In a historic surgical procedure, an American patient received two donor organs, a liver and a heart, to prevent the extreme likelihood that her body would reject a donor heart transplanted alone – with the organ recipient’s own healthy liver being transplanted, domino-like, into a second patient who had advanced liver disease.
The dual-organ recipient, Adriana Rodriguez (31) of Washington, has recovered well since the January procedures, said Dr Shin Lin, a cardiologist at the University of Washington School of Medicine Heart Institute and lead author of the paper published in the Journal of Heart and Lung Transplantation.
Heart-liver transplants to one recipient are seldom performed, Lin said. In fact, this was the first such case for UW Medicine surgeons. In cases previously reported in literature, the patients have needed the two grafts to replace both failing organs, reports MedicalXPress.
Rodriguez’s case was unprecedented in two ways: her own liver was healthy, and she received a donor liver only to mitigate the near-certainty, in her medical team’s opinion, that her body would immediately reject the donor heart she desperately needed.
“She met all criteria for transplant, but her antibodies (to the antigens of organ donors) were the highest we’ve ever seen,” Lin said. “Finding an immunologic match for her heart alone was going to be like trying to win the lottery. Essentially she would have needed the donor to be her immunologic twin.”
Rodriguez’s need for a heart transplant stemmed from a spontaneous tear within her coronary artery that occurred in December 2022. Such “dissections”, in medical parlance, are rare but not unheard-of among women around the time of pregnancy.
Two weeks earlier, Rodriguez had given birth to her third child at PeaceHealth St Joseph Medical Centre.
“There are thought to be hormonal changes and stress in pregnancy that can make the coronary arteries vulnerable to these tears,” said Dr Daniel Fishbein, a heart failure specialist on Rodriguez’s team.
“In the best-case scenario, a dissection heals without much heart damage and the patient goes home with medications and gets better. But this patient had terrible heart failure.”
Rodriguez’s doctors at PeaceHealth initially treated the coronary artery dissection with an aortic balloon pump to help her heart circulate blood. Then they transferred her to UW Medicine, where doctors found that her dissection had caused widespread, permanent damage to her heart.
In the month afterwards, the team removed the balloon pump and employed other devices to try to supplant her heart’s pumping function.
“The dissection injured her heart a lot. We attempted to remove her from support over time to see if her heart were recovering, but she continued to fail that,” said Dr Jay Pal, a cardiothoracic surgeon. “We went through various support strategies to try to help her heal without ECMO and without transplant, but ultimately there was no other choice.”
On 14 December, doctors connected Rodriguez to an extracorporeal membrane oxygenation system (ECMO) to pump and oxygenate the blood, temporarily unburdening the heart and lungs. ECMO enables some patients to recover strength and forgo additional procedures, but in this case, Pal said, “going on ECMO meant she probably was going to need a transplant to get off ECMO”.
Rodriguez was officially listed for heart transplant on 5 January.
With every transplant, doctors measure the prospective recipient’s antibodies to gauge the likelihood of donor organ rejection. Someone whose levels are high is described as being “highly sensitised”.
“Pregnant women are more likely to have high sensitisation because their body develops antibodies against antigens that come from the father,” said Lin. “These antibodies don’t attack the foetus, but if you transplant that person, those antibodies will attack the transplanted organ – sometimes within minutes.”
Rodriguez’s workup suggested she had a high likelihood of rejecting an organ from 99% of potential donors.
Poring through medical literature for other ideas, Lin found an observational study from 2021 that noted a “profound immunologic protection” seen with a heart-after-liver transplant (HALT) protocol among seven highly sensitised patients who needed both organs.
Although the data pool was too small to instil full confidence, and even though Rodriguez didn’t need a liver, Lin thought the HALT protocol was her best chance to survive. He proposed the idea to the team, with one amendment: Rodriguez’s healthy liver would be transplanted in parallel to another patient who needed that organ. HALT could become HALT-D, for domino.
Several of Lin’s colleagues initially were resistant.
“There was concern that this was an unproven treatment in a complex patient. But there were no other ideas or techniques that would allow this young mother to be free from ECMO and leave the hospital,” Pal said.
“Dr Lin’s unyielding belief that HALT-D would be successful convinced us. Ultimately, Adriana is alive and doing well because of his conviction.”
On 14 January UW Medicine was notified that two organs had become available from a deceased donor. This set in motion a carefully orchestrated, 17-hour sequence at UW Medical Centre-Montlake.
First, Drs Mark Sturdevant and Ramasamy Bakthavatsalam removed Rodriguez’s liver and placed it on ice, then transplanted her with the donor liver. Pal and Dr Ionnis Dimarakis then transplanted the donor heart while Sturdevant and Bakthavatsalam transplanted Rodriguez’s liver into a patient in an adjacent operating room.
“We looked at (Rodriguez’s) antibodies almost every day,” Lin recalled. “It was not until 65 days after transplant that her antibodies against these donor organs disappeared altogether.
“That’s when I felt I could finally breathe easier. That meant it was an unqualified success.”
Exactly why a donor liver would confer immunoprotection on a donor heart is still a bit of medical mystery, Fishbein said.
“I think we don’t fully understand the science of transplant immunology. We can learn a lot from patients like this. We need to understand the magic so we can hopefully, someday, repeat it with medications instead of an organ.”
Study details
Heart after Liver Transplantation with Domino for a Highly Sensitised Patient
Shin Lin, Elina Minami, Kevin O'Brien, Ioannis Dimarakis, Daniel Fishbein, Jay Pal.
Published in JHLT on 29 June 2023
In dual organ transplantation, inclusion of a liver is known to confer immunoprotection to the other graft. In 2021, Daly and colleagues described successful heart after liver transplantation (HALT) in seven highly sensitised patients with end stage heart and liver disease.
Herein, we report taking the next logical step of performing the world's first-ever HALT on a patient solely for high sensitisation. Because her normal liver was dominoed into another patient, we call our procedure HALT with domino (HALT-D).
The Journal of Heart & Lung Transplantation article – Full abstract/study not available
MedicalXPress article – In historic procedure, donor liver protects heart transplant (Open access)
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