By Hendra Lukman 
Children’s Hospital Colorado (Children’s Colorado) has successfully performed its first-ever dual heart and liver transplant, a complex and groundbreaking procedure that signifies a monumental achievement for its Pediatric Transplant Program and elevates the standard of care for critically ill children in the Rocky Mountain region. This intricate surgery, involving the coordinated efforts of dozens of specialists across 25 multidisciplinary care teams, marks a significant milestone, placing Children’s Colorado among a select group of institutions capable of such life-saving interventions. Nationally, only 38 pediatric patients have previously undergone this combined organ transplant, underscoring the rarity and complexity of the procedure.
The successful transplant is a testament to years of dedicated preparation, meticulous planning, and an unwavering commitment to advancing pediatric transplant medicine. Dr. Megan Adams, surgical director of the Pediatric Liver Transplant and Kidney Transplant Programs at Children’s Colorado, emphasized the program’s long-standing dedication. "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." This sentiment reflects the hospital’s broader mission to provide comprehensive, high-level care to a vast geographic area, often serving as a vital resource for families facing rare and severe medical conditions.
A Lifelong Journey of Complex Cardiac Care
The patient at the center of this remarkable achievement is 11-year-old Gracie Greenlaw, whose journey with a severe congenital heart defect necessitated this extraordinary intervention. Gracie was born with hypoplastic left heart syndrome (HLHS), a rare and serious condition characterized by the underdevelopment of the left side of the heart. In HLHS, the left ventricle, the heart’s main pumping chamber, is too small to pump blood effectively to the rest of the body. This condition necessitates a series of complex surgical interventions in infancy and early childhood to reroute blood flow and allow the single functioning pumping chamber to sustain circulation.
Gracie’s life has been defined by a remarkable resilience and a series of life-saving surgeries. Before her third birthday, she underwent three major cardiac procedures: the Norwood, the Glenn, and the Fontan. These surgeries are staged interventions designed to gradually adapt the circulatory system to function with a single pumping ventricle. While advancements in medical care have significantly improved the survival rates for children with HLHS, allowing many to live into adolescence and adulthood, these palliative surgical approaches can lead to significant long-term complications, particularly impacting liver function.
Managing the Long-Term Consequences of Single Ventricle Physiology
The Fontan procedure, while life-saving, creates a unique physiological state where blood from the lower body returns directly to the lungs without passing through the left side of the heart. Over time, this can lead to increased pressure in the veins, reduced blood flow to the liver, and the eventual development of liver damage and failure. Recognizing this predictable long-term complication, Children’s Colorado proactively established the Fontan Multidisciplinary Clinic in 2016. This specialized clinic, part of the hospital’s comprehensive Single Ventricle Program, is dedicated to providing holistic, coordinated care for patients with HLHS and other single ventricle conditions.
The clinic’s multidisciplinary approach ensures that patients like Gracie receive continuous monitoring and integrated treatment plans addressing both their cardiac and hepatic health. Experts in cardiology, hepatology, pulmonology, and other specialties collaborate closely to manage the complex interplay of organ systems. Dr. Kathleen Simpson, a cardiologist involved in Gracie’s care, explained the rationale behind this proactive management. "The Fontan is a lifesaving surgery, but the longer someone lives after the procedure, there is an increased chance of developing comorbidities," Dr. Simpson noted. "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 approach exemplifies a shift towards anticipating and mitigating future health issues, rather than merely reacting to them.
The Escalation to Dual Organ Transplantation
For Gracie, the long-term effects of her Fontan circulation began to manifest more acutely. She developed plastic bronchitis, a serious condition characterized by the formation of thick, protein-rich casts in the airways, which can obstruct breathing and lead to chronic respiratory distress. Over the past year, Gracie’s symptoms of plastic bronchitis significantly worsened, coinciding with the emergence of clear signs of liver failure. This critical decline in her health led her medical team to the difficult but necessary conclusion that a dual heart and liver transplant was the only viable option to provide her with a chance at a healthy future.
In April, Gracie was placed on the national transplant waitlist for both a heart and a liver. The journey from waitlist to transplant is often fraught with uncertainty, with the availability of compatible organs being a significant variable. For a dual transplant, the logistical and medical challenges are amplified, requiring precise timing and coordination between multiple surgical teams and organ procurement organizations.
Meticulous Preparation for a High-Stakes Procedure
The prospect of a dual heart and liver transplant demanded an unprecedented level of preparation within Children’s Colorado. Recognizing this as a potential future need for their Fontan patients, hospital leadership and the transplant teams had been investing in the necessary infrastructure, expertise, and collaborative protocols for years. When Gracie’s condition necessitated the procedure, the hospital was ready.
Dozens of specialists, including cardiac surgeons, hepatobiliary surgeons, anesthesiologists, intensivists, transplant coordinators, nurses, and support staff, convened regularly for months leading up to Gracie’s transplant. These meetings were crucial for meticulously planning every aspect of the surgery, from the precise sequence of organ implantation to the management of complex physiological changes during the operation. Key considerations included the differing perfusion requirements of the heart and liver, the management of blood volume and coagulation, and the potential for immunological rejection of two transplanted organs simultaneously. This extensive pre-operative planning was designed to minimize risks and maximize the chances of a successful outcome for Gracie.
A 16-Hour Marathon of Surgical Precision
The call for Gracie’s dual transplant came less than a month after she was placed on the waitlist, a remarkably swift turnaround that highlighted the urgency of her condition and the efficiency of the organ allocation system. The availability of suitable donor organs was a profound gift from another family’s decision to donate, underscoring the vital role of organ donation in saving lives.
The surgical marathon commenced with the heart transplant, a procedure with a very limited window for organ viability. Dr. Matthew Stone, surgical director of the Pediatric Heart Transplant Program, and congenital heart surgeon Dr. Emily Downs spearheaded this critical phase. The nine-hour heart transplant involved the meticulous removal of Gracie’s failing heart and its replacement with the donor organ, followed by the complex task of reconnecting her circulatory system.
Simultaneously, and with remarkable innovation, the donor liver was placed on a TransMedics Organ Care System (OCS). This advanced ex-vivo perfusion device is designed to replicate the conditions of the human body, allowing the donor liver to be kept warm and perfused with oxygenated blood and nutrients outside of the body. The OCS technology was instrumental in preserving the liver’s viability and function during the duration of the heart transplant, providing the surgical team with the necessary time to complete their work without compromising the organ’s integrity.
Once the heart transplant was successfully completed, the focus shifted to the liver. Dr. Adams, along with transplant surgeon Dr. Kendra Conzen, took over for the second phase of the operation. The liver transplant, which lasted an additional seven hours, involved the removal of Gracie’s damaged liver and its replacement with the donor organ. Throughout this entire 16-hour period, constant communication and coordination with the anesthesiology teams were paramount to ensure Gracie’s physiological stability and protect her vital organs. The success of such a lengthy and complex procedure hinges on the seamless integration of multiple surgical specialties and critical care support.
Recovery and a Promising Future
The immediate aftermath of such a profound surgery is a period of intense scrutiny and care. Gracie’s recovery in the cardiac progressive care unit was closely monitored by a dedicated team of intensivists and nurses. Her strength and resilience shone through, and just over a month after the surgery, she was able to leave the intensive care environment.
Seven months post-transplant, Gracie is not only recovering but thriving. She has returned to school, resuming a semblance of normalcy in her young life, and is back home enjoying the company of her dogs. While her journey with a transplanted heart means she will likely require another heart transplant later in life, a common reality for pediatric heart recipients, her transplanted liver is expected to function well for the remainder of her lifetime. This dual outcome offers a profound dual benefit, addressing both her immediate life-threatening conditions and significantly improving her long-term prognosis.
A New Era in Pediatric Transplant Care
The successful dual heart and liver transplant at Children’s Colorado represents more than just a medical feat; it signifies the hospital’s growing capacity to handle the most complex pediatric cases and its commitment to pushing the boundaries of medical innovation. Dr. Duncan Wilcox, Surgeon in Chief at Children’s Colorado, underscored the 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."
The implications of this milestone are far-reaching. It positions Children’s Colorado as a regional leader in advanced pediatric transplant surgery, capable of offering hope and life-saving interventions to children who might otherwise have limited options. The experience gained from Gracie’s transplant will undoubtedly refine the hospital’s protocols, enhance training for its multidisciplinary teams, and ultimately benefit future patients requiring similar complex organ replacements. This achievement is a beacon of hope, demonstrating the power of specialized medical expertise, collaborative care, and the profound impact of organ donation in transforming lives.
