On the rare occasion when a patient’s heart and liver are both exchanged for a second-hand set from an organ donor, it’s because something has gone seriously wrong with both.
While 31-year-old Washington state resident Adriana Rodriguez met all the requirements for a heart transplant, her liver was humming just fine. Nevertheless, surgeons traded it in a two-for-one deal in a historic first.
A team of medical researchers from the University of Washington School of Medicine in the US made the groundbreaking decision based on the almost certain probability that her immune system would destroy any foreign tissue that invaded her territory.
“She met all the criteria for transplantation, but her antibodies (to organ donor antigens) were the highest we’ve ever seen,” says cardiologist Shin Lin. explained.
“Just finding an immunological match for her heart would be like trying to win the lottery. Essentially, she would have needed the donor to be her immunological twin.”
Her only chance, they concluded, was to deliver a liver along with the new ticker in what’s known as a heart-to-liver transplant (HALT).
Since her own liver was perfectly functional, it went to a second recipient as a HALT domino (HALT-D) procedure.
2021a team led by cardiovascular surgeon Richard Daly reported on the favorable long-term outcomes of HALT in patients with end-stage heart and liver disease, compared to transplants involving only the heart.
It’s not clear why a donated liver reduces the chance of heart rejection. Livers are hardened organs, better able to withstand antibody attack than most imported tissues. Perhaps the sheer surface area divides the body’s defenses, giving other transplanted organs a chance to establish themselves.
However it works, Lin knew this was the best chance to save Adriana’s life.
“Dr. Lin’s unwavering belief that HALT-D would be successful convinced us. Ultimately, Adriana lives and thrives because of his belief,” said cardiothoracic surgeon Jay Pal.
Rodriguez’s search for a new heart began just weeks after she gave birth to her third child late last year. With pregnancy hormones wreaking havoc on her coronary system, one of her heart arteries ruptured, leading to catastrophic failure.
“We tried to take her off support over time to see if her heart was recovering, and she kept failing,” said Friend.
Placed on a machine that oxygenates and pumps blood to her body, Rodriguez waited for a heart made up of tissues almost identical to her own. Although it had been more than a month since she had given birth, her immune system remained highly sensitive to the new life she had within her, reducing her chances of finding a suitable donor to virtually zero.
Based on Daly’s reported findings, Lin thought a HALT was worth trying.
On January 14, 2023, Rodriguez received the news she so desperately needed. A suitable heart and liver had become available.
It took Rodriguez’s immune system just over two months to settle down after her surgery, with assessments of her antibodies suggesting the liver played a major role in taming her wild immune response.
What the future holds for the patient or the procedure is not clear. There is a shortage of compatible organs, prompting researchers to find better ways to provide tissues that are less likely to be rejected. In the meantime, HALT-D may be an option in cases where the outlook for the recipient is bleak.
Six months after her surgery, Rodriguez has nothing but appreciation for the path her surgeons have taken.
“There are no words to express my gratitude for my exceptional care – to the doctors and surgeons who brainstorm how to save my life, to my nurses who go out of their way to make me feel comfortable, and to everyone who works on my case whom I have not met’ she says.
This case study was published in The Journal of Heart and Lung Transplantation.