not only benefits individual patients like Gracie by offering them a chance at a healthier, longer life but also contributes to the collective knowledge and experience within the pediatric transplant community. As only a limited number of centers worldwide perform such procedures, Children’s Colorado’s success can serve as a model and an inspiration for other institutions seeking to expand their transplant services.
The event underscores the critical importance of specialized programs like the Fontan Multidisciplinary Clinic, which provide ongoing, integrated care for patients with chronic and complex conditions. By addressing the cascading effects of congenital heart disease, such as liver dysfunction, these programs can proactively manage patient health and identify the optimal timing for life-saving interventions like dual organ transplantation.
The hospital’s commitment to innovation, exemplified by the use of advanced technologies like the Organ Care System, further highlights its dedication to pushing the boundaries of medical care. This successful dual transplant is a testament to the power of collaborative medicine, technological advancement, and the unwavering dedication of healthcare professionals working to improve the lives of children facing life-threatening illnesses. Children’s Hospital Colorado’s achievement is a beacon of hope for families navigating the challenges of rare and complex medical conditions, reinforcing its position as a leader in pediatric healthcare.