At The Forefront Live: History-Making Triple-Organ Transplants

[MUSIC PLAYING] Hello, and welcome to the University of Chicago Medicine at the Forefront Live. It was a history making effort. Transplant teams at UChicago Medicine performed back to back triple transplants on two 29-year-old patients. The transplants replaced their failing hearts, livers, and kidneys marking a first in US health care history.

Now these complex procedures had never been performed in the same US hospital within a year, and in this case, they were done within 27 hours of each other. Now today, we will meet members of the team responsible for this incredible effort, and we will meet the two patients. We'll also take your questions and comments. So please type those in the comment session below. Now, joining us today are doctors Nir Uriel and Val Jeevanandam. First, congratulations on this extraordinary achievement.

Thank you very much. Thank you very much. Very exciting.

Just, kind of, walk us through the process. And Nir, I want to start with you, because we have two patients that we're dealing with here and you knew about one of them quite a ways in advance. The other one you didn't know about so much in advance. Talk to us and tell us what happened here.

You know, life is always full of surprises. One of the patients, Sarah McPharlin, came to us because she seek us. She seek a center that will provide her triple organ transplant. She was already a patient for many, many years. She had a heart transplant 18 years ago. And unfortunately, this sometimes happen 18 years after heart transplant, the heart is failing. And as a result of that, she knew that she needed triple organ transplants.

She came to us after multiple centers said to her no. And after we met her and we investigate her case and did our evaluation, we feel that she's the right one. We get into the mindset that we are going to do a triple organ transplant in 2018. We knew that Sarah is on our list, and whenever the right organs will come, we are going to perform this surgery and, eventually, follow her thereafter.

During that period of time, one of the patient here from Chicago came to the University of Chicago Medicine, actually, to the eventually intensive care unit with cartogenic shock, extreme case. He was also a patient that had a condition for multiple years. He was diagnosed with sarcoidosis for five years, however, never knew that the condition is so advanced in that actually already his heart and his liver was failing. As a result of that, his kidney already gave up as well. And at the same time that Sarah already waiting on the list, we took care of first Daru Smith trying to actually save his life from their pneumonia and the cartogenic shock that he was at.

And following more than a month in the hospital while we succeeded in stabilizing the situation, we understood this stabilization is just temporary. And if he will not go through a triple organ transplant, he will die. We were ready with one, and we decide to be ready with two. And also Daru join us and became on the transplant list waiting for a transplant.

Now I want to introduce our patients, because it's very important, I think, to get to know these two incredible people. And then, Val, I want to get into some more detail with you as far as how the process works and what you did. But first, let's introduce our first transplant patient. He's Daru Smith, and he's a truck driver, as you mentioned, Nir, who lives here in Chicago, very close actually to UChicago Med. Now Darus has a 3-year-old boy and a son is one of the reasons that he's such a fighter with a will to live.

It was getting to the point to where, like, I couldn't even keep up with my baby. Like I told y'all, he's so smart. Like he would be on his bike and I'd be walking him, and it'd be a struggle to keep up with him. But he's so smart and compassionate.

He would just be like come on, daddy. You got it. Don't give up. I'll ride slow so you can stay with me, daddy. And, like, that used to be the motivation and the will that pushed me.

I'm, like, come on, Daru. You got this. You can do this. You can keep doing this. You can go. you can go. But it would be an honest struggle, right. I felt like-- I honestly have 911 on speed dial on my phone, like, with the location and everything, like, just trying to keep up with him and trying to stay up with him.

And that was like really bothering. I mean, it really bothered me, because it was like I couldn't do nothing about it. That was the hard part about it.

Now Sarah McPharlin is from Michigan. She came to UChicago Medicine, because no medical facility in Michigan would perform the procedure. She is the 17th person to receive a triple transplant in the United States.

It's amazing, because my favorite number is 17. And I've always been travel soccer person number 17. So that was just exciting on its own. But yeah, it's cool to be part of, like, helping them with their medical knowledge and--

That's fantastic.

Yeah.

So 17 is your favorite number?

Yeah.

That's great.

So like when December 17 passed, I was like, oh, it didn't come on my day. And then we had gotten two other offers potentially, and both of those had been declined. And so I was like, oh, I guess if we had those, we wouldn't have been, like, the 17th person.

So Val, first of all, the patients are fantastic there. You guys, just again congratulations.

Well, they're the heroes and so are the donors.

Yeah. It's just-- it's so neat to see something like this. And you've been involved now in six of these. Is that correct?

Yep, all the six done at University of Chicago. So University of Chicago Medicine has done six out of the 17 known transplants in the world.

That is amazing right there. And so university of Chicago Medicine, of course, leads the nation in that effort as well. Tell us a little bit about how this works, because you handle the hearts and then-- so you're first in line with the process. Is that correct?

Yeah, so they get listed for all the three organs, and that poses a challenge in itself. Because oftentimes, the heart may be good, but the livers not good. Or the liver's good and the heart-- and the kidney's not. And if you get organs from a further distance, they don't necessarily have to come with each other.

So getting the organs number one is the challenge. The next thing is getting the patients who are very, very sick-- now remember, it's hard enough getting a person who's got heart disease to a transplant. These people have a heart, liver, and kidney that are failing. So the medical personnel getting them to a transplant are spectacular.

And then, of course, the operating team that's taking care of them, these procedures take a long period of time. So the heart goes first. We do the heart transplant, and then you have to get the heart ready to now sustain what is essentially a marathon run.

So remember, this heart is coming out of a donor. It's going into a jar. It's being preserved for four hours. We're then implanting it, and then asking it to immediately run a marathon having to do two other transplants.

So we get the heart sewn and the patient is off the heart, lung machine and purely on their new transplanted heart. Then we hand off to the liver transplant team, and they have to do the liver transplant without, again, affecting the other organs as much. Then we come back and the liver team and the heart team close the sternum and the abdomen at the same time. And then the liver-- the kidney teams comes in, and they finish up with the kidney transplant. So it's really like a relay race, and you can't let the baton drop on this one.

And time, as you mentioned, really the essence in all of this, because you have such a limited amount of time, particularly with heart, as you start.

So we like to get the heart-- we call it its scheming time or time that the heart is actually outside the body without blood perfusion, and we like to do that within four hours. And similarly, the liver needs to be done within about eight to 10 hours.

Now, Nir, I was noticing the other day when you were talking during the news conference. And one of the questions was you're working and you were in the process with Daru, and then you got the word that-- I don't know where this was in the process-- but that there was another set. And so it was a pretty easy decision for you, a complicated situation, but an easy decision. Let's go for it, and we're just going to do one right after the other.

I think that, first of all, we need to understand how hard it is to identify the donors for those patients. So whenever a donor is right, we identify the donor based on the blood type of the recipient, Sarah and Daru, and as much as we can also about their body size. But further more, this time we need a special donor-- a donor that not only that his heart is good, his liver is good and his kidneys are good. So when something like that coming to us, we cannot say no. And it was very clear, unfortunately, for Dr. Jeevanandam is the one that needed to continue and just finished one marathon and is going to go into the second one. And so he did an Iron Man.

Well, it's not-- it's not only the surgeon, right. So it's the entire team, and it was an incredibly dedicated team that did not even flinch when we heard that there was going to be a second transplant. Because everybody was invested in getting them through these procedures. So you have to understand the operating room is full of nurses, perfusionist, anesthesiologist, physician assistants, and many of them actually stayed throughout the entire 37 hours of both procedures not only on the heart side but also on the liver and the kidney-- the liver and the kidney side. And what gave us a safety margin is that we had a great team outside the operating room. So when the first patient, Daru, got delivered outside the operating room, we didn't have to worry about how they were being managed, because they were being managed so well with the medical team.

And how big of a team are we talking about? Because this is a lot of people working on these two folks. So it's a very-- very much a coordinated effort. There was about 25 to 30 people in the operating room alone and not including Nir and the team of the experts taking care of the patients outside the operating room and the ICU. How many people were those, Nir?

So outside on the medical team, including actually the anesthesia team and the city ICU, we're talking about another 20 people that are involved. So I think, overall, there was a huge commitment just before the holiday from a surgical, medical, and anesthesia team to make it happen. And, again, there was-- as Val said, nobody even questioned if those donor come, those transplant are going to happen.

We are getting a lot of questions from our viewers, which is really neat to see, and so I want to get to a few of these. First of all, compliment for the transplant team. This viewer says this is awesome. This transplant team did my brother's heart transplant two years ago. You folks up there are the best. So, again, compliment to you guys.

This is interesting. This is one of the first questions we got. How did the transplant teams have the stamina to perform these two triple organ transplants back to back? Because the concentration levels, first of all, have to be very high. I would imagine emotionally it's tiring as well. That's got to be tough for you guys.

Well, the good news is that as transplant surgeons and transplant professionals, we're all used to endurance. So it's kind of like a marathon run anyway. So doing two marathons back to back was not-- was not difficult realizing what the end result was going to be that we were going to be able to help both these people. So as Nir and I said, there wasn't any flinching of anybody in the team. No one said, oh my god, do I have to do another one? It was more like, yes, let's get them done.

There was a lot of excitement. And I think another thing that we need to remember, the medicine profession as a whole, not on the transplant, is training you to live in those moments in which you need to find the strength and power. And actually, there is a lot of adrenaline involved to make sure that you will need to be-- and you will need and you will be able to do the right thing regardless how many hours you work in and how many times you're doing.

Since the end of our medical school, Dr. Jeevanandam and myself did residency and fellowship that included a long, long shift. And I think it's prepare you to those moments in which you really need to stand longer. And Dr. Jeevanandam this time stand a long, long hour and make it happen.

That's fantastic. Now the care team really develops a bond with these patients and their families, and it has to be exciting to see them progress. Daru talked to us about the team and how wonderful his care has been.

I feel like they've been exceptionally, like, amazing, all of them. A lot of people like to work for the money. I think everything they do come from the heart. Like, they seem so compass-- I'm not going to say seem. I'm going to say they are so compassionate and genuine and sweet about everything.

And I can attest to that as an observer, I've seen both of you with these patients and how you interact with them and the rest of the care team as well. And it's just-- it's fantastic. It's really a neat thing to see.

More questions from our viewers. One wants to know if there have been any complications after the surgeries. How are the patients doing so far?

So I think both of the patient are doing extremely, extremely well. Both of them are already doing multiple circle in our floor. Our floor is 0.25 miles. So we always ask them to walk as much as they can, and one of them, hopefully, will be discharged later on today and the other one probably soon after.

I think both of them for the, meanwhile, is doing exactly as Dr. Jeevanandam and myself expected, and they're progressing even faster I have to say than what we anticipated. I think it was a much smoother course compared to what we had in mind. We plan for a very long-- we had a game plan to all of this, and we're actually ahead of it for the meanwhile.

One of the unique things about our heart and vascular center is that it's on one floor. It's a gigantic floor, and as Nir says, there's a track of 0.25 miles. And I think a lot of our transplant patients, especially Sarah and Daru have taken advantage of it before transplant, so they're strong and then after transplant. And I think Sarah is up to walking two or three miles a day, right.

Yes, she's already walking two to three miles. Daru just before I came here to this office-- and this is only midday-- he's already finished his first mile of the day. I think he will finish this day also with two to three miles.

That's incredible.

They're in better shape than I am.

I'm just saying that's amazing when you think about what they've been through in these past just a little over a week ago. It's incredible. It's quite a testament to them and to the skill that was displayed by the team. More questions from our viewers. And, Val, I want you to answer this one. What kind of mindset do you need to keep up with such complicated procedures, and what kind of thoughts motivated you to succeed as you went through this?

Well, I think the number one motivation is to be helping the patient, right. And everybody says you've got a set of goal, and my goal was having them do exactly what they did just a couple of days ago, which is being together, smiling, and walking around the ICU. And now the next goal, of course, is going home.

In terms of concentration, again, us as cardiac surgeons, we're trained that once you start a procedure, you're completely focused. There's music that plays in the background more as like-- more like, kind of, a noise suppression. But there's a concentration that you're taught, and Sarah, especially, was a very difficult transplant. She had had five previous entries into her chest with a sternotomy.

She was very, very complicated, and her surgeon, who had taken care of her wonderfully over the years, sent me a lovely email with the op notes from each one, and then at the end he said, god bless you for even trying. So Nir and I sat down, and we actually planned out exactly how we were going to transplant her to minimize her risk. And she actually went to the cath lab before-- we got a heart and we got her organs.

She went to the cath lab, and there we did angiograms and we put catheters to prepare her for anticipated problems during the transplant. So Once we knew we were going to do her, there was a 100% attention and concentration, because we knew she was going to be difficult. And all that preparation really made her transplant go very smoothly.

It's interesting you bring up her prior surgeon, because I was in the room when you came and you were speaking with her that day. I don't know when this was, earlier this week. Maybe it was last week. Anyway, it's, kind of, all blending together at this point.

But you were talking, and you mentioned that you had spoken with her surgeon and he, kind of, told you what he envisioned would be the challenges from what he'd seen in the past and how tremendously helpful that was. And I thought that was really, kind of, neat to hear. Because, obviously, the fact that he cared enough to respond to talk to you and just that collaboration made a big difference.

It's very unique. I don't think I've ever had a surgeon actually call me up and send me an email and give all the detail road plan of where all the mines were, and most surgeons say, well, it's not my patient. You go take care of it, right. But I think he actually had bonded with Sarah, had taken care of her from the very first transplant, become family friends. So he helped tremendously with helping us map out her surgery to minimize any complications.

Nir, another question from a viewer wanting to know what caused three major organs to need transplantation simultaneously. Why was that so critical to do three simultaneously?

So there is multiple reasons that we will see what we call the multi-organ failure exactly like in those two cases. For example, in Sarah cases, this is a price of a long standing heart failure after the graft, the heart that was already transplanted is failing. When the heart was failing, a lot of fluid accumulate on the inside of the heart and causing the liver to feel all the time congested with fluid. Over time, this congestion of the liver caused the liver to become serrated.

Kidney, unfortunately, doesn't like the medication that we give people after transplant. Those medication can cause sometimes on the long run a kidney failure. As a result, this is one example. Darus represent a completely different example. Daru had a disease that's called sarcoidosis.

Sarcoidosis can affect multiple organs in the body. Actually, almost every organ in the body can be affected. He had a systemic sarcoidosis that had affected the liver and the heart and, as a result of that, caused him to be in both liver and heart failure. And whenever the heart and liver is failing, the kidney doesn't feel that they can stay long and they join this act of failing. And the reason is there is not enough blood supplying to the kidney, and the kidney slowly, slowly deteriorates to function. But there is multiple other reason to see multiple organ failure.

That's interesting. So I want to play this clip, because it's so fun to see how well these folks are doing. It's exciting to listen to Sarah and Daru talk about how well they're doing after the transplant procedure. And Sarah told us that she was feeling much better just days after the surgery, which I thought was incredible.

I actually felt really good. It's amazing, because I'm not cold. I used to always be freezing even if it was like 65 out. I have a lot of energy.

My legs are pretty. Because before the transplant, I had gained like 30 pounds of water and even my larger pants wouldn't fit. So yeah, it's nice to have my tiny legs and to not be really tired. Like I've been able to walk and talk pretty easily, where before the transplant I, kind of, was always glad my mom was walking with me, because she would talk to the nurse.

And I could just focus on the walking part. But yeah, again, like I think everything hasn't totally clicked in, but now that you can tell if there symptoms are-- or systems are fully engaging together. I can tell I'm even feeling better every day.

This is fantastic to see. I have to say that this is so fantastic, and this is an important point. Sarah has mentioned an important point for, I think, the audience here. And one of the first sign that people with heart failure will see is that their temperature tolerance is completely different.

The reason that we are not-- we can tolerate temperature, because we have the heart supplying blood and the blood going all across the body. And when the heart is failing, eventually, the extreme of the organs will not get blood supply, and we will feel the cold. And that's the reason you're tired, you're cold. And what she's describing is the essence of what heart failure is all about.

I think the other thing that she describes is just very important is that she couldn't walk and talk at the same time. And I think that's called dyspnea on exertion or shortness of breath. And I think if people have that and it's something new, they should probably call and see a doctor.

And it was just amazing to see her walking up there, because, like you mentioned, it's a quarter mile around. And she was-- she was pretty proud of herself, because she had done four laps the day that I was up. And it's like, OK, you've already knocked out a mile, and she was ready to do some more, I think.

Oh my god, you should see her this morning. I think that's it. She's ready. Sarah and after her first transplant she participate in the Transplant Olympic. She told me she is going for it again.

And as the recipient of triple organ transplant after already one transplant, this is by itself unique. And just to know that she is going to have a wonderful life with a great quality of life that she can think of participating. And as we already learned to know Sarah, she will. And she will find back her sport and do whatever she want to do. That's all the goal of it, to do what you want to do.

In a sense, she has an unfair advantage, because she's got three turbo-charged organs.

There you go. Another question from a viewer. This is a viewer that's on the liver transplant list and, again, probably some broad advice. We don't need to get into specifics here. But they want some transplant-- or some advice as to what to do before transplant, maybe how to lifestyle, eating, that, sort of, thing. What would you tell somebody who is on the transplant list?

So I think the most important thing that we can tell to patient on the transplant list, regardless of which organ, the healthier and the more strong they will get to the surgery is going to bring the surgery to a bigger success. What do I mean? First of all, we have muscles. We need to maintain them. As hard as it be, even if the people find a hard time to get out of bed to find to do small weights in bed to activate their muscle, to make sure that they're in mobility.

We speak about working here non-stop, because both Dr. Jeevanandam and I feel-- myself feeling that this is a key to a success. We need to open the lung to avoid pneumonia and other respiratory complications. There is a very basic thing called spirometer. It's actually in the size of a hand, and you just need to breath into it every couple hours and do 10 breath, and you can train your lung muscle, actually, your respiratory muscles to be [INAUDIBLE]. I think, again, nutrition, muscle training, and physical activity together with respiratory training is the key to any surgery as a whole, a transplant surgery in specific.

Another comment from a viewer that I wanted to pass along. We agree with Daru, Dr. Jeevanandam, Dr. Uriel, and the whole team are the greatest medical professionals, but also the kindest friendliest and most genuine people you'll ever meet. Our family owes our future to them, so you've touched all our lives. So it's nice to-- nice to hear things like.

Thank you.

Thank you.

I do want to talk a little bit about organ donation, because this wouldn't have happened, obviously, without organ donation. And both Daru and Sarah know that they wouldn't have had this opportunity at life without the donation of organs by someone else. It's something that they don't take for granted.

It made me so happy, man, because I was just thinking, like, a lot of people are just waiting months and months for a kidney or just a liver. I've been here a month, and I got blessed with three organs. So that kind of touched me. It made me feel like I was really special. Like, I got a true definition and a meaning for life. So I was, like, real, real happy.

I would say that it's just always very nice that and, like, at the time of someone's sadness that they're able to make a decision to donate their organs and help someone else. And I think it's important for them to know that recipients do treat their organs well and that they give their second chance of life, like, meaning and they take care of it and they live their life to the fullest afterwards. And we really did that for our first donor, and we'll do it this time.

That was really something to see. And I do have one final question, because we've got one more that came in. We're about out of time, but I've got to ask this one anyway. What's the most rewarding part about your jobs when you see the fruition of this? What's the most rewarding thing?

Every day when you wake up in the morning you need to have a reason. And every day that I'm waking up in the morning, I think about all the patient that we take care of. And they have the ability to wake up in the morning, and they have the ability to go to work or do whatever they want. They have the ability to meet their family.

They have the opportunity to [? seize ?] [? or ?] at day 1 and to participate in their family, friend, life. I think there is nothing in the world that is worth to see Sarah and Daru and all the other people that Dr. Jeevanandam and myself had the opportunity to take care continue and have a life. As simple as that, enjoy life. So this is very rich. For us, it's the goal of all of it.

Val?

Yeah, I absolutely agree. I mean, Nir said it very, very well. I mean, for us, it's our patients and what we can do-- what we can help our patients with. And you said, how do you have the stamina? Well, if you really, really enjoy what you're doing and it's not a job, then it's very enjoyable. And the enjoyment that you see is them walking down the hall. And now it's just walking down the hall. I mean, they're going to be skateboarding or something. [INAUDIBLE].

Think about it. Daru is going to go back to his son, his 4-year-old son. Sarah eventually going back to Michigan, and she's occupational therapist. And she is going to-- they are going to do what we want to do, what each one of them. Now they have a chance.

That's exciting. All right, here's a few statistics on organ donation, and this is why it's so important. More than 114,000 people are on waiting lists for organs in the United States. Every 10 minutes, another person is added to the waiting list. 20 people die every day waiting for a transplant, and one donor can save up to eight lives. If you want to become an organ and tissue donor, you can visit organdonor.gov to learn how to sign up in your state.

That's all the time we have for At The Forefront Live today. Of course, I want to thank the doctors for being on the program today. If you want to learn more about these historic triple transplants, please visit our website site at uchicagomedicine.org. And make sure you watch January 17th as we discuss weight management options offered here at UChicago Medicine. We'll take your questions and have our experts on to answer as many as possible. That's Thursday, January 17th. Watch our Facebook page for more information on coming program. Thanks again for watching At The Forefront Live, and I hope you have a great week.

In December of 2018, transplant teams at UChicago Medicine took on a medical first: back-to-back triple-transplants replacing the hearts, livers, and kidneys for two patients in a row.

We spoke with heart transplant experts Nir Uriel, MD, and Valluvan Jeevanandam, MD, about the historic back-to-back triple-transplants. We also took some time and caught up with the two patients, Sarah McPharlin and Daru Smith.

From left, Dr. Anjana Pillai, Section Chief Michael Charleton and Dr. Talia Baker, of the Liver Tumor Clinic at the University of Chicago Medicine

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