By Hendra Lukman 
Children’s Hospital Colorado (Children’s Colorado) has successfully completed its first-ever dual heart and liver transplant, a groundbreaking achievement for its Pediatric Transplant Program and a testament to its advanced multidisciplinary capabilities. This complex procedure, involving an intricate orchestration of dozens of specialists across 25 care teams, marks a significant advancement in the hospital’s capacity to treat critically ill children with life-threatening conditions. Nationally, such combined heart and liver transplants are exceedingly rare, with only 38 pediatric patients having undergone this procedure previously.
The successful completion of this life-saving surgery on 11-year-old Gracie Greenlaw underscores Children’s Colorado’s commitment to providing unparalleled care for children facing the most challenging medical circumstances. Dr. Megan Adams, Surgical Director of the Pediatric Liver Transplant and Kidney Transplant Programs, expressed profound 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."
Years of Dedicated Preparation Culminate in a Life-Saving Intervention
The journey to this remarkable achievement was paved with years of meticulous preparation, strategic planning, and unwavering commitment from the medical staff at Children’s Colorado. The hospital’s leadership recognized the growing need for comprehensive care for children with complex congenital heart conditions that often lead to secondary organ damage. Consequently, extensive resources and specialized training were dedicated to building the infrastructure and expertise necessary to perform such intricate multi-organ transplants.
The successful execution of Gracie’s transplant was the direct result of seamless collaboration among a diverse array of specialists. This included surgeons with expertise in cardiac and liver transplantation, cardiologists, hepatologists, anesthesiologists, intensivists, nurses, social workers, and child life specialists, among others. This integrated approach ensured that every facet of Gracie’s complex medical needs was anticipated and addressed with precision.
Gracie Greenlaw’s Medical Journey: A Chronicle of Resilience
Gracie Greenlaw’s story is one of remarkable resilience in the face of profound medical challenges. Born with hypoplastic left heart syndrome (HLHS), a severe congenital heart defect characterized by the underdevelopment of the left ventricle, Gracie’s young life was defined by a series of critical interventions. HLHS is one of the most complex congenital heart defects, affecting approximately 1 in 4,000 newborns. In utero, the right ventricle of the heart takes over the work of pumping blood to both the body and the lungs.
Before reaching her third birthday, Gracie underwent three major open-heart surgeries, essential palliative procedures designed to reroute blood flow and enable her single functioning ventricle to support circulation. These surgeries, known as the Norwood procedure, the Glenn shunt, and the Fontan procedure, are typically performed in stages and are designed to improve blood oxygenation and reduce the workload on the underdeveloped heart. While these life-saving operations have significantly improved survival rates for children with HLHS, allowing many to live into adulthood, they can also lead to serious long-term complications, most notably liver damage and eventual liver failure.
Managing Long-Term Complications: The Fontan Multidisciplinary Clinic
Recognizing the persistent and evolving health concerns faced by patients with single-ventricle physiology, Children’s Colorado established the Fontan Multidisciplinary Clinic in 2016. This specialized clinic operates as a cornerstone of the hospital’s Single Ventricle Program, providing comprehensive, coordinated care for patients with HLHS and other similar complex congenital heart conditions, such as tricuspid atresia and unbalanced common atrioventricular canal. The program’s philosophy centers on a holistic approach, ensuring that every aspect of a child’s health is monitored and managed by a dedicated team of experts.
Through this program, Gracie received continuous, expert monitoring and management of both her cardiac and hepatic conditions. Her care team included leading specialists such as cardiologist Dr. Kathleen Simpson and hepatologist Dr. Dania Brigham. Their collaborative efforts were instrumental in managing Gracie’s complex health status, meticulously tracking the progression of her liver disease, and determining the optimal time for intervention.
"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, highlighting the inherent risks associated with long-term survival after Fontan palliation. "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 underscores the program’s commitment to maximizing a patient’s quality of life while diligently preparing for future medical needs.
The Growing Need for Dual Organ Transplantation
The progression of liver disease in patients with Fontan physiology is a well-documented phenomenon. The elevated venous pressures and reduced cardiac output associated with the Fontan circulation can lead to chronic passive congestion of the liver, resulting in fibrosis and, eventually, cirrhosis and liver failure. For some of these patients, a liver transplant becomes the only viable option to restore organ function and improve survival.
In Gracie’s case, the long-term effects of her congenital heart disease manifested as plastic bronchitis, a rare and serious complication of Fontan circulation. This condition causes protein-rich fluid to accumulate in the lungs, leading to airway obstruction and respiratory distress. Over the past year, Gracie’s symptoms of plastic bronchitis had significantly worsened, and concurrent signs of liver failure began to emerge. This dual deterioration of critical organ systems necessitated an urgent and complex intervention.
After careful evaluation and extensive consultation among her multidisciplinary team, the decision was made that a dual heart and liver transplant was the most effective course of action to provide Gracie with a chance at a healthy and extended life. She was subsequently placed on the national transplant waitlist in April, initiating a period of intense anticipation and preparation.
Orchestrating a Complex Surgical Endeavor
The preparation for Gracie’s dual organ transplant was an exercise in meticulous planning and coordination. Dozens of specialists convened regularly for pre-transplant meetings, meticulously reviewing Gracie’s medical history, current condition, and the unique challenges posed by transplanting two major organs simultaneously. Key considerations included managing differences in blood volume requirements between the two organs, precise electrolyte balance during the prolonged surgery, and the intricate coordination of surgical teams working in tandem.
The complexity of a dual heart and liver transplant is amplified by the limited window of organ viability. Donor hearts typically have a preservation time of only four to six hours, while donor livers can remain viable for up to 12 hours when preserved with specialized technology. This critical time constraint necessitates a carefully orchestrated surgical sequence.
When compatible donor organs became available, made possible by the selfless decision of another family to donate, the surgical team sprang into action. The 16-hour surgical marathon commenced with the heart transplant, led by Dr. Matthew Stone, Surgical Director of the Pediatric Heart Transplant Program, and congenital heart surgeon Dr. Emily Downs. This initial phase of the operation lasted approximately nine hours.
Crucially, while the heart transplant was underway, the donor liver was meticulously preserved using a TransMedics Organ Care System. This advanced technology, often referred to as a "heart-lung machine for the liver," allows the organ to be kept warm and perfused with oxygenated blood and nutrients, mimicking its natural state outside the body. This innovative approach significantly extends the window of viability and ensures the organ’s optimal condition upon transplantation. Following the completion of the heart transplant, Dr. Adams and transplant surgeon Dr. Kendra Conzen took over to perform the liver transplant, which required an additional seven hours. Throughout this entire demanding procedure, constant communication and close collaboration with the anesthesiology teams were paramount to ensuring Gracie’s stability and safety.
A Promising Recovery and a Return to Life
The complex and demanding surgery proved successful. Gracie’s recovery in the cardiac progressive care unit was a testament to her strength and the exceptional care provided by the Children’s Colorado team. She was discharged from the unit just over a month after the procedure.
Seven months post-transplant, Gracie is not only home with her beloved dogs but has also returned to school, a significant milestone that underscores the profound impact of this life-saving intervention. While she will require ongoing monthly follow-up visits, as is standard for pediatric heart transplant recipients, her transplanted liver is expected to provide a lifelong solution. The long-term prognosis for her new heart, however, is acknowledged to require a future heart transplant, a common reality for pediatric heart recipients due to the long-term challenges of transplanted organs.
A Benchmark for Pediatric Transplant Care
The successful dual heart and liver transplant at Children’s Colorado represents a significant advancement in the hospital’s capabilities and a beacon of hope for children with complex congenital conditions. Dr. Duncan Wilcox, Surgeon in Chief at Children’s Colorado, lauded the achievement as a demonstration of the hospital’s commitment to excellence. "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 landmark surgery positions Children’s Colorado at the forefront of pediatric multi-organ transplantation in the region. It highlights the hospital’s investment in advanced medical technology, specialized training for its clinicians, and its ability to foster a highly collaborative environment essential for managing the most intricate medical cases. The success of Gracie’s transplant not only transforms her life but also strengthens the hospital’s capacity to offer similar life-saving interventions to other children facing similar dire circumstances, reinforcing its role as a vital center for pediatric critical care and advanced surgical interventions. The implications extend beyond individual patient outcomes, contributing to the broader knowledge base and surgical techniques in the field of pediatric transplantation.
