Man recovering from multi-organ transplant at University of Md.

Heart-liver transplantation a complicated, rare procedure

  • David Krech (right, sitting) had a rare heart/liver transplant at the University of Maryland Medical Center. He is shown with the lead doctors (clockwise), Sameh Fayek, liver transplant surgeon; Erika Feller, medical director of the center's heart transplant program; and Bartley P. Griffith, chief of cardiac surgery.
David Krech (right, sitting) had a rare heart/liver transplant… (Gene Sweeney Jr., Baltimore…)
November 14, 2010|By Meredith Cohn, The Baltimore Sun

A 28-year-old man flown to Maryland six months ago with a failing heart and liver expects to soon return to his Georgia home with healthy new organs, both transplanted during a surgery performed only a dozen other times this year across the country.

The rare effort by University of Maryland doctors means David Krech, who was born with a heart defect and has endured many other procedures, may soon be planning a future as a schoolteacher.

"The previous operations were stopgap measures, not a cure. The transplant is a cure," said Dr. Erika Feller, medical director of the Heart Transplant Program at the University of Maryland Medical Center and an assistant professor of medicine.

Transplants in general are now a regular remedy for failing organs — more than 19,000 have been performed so far this year nationwide. But multi-organ transplantation is still evolving, and heart-liver combinations remain among the least common.

Doctors at several institutions say that there is less need for multiple organs than single ones. But they also say there's also less expertise, and willingness, to transplant more than one because of the complexity and risk.

There have been just 90 heart- liver transplants since the 1980s, according to data from the United Network for Organ Sharing, a nonprofit organization that manages the nation's organ transplant system for the federal government.

That system doesn't even have a waiting list for heart-liver patients. Krech was put on separate organ lists and got both when a donor also had a second suitable part. A network spokeswoman said officials are constantly retooling policies on how to allocate scarce resources, now based on severity of illness, geography and other measures.

The group reports that more than 200 centers perform transplants, but only 26 have undertaken a heart-liver procedure — Maryland, which has performed three, is one of just a few on the East Coast. Maryland and Johns Hopkins University in Baltimore also have performed other multi-organ transplants.

There are generally long wait times for all. Krech matched more quickly than many others at five months because he has a rare blood type that meant less competition. More than 100,000 people are currently waiting.

At the University of Pittsburgh Medical Center, where 13 heart-liver transplants have been performed, doctors have been trying to increase use of flawed organs that may be rejected elsewhere, said Dr. Jay K. Bhama, a cardiothoracic surgeon. He also said they are more aggressive in selecting patients in need of more than one organ. Most have survived surgery well, he said. For transplants in general, national statistics show about 90 percent survive the first year.

"We've found if we get them through the surgery they enjoy the same survival rates as patients with the isolated organ transplant," he said. "Other institutions are still more hesitant because it's a big operation and they believe the risk is too high or they don't have the resources."

He and others said positive results may prompt more centers to step up. That would mean less travel for people like Krech.

At the University of Chicago Medical Center, doctors have worked to advance a surgical method specific to multi-organ transplant, including a procedure used at Maryland. It involves opening the chest for the new heart and leaving it open for the liver team. Heart doctors can then ensure there isn't bleeding, a common surgical complication, before closing.

Dr. J. Michael Millis, director of the Chicago hospital's transplant center, said successes have prompted doctors there to perform heart-liver-kidney transplants.

"We're trying to raise the bar, while making sure not to waste two or three organs," he said. "We don't want to look back and say the person wasn't a good candidate and we shouldn't have done it."

Millis and Maryland doctors said they consider more than just failing organs. They need transplant teams to effectively communicate and form a single plan. And because the patient must take anti-rejection medications for the rest of his life and return for care regularly, he and his family must demonstrate commitment.

Krech's family helped cement the decision to operate at Maryland, said Dr. Bartley P. Griffith, chief of cardiac surgery at the University of Maryland Medical Center and professor of surgery.

Griffith, who performed the heart transplant, said scarring from past procedures made surgery challenging. Two main arteries had fused, making extraction of the old heart difficult. He was aware many other centers wouldn't have done the surgery, seeing less risk in giving the organs to two other patients.

"I think we struggle with taking risks today, even though we had a great kid who deserved a chance," he said. "But everyone here was on board."

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