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Kathryn Holleman
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The combined heart/liver transplant April 8 was the first performed by Washington University surgeons at Barnes-Jewish Hospital. It was emblematic, though, of the transplant program’s long tradition of innovative care, especially for patients with limited treatment options.

The patient, Tish Hatley, 47, a long-time nurse at Barnes-Jewish, suffered from hereditary amyloidosis, a rare condition in which the liver produces defective amyloid proteins that are deposited and build up in other organs.  

In most amyloidosis cases, liver transplant alone, to stop the production of the defective protein, is sufficient treatment. 

When Hatley was first diagnosed, it looked as though she would need just a liver transplant, too.

But it soon became apparent that amyloid deposits in her heart had caused irreversible heart failure. The combined heart/liver transplant was considered to be Hatley’s best option.

“Many centers say if you’re coming for a liver transplant or you’re coming for a heart transplant – all your other organs systems need to be in good shape,” William C. Chapman, MD, chief of abdominal transplant at Washington University and surgical director of liver transplant at Barnes-Jewish. “So if you have more than one organ system involved – then that’s going to knock you out of the game.”

Only a few centers in the U.S. have both the expertise and resources to take on a complex procedure like a combined organ transplant and the possible complications that could follow it, Dr. Chapman said.

But despite the complexity of the procedure, a combined transplant looked like a good option in Hatley’s case.

“Because she had a process that was affecting her likelihood of living significantly longer but not affecting the functioning of her kidneys or clotting factors and she was not yet suffering from ravages of heart failure, she really was an ideal candidate for this,” said Scott C. Silvestry, MD, former Washington University cardiothoracic surgeon and former surgical director of heart transplant at Barnes-Jewish.

And though this particular procedure would be a first for the Washington University/Barnes-Jewish program, the doctors and transplant teams had a long history of caring for other complex cases, including combine heart/kidney, kidney/pancreas, heart/lung and kidney/liver transplants.

This would basically be a case of applying knowledge and skill gained in other similar cases to a new situation, the doctors said.

“While we had not done a heart-liver transplant, we had done several heart-kidney transplants, and we have an increasing era of collaboration between the abdominal transplant surgeons and the thoracic surgeons,” Dr. Silvestry said.

In addition to the skill of the surgical teams, the depth of experience in the rest of the transplant team – from the liver and heart specialists, to Barnes-Jewish transplant nurses, pharmacists, dietitians and other staff – and their ability to handle virtually any complication, were key in convincing doctors to take Hatley’s case, Dr. Chapman said.

For her part, Hatley, who now works in clinical information systems at the hospital, said her experience working as a staff nurse and in the intensive care units at Barnes-Jewish convinced her to go ahead with the procedure.

“I’d taken care of transplant patients on the floor,” she said. “I never thought I’d be one. But I knew the people involved. I was confident in my doctors, I trusted them.”

So Hatley was added to the transplant waiting list for both organs in early 2011. Her need for two organs meant put her near the top of the list.

In the meantime, the two transplant teams put together a protocol to follow during the actual procedure. The heart team, led by Dr. Silvestry, would go first because a heart can survive out of the body on ice for shorter time than the liver.  

Once the heart was transplanted and beating on its own, the liver team, led by Dr. Chapman, would take over. 

In April, Hatley finally got the call that donor organs had become available. From the time she arrived at Barnes-Jewish for the operation, until she was wheeled into the cardiothoracic intensive care unit, the procedure went almost exactly as planned.

“The teams were able to proceed rather flawlessly and with great collaboration to the benefit of the patient,” Dr. Silvestry said.

Hatley recovered from the surgery quickly. She was discharged from Barnes-Jewish after 14 days. Now, almost three months after surgery, she feels better than she did before the procedure and has resumed many of her normal activities. She plans to return to work soon.

“People tell me I look healthier than I have in a long time,” she said.

Dr. Chapman and Dr. Silvestry said they are pleased with the outcome of the procedure and the opportunity to add to the array of procedures done at Barne-Jewish. But they know it may be a long time until they have another patient like Hatley.

“It’s going to be only a certain type of patient who will need this type of procedure,” said Dr. Chapman. “But this opens the door for patients who would otherwise have a bleak future to have a chance at a good outcome long-term.”