Organ Transplant

I had a middle aged patient with primary pulmonary hypertension leading to multi-organ system dysfunction. Primary pulmonary hypertension is a rare entity where instead of having high blood pressures in the rest of the body, it occurs in the lungs. While there many possible causes of this, in my patient, it was idiopathic - we did not know why he had it. When people get the common sort of hypertension, the left side of the heart adapts by growing thicker, pumping harder. But the right side of the heart does not adapt that easily; it is a fragile thing, and instead of growing thicker, it often balloons out and ultimately fails.

My patient, as a result of longstanding primary pulmonary hypertension, had a failing right heart and resultant congestion and injury to his kidneys and liver. He was at the top of the transplant list, and when we had a donor heart, lung, and kidneys, we called him in for a triple organ transplant.

I thought this was interesting. There are some centers that would only transplant the lung; others that would transplant the heart and lung, and some that might do all three. The theory is that the lung is causing all  the mayhem and replacing it will allow the other organs - heart, liver, kidney - to heal. But the counterpoint is that if the right heart has taken too much of a toll from pushing against high pressures, then it may not fully recover. Similarly, the kidneys are liable to take a hit from cardiopulmonary bypass and the immunosuppressants, so if they are dysfunctional at baseline, we should switch them out at the same time.

What's the right answer? On the one hand, if you're going to transplant a patient, you might as well maximize their chances of doing well after the surgery; it would be a shame to choose only to transplant a lung and to find that the heart and kidneys failed after the operation. On the other hand, organs are of such short supply and using two additional organs where they might not be necessary deprives other transplant patients.

In the end, we transplanted the heart and lungs en bloc, an amazing operation where there is a moment when the chest cavity is completely empty. However, it was a difficult prolonged procedure, and post-bypass, we had to transfuse a lot of blood products and support the blood pressure with multiple agents. Thus, we elected not to do the kidney transplant at the time, but rather to stabilize things in the intensive care unit and dialyze as needed until the heart and lungs settled in.

The image shown above is an amazing shot of Bruce Reitz and Norman Shumway performing the world's first successful heart-lung transplant in 1981, shown under fair use, from scopeblog.stanford.edu.