Historic triple-organ transplants: Big Brains podcast

Show Notes

Doctor Valluvan Jeevanandam says that transplantation is a “spiritual journey.” One person’s tragic loss leads to the another’s second chance at life. But not all transplants are the same.

In 2018, patients Daru Smith and Sarah McPharlin were both waiting on the donor list for not one but three organs. They were to be only the 16th and 17th triple organ transplant patients. But a shocking coincidence would push their doctors to attempt a medical feat no one has ever attempted.

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Transcript

Paul Rand: Five years ago, Chicago resident Daru Smith started having trouble breathing.

Daru Smith: They ran some tests, and they told me I had a heart problem. And I was just trying to figure out like…a heart problem…how did this happen? Where did it come from? They said it was sarcoidosis in my heart. I didn’t understand it.

Paul Rand: Sarcoidosis is a really rare condition that causes clusters of inflammatory cells to develop on organs. Eventually, it spread from Smith’s heart to his liver and kidneys. To survive, he needed a triple transplant of all three organs, an incredibly rare medical procedure. With his heart failing, he was in the hospital at the University of Chicago Medicine waiting on the donor list. Coincidentally, down the hall from his room, was another patient in the exact same situation. Her name was Sarah McPharlin.

Sarah McPharlin: It was really cool to learn, I didn’t know both of us were waiting for the same thing.

Paul Rand: In November 2018, McPharlin and Smith, who’re both 29 years old, met each other in the hallways of the hospital. But neither of them knew that a Christmas surprise was on the way for both of them.

Valluvan Jeevanandam: I don't even think you could say what the odds are because they're like indescribable. I mean it's infinitesimally low.

Paul Rand: That’s Dr. Valluvan Jeevenadam, or Val for short. He’s in charge of heart transplants at the University of Chicago Medicine. His colleague, Dr. Talia Baker, is in charge of liver transplants.

Talia Baker: Transplant is what transplant is—it's always at the wrong time. It's always inconvenient, but if an organ becomes available. That's what you do.

Paul Rand: The transplant miracle coming for Daru Smith and Sarah McPharlin would push these two doctors to attempt a medical feat that no one has ever tried to do: back-to-back triple transplant surgeries.

(Music Up)

Paul Rand: From the University of Chicago this is Big Brains, a podcast about the stories behind the pivotal research and pioneering breakthroughs reshaping our world. On this episode, Doctors Val Jeevenadam, Talia Baker and a modern-day medical miracle. I’m you’re host Paul Rand.

Paul Rand: Sarah McPharlin had been in and out of hospitals almost her entire life.

Sarah McPharlin: So when I was eleven, I caught a virus and it told my immune system to attack my heart. They tried different options like a pacemaker, medications and it just continued to get worse and that was cause the immune system was making the heart fail.

Paul Rand: Her condition got so bad she had to have her first heart transplant in 2001.

Sarah McPharlin: Since then, your organ can start to get worse. We started then doing the reevaluation for the second transplant. And while we were doing that in Michigan, they determined that my liver and kidney were also struggling. In order to qualify as a viable recipient for a transplant, you have to have all your system clear to make sure that the organ is going into a healthy body. For me to receive a heart transplant, I was going to require all three.

Paul Rand: There was just one problem: every hospital Sarah approached for a triple transplant turned her away. They all said the surgery was far too risky for them to perform. But Sarah’s family refused to give up.

Sarah McPharlin: Since we had been through this since I was 12, we’ve just done it as a team as a group. So as much as it might seem like it’s more difficult for me since I’m the one in the hospital having it done, they’re the ones who have to watch me go through it all or be there.

Paul Rand: McPharlin’s situation started to seem dire. She still couldn’t find a hospital to take her case. One even told her family they should start making end-of-life plans, but then they reached out to the University of Chicago Medicine.

Valluvan Jeevanandam: We actually got an e-mail. We read the e-mail, and on paper it's like…okay you got to be kidding. Her father was very insistent that we need to meet Sarah. So we had them come over to the clinic, and I will say that the second you met the McPharlins, especially Sarah, you really wanted to do anything you could to help.

Paul Rand: Meanwhile, for Daru Smith, watching his family suffer as his sarcoidosis took over his life was a difficult struggle.

Daru Smith: It was getting to the point where like, I couldn’t even keep up with my baby. He would be on his bike and I’d be walking him, and it would be a struggle to keep up with him. But he’s so smart and compassionate he would be like “come on daddy, you got it, don’t give up, I’ll ride slow so you can stay with me daddy”. That used to be the motivation and the will that would push me like, “come on Daru you got this, you can do this, you can go, you can go.” But it would be an honest struggle, I would feel like just trying to keep up with him, trying to stay up with him.

Paul Rand: Smith was a truck driver, a job which took him across the country. Eventually, his illness got so bad that when he was out on the road, he would take extreme precautions.

Daru Smith: Sometimes I would screenshot my mother the location that I’m at and then I’m like, “if I don’t call you in the morning by this time, this is when I’m supposed to be up, call the ambulance, call somebody”.

Paul Rand: Then it happened. Smith caught a case of pneumonia but, with his condition, it pushed him to brink. He was rushed to the University of Chicago, where he was seen by Doctor Val Jeevenadum.

Valluvan Jeevanandam: I mean he came in practically dead. And then the first step was to kind of resurrect him from the dead even before his transplant.

Paul Rand: Talia Baker, the head of liver surgery at the hospital, says it was really important for the transplant doctors to form a bond with Smith and McPharlin, just like any transplant patients for that matter.

Talia Baker: When you talk about what the luster and the art of transplant is, that’s really what it is is the relationship you form with these patients.

Valluvan Jeevanandam: They actually become part of a family. And so when you transplant somebody you're marrying them. And sometimes we will turn patients down if we cannot form that relationship with them for a variety of reasons, whether they're not listening to us, they're not compliant, they're taking alcohol or smoking which they’re not supposed to. So there are a lot of reasons other than medical criteria that we may turn down a patient because we think that marriage will fail.

Talia Baker: And from an organ utilization perspective you're also taking three organs from very healthy people. So three what we call primo organs.

Paul Rand: Going to one person.

Talia Baker: Going to one person. So you really have to have the confidence that it’s going to result in excellent quality of life for that recipient afterwards. Otherwise, you've taken away the potential for a heart, liver and a kidney to be given to three separate people.

Paul Rand: Baker and Jeevenandum both saw exactly what they were looking for in Smith and McPharlin. Then, it was just a matter of waiting for donors. As the two patients spent weeks walking the halls of their ward trying to keep up their strength, they bumped into each other, realizing they were in the same boat, and struck up a friendship that Smith said helped him stay positive when it felt like everything was falling apart.

Sarah McPharlin: That was a very nice compliment. It’s good to know that my positivity and trying my best in the situation I’m in could help him relate and feel better involved.

Paul Rand: Christmas was approaching, and neither Smith nor McPharlin had gotten the call. Despite McPharlin’s positivity, Daru was losing hope, until…

Daru Smith: I was sitting in here, I’m not gonna say thinking to myself, I caught myself talking to God but I wasn’t praying. I was just putting it out there and I was like, “God I’m gonna have me a donor within the next week”. And I said it three times. Each time I got sterner and sterner, “God, I’m gonna have me a donor within the next week, God I’m gonna have me a donor within the next week”. I believe that you speak stuff into existence. Two days later Doctor Smith walked in and he was like, we have a possible match.

Paul Rand: The match came through, and Smith was rushed off to surgery. McPharlin was so happy to see her friend getting treated even though she was still waiting for a donor that she feared would never come.

Sarah McPharlin: I think I do best when I try not to predict what will happen. The uncertainty sometimes helps me get through challenging situations I guess.

Paul Rand: Then, in the middle of Smith’s surgery, something shocking happened. The hospital got another call. McPharlin had a donor.

Valluvan Jeevanandam: Transplant is a spiritual journey. Why is it a tragedy for one person, joy for another you know. How does that even work in a karmic or in a cosmic sense, right. And then you have two transplants that go back to back.

Paul Rand: Time was of the essence, and the transplant team was left with a decision. Do they try to perform these triple transplants back-to-back—something no one has ever done before?

Valluvan Jeevanandam: Well first of all realize that before these two there's only 14 done in the entire world. Right. And that is over 40 years of transplantation. And so now you're gonna do two of those back-to-back. So the odds are…I don't know how many transplants are done, probably about a million transplants are done on an annual basis. And you've got 14 out of a million, and then you're taking two of them and doing them back-to-back. But the problem is that you know each one of the transplants has to go perfectly fine. And for her there was a lot of doubt about the technical challenges for the heart that would allow the other transplants to occur.

Paul Rand: But you decided you guys thought you could pull off.

Valluvan Jeevanandam: Yeah. We thought we could pull it off…

Paul Rand: The historic first attempted back-to-back triple transplant…after the break.

(Break)

Paul Rand: It seemed completely magical. In the middle of a triple transplant surgery, only the 16th ever done, the call came that a second set of organs was available. If the doctors were going to pull off the first back-to-back triple transplant, it would take perfect coordination.

Valluvan Jeevanandam: So there's three separate teams. There's a team for the heart, there's a team for the liver and there's a team for the kidney.

Talia Baker: I think it's really important to remember that we work as a group, as a team. It's like a really well orchestrated ballet. So the first group of people are the cardiac team. And they do a phenomenal job of start, middle and finish and then, only when they're comfortable that they're finished, can they hand off to the liver team. And then we try to have an amicable, nice handoff. If you could imagine one of the things I think from the nursing perspective that's complicated and frustrating when you're doing these multi-step operations is that we all have separate groups of instruments that we use, and we use them in a very distinct sequence. So they literally have to take the hundreds of instruments that Dr. Jeevanandam uses for the heart transplant and swap them out for those that I use for the liver transplant and they did that in a seamless way. They have to make sure that everything is counted and accountable before they switch out, and all of that was done almost without us noticing it was being done.

Valluvan Jeevanandam: One by one, sequentially, they'll change. And you won't even notice that they're changing. But as you're finishing up—and they know we're finishing up—they'll say, well how long do you have. They're actually sequentially changing. So the circulator changes, the scrub tech, the scrub nurse changes and then the instruments change. And Talia will tell you I'm a little intolerant because instruments make noise. So I'm like, okay, cut the noise out.

Talia Baker: Understandably.

Valluvan Jeevanandam: And then, as that is occurring, the anesthesiologists are changing too because there's an anesthesiologist for the heart team, there's a separate one for the liver and kidney. Right. So they're changing. And then our perfusionists are changing. So, all in all, for these two transplants, probably over forty-five people were involved and they're all switching off right at the right time to make the whole ballet work.

Paul Rand: The first act of the ballet is, in many ways, the most important: the heart. Without it, everything else would fall apart.

Valluvan Jeevanandam: Remember the heart has gotten an assault and that's why the donor has been brain dead. So it's been assaulted once. Then you stop the heart, you throw it into an ice bucket and then you resuscitate the heart. So that's assault number two. And then you need to get the heart beating again, and then now it's going through a marathon because instead of just going to the ICU and resting it now has to have enough energy to put through a liver transplant and a kidney transplant.

Paul Rand: And Sarah had a particularly complicated heart.

Valluvan Jeevanandam: Well first of all, she'd had I think it was four previous open heart surgeries or sternotomies. And just going in her a fifth time is a Herculean task because…

Paul Rand: Scar tissue or…

Valluvan Jeevanandam: The heart’s scarred in. Yeah. And you're basically doing archaeology on the heart. Right, you're chipping away till you can actually find the structures that you need to take apart to put back together. And so, we make sure that nothing is bleeding too much. And that the heart is working well. And then what we do is we leave some of the tubes around the heart to help the liver transplant team, Talia and her team, and then we pack everything with gauze just to make sure that you put pressure on whatever is bleeding

Talia Baker: You have to remember also, she had been on steroids since she was 12 years old. So her tissues were like toilet paper basically, just totally falling apart. We actually had one complication while we were doing the one of the hook ups of the liver to the portal vein, that her portal vein was so friable just because of her steroid use that it literally fell apart in her hands. The technical challenges of that are real and we all have to kind of be on our A game to make sure all of that went well. It was extraordinarily seamless it was really like a ballet it was beautifully choreographed. And that's what it takes to really pull off these transplants.

Paul Rand: After 17 hours of surgery for Smith and 20 for McPharlin, Doctor Val Jeevenadum, Talia Baker and the kidney surgeon, Yolanda Becker, pulled it off. The first ever back-to-back triple transplant was successful.

Valluvan Jeevanandam: Well I just think Holy God thank God that went well.

Daru Smith: It made me so happy cause, I was just thinking like, a lot of people are just waiting months and months for a kidney or just a liver, and I’ve been here a month and I got blessed with three organs. That kinda touched me like made me feel like I was really special, like I got a true definition and a meaning for life. So, I was real happy man.

Talia Baker: Each day of their recovery, we all rounded together, every day, and that was really a remarkable thing to see them getting better. And these two kids were inspiring. I mean from postop day one they were both so motivated to get better and so grateful and immediately started talking about how grateful they were about their donors.

Sarah McPharlin: I think it’s important for them to know that recipients do treat their organs well. And that they give their second chance at life meaning and they take care of it and live their life to the fullest afterwards. We did that with our first donor and we’ll do it this time.

Valluvan Jeevanandam: I think the other thing that's really interesting is that since we're able to pull them off, we get more confidence in our team. So we actually have two more people who are waiting for heart, liver, kidneys. One person who we evaluated before these two patients had their transplants and we thought that he would be too difficult to do because he's a six time into the chest. And so we didn't know we'd be able to actually get him done, so after we did these two patients we revisited him and now he's on the list to get a triple. And we have another person. So it was interesting like, I've been doing transplants now for almost 30 years and I got more recognition from these two transplants than what I've done for the last 30 years.

Paul Rand: If you had to say why that is is just the sheer—novelty is probably the wrong word—but the coincidence of being able to two triples back-to-back is what's making it so compelling.

Talia Baker: It's kind of magical.

Paul Rand: Yes it is magical.

Talia Baker: Val keeps on talking about it being spiritual. It really is. Like how is that even possible. I mean, the recipients that you're talking about who are in-house now, they've been waiting for a while…

Valluvan Jeevanandam: And who knows maybe they'll get them sequentially too…

Talia Baker: But there's something magical about transplant. It's been a hugely fun to get all the attention because it kind of brings together the whole transplant community. I think one of the really important parts that we all feel being part of transplant is the ability to do a transplant is relatively well established now. We're all of course plagued by a lack of available organs to be able to offer our patients who we recognize need an organ transplant whether it's a heart, lung, liver kidney, pancreas, the intestine, nobody has enough organs available. But I think pushing the envelope and being able to do something like not just a liver or just a heart or just a kidney and putting them all together and being able to do it well with excellent outcomes teaches us all that there's always the next level to get to.

Paul Rand: What that next level of transplantation might look like is both stunning and exciting, that’s after the break.

(Break)

Paul Rand: The transplant team at University of Chicago Medicine is proud of its accomplishment, but the doctors are still looking toward the future of transplantation, and what may be coming down the road in terms of innovation is shocking.

Valluvan Jeevanandam: You know surgery, you can only innovate so much on doing the anastomosis. So, from a surgery perspective, it's more about donor quality. You know, you take the heart out, you put it into a preservative solution—it literally goes into a pickle jar on ice—and it’s transported. And the question is, is that the best way to do it? There are now machines that can actually profuse the heart with warm blood, keep the heart beating. Right now, we only have four hours before you have to put it in, and with the other machines you can put it in for a much longer period of time and perhaps then you maybe give some gene therapy, or you can give some drugs too. Let's say you can you mask the heart with something so you don't have a rejection and then you can go for much longer term. Right now, if you get a heart transplant, there's a 50 percent chance you live more than 16 years. And the reason people aren't immortal is because there's like a chronic rejection that isn't really treated with medication. But what happens if you can somehow alter that organ because now you can profuse the organ outside the body to prevent that chronic rejection. Now you can make somebody last a lot longer. I mean we often put in hearts from 15 year olds or 20 year olds so you know maybe that heart will last a lot longer. So there's a lot of modifications of what we're doing with the heart. Then there's medication changes that occur with transplantation and also diagnosis of rejection. Right. Because we give medication in set doses, and some people may react to medication very differently. And maybe you don't have to give him such a high dose. Maybe you can get away with a much smaller dose so it's more personalized medicine in terms of targeting rejection and infections. That is the next wave. So there are many many aspects of transplant that are evolving.

Talia Baker: Absolutely I think this whole idea of machine perfusion and organ recovery centers is, I believe, what's going to be the next thing in transplantation. So this whole idea of gene modification…there is a lot of really important work being done in taking fatty livers and defatting them while they're outside the body so they're more appropriate for transplantation and have better outcomes. There are ways to modulate the immune response as you go and the liver is really protected from an immunological perspective, it's the organ that probably needs the least amount of immunosuppression. The heart is one of the ones that needs the most amount of immunosuppression. So there are ways that we could modulate the immune response of the liver which would perhaps leave the patient with a need for no immunosuppression after the transplant. So this idea of machine perfusion probably at a physiological temperature with modification of the organ on the outside and then transplantation is something that I think has yet to be really realized.

Valluvan Jeevanandam: So transplantation of donors is what we do now. But eventually the donors may come from animals which is called xenotransplantation. So, each animal has antigens that the human body reacts to and you can hyper acute reject those organs. But now, with a lot of gene modification, you can actually modify those organs and perhaps not express some of the antigens that are specifically energetic. And so there's a lot of work done on xenotransplants and there's also a lot of work done on recreating your own heart by using scaffolding and then profusion the heart of the scaffolding with stem cells to try to create your own heart when you need it on demand.

Paul Rand: So that would be done at some point in advance. So if you knew you were going to need it you would start planning.

Valluvan Jeevanandam: Well if you let's say had a massive heart attack and you know that your heart ejection fraction or your contractility is decreased, then you may start planning it right there. And you know in anticipation of you needing one and…

Paul Rand: Interesting times ahead.

Talia Baker: Yeah. And also in other solid organs, in kidney for example, this whole idea of scaffolding down to stem cells. Repopulation of the scaffold has gone pretty far already because the patients can be on dialysis etc. but they're even using 3D printing to create those scaffolding which is kind of remarkable

Paul Rand: That is remarkable.