If surgery were gymnastics, a triple-organ transplant would be a feat worthy of the Olympics.
It has everything: Complex and intricate procedure? Check. Frequency of pre-existing conditions that can increase risk? Check. Prerequisites of flawless technique and seamless intraoperative collaboration? Check and check. Rarely performed? Also check.
If Clayton Barber were to overcome his congenital heart problem, his University of Florida Health surgical team would have to successfully transplant a heart, liver and kidney. They would have to go for the gold.
A triple-organ transplant like this would not only be a first at UF Health, it would be the first of its kind in the state of Florida. The milestone was soon followed by a second triple-organ transplant, and three more multiorgan transplants are already on the wait list.
“We have a very unique situation here,” said Dr. Thiago Beduschi, chief of transplantation and hepatobiliary surgery at the UF College of Medicine’s surgery department. “We have an incredibly strong transplant team for the lungs, heart, liver, kidney, pancreas, intestine and multivisceral. Not only do we have the structure — we also have the process, experience and expertise. That’s part of the reason we were able to do complex procedures such as this.”
When performing something as complex as a triple-organ transplant, process is key — and process is where Beduschi made the call to transplant the organs en bloc, a technique in which organs are transplanted simultaneously into a patient, rather than one after the other.
This meant that Beduschi and Dr. Mark Bleiweis, director of the UF Health Congenital Heart Center and Barber’s heart surgeon, would be working elbow-to-elbow to sync their movements while implanting Barber’s three chances for a new life.
“When you’re working this closely with another surgeon, you need to be on the same page,” Beduschi said. “It can be challenging to get out of your comfort zone and rely on someone else. But our teams have a foundation of trust and respect.”
Multiorgan transplants like these are rare. But in the context of Barber’s health prior to his surgery, it pushed the envelope of what was possible. After all, an individual who needs three new organs is an individual who, as Barber observed in a classic understatement, is “just not doing well.”
“It wasn’t the first time I knew something was wrong,” said Barber, who’s been a UF Health frequent visitor for over 10 years due to his congenital heart defect. “But this time, I felt…off.”
In 2014, Barber began visiting UF Health’s Congenital Heart Center every six months. After offering him a mitral valve repair, Bleiweis and his care team, which included Dr. Diego Moguillansky, director of the adult congenital cardiology program, would periodically optimize Barber’s medications, assess the state of his heart failure, and send him on his way.
But around 2018, he started to get worse.
“Each time we would see him, he would either have more symptoms, like increased swelling or poor quality of life,” Moguillansky said. “Increasingly, despite titrating his heart failure therapy, his (heart) function decreased.”
There are multiple reasons a patient can be considered for a multiorgan failure transplantation, Moguillansky said. And the CHC — the largest and most established comprehensive congenital heart program in Florida — is no stranger to the variety of complex congenital heart disease patients who come through its door. Although all have heart failure, those with a single ventricle are more likely to also develop advanced liver disease.
“The liver and heart is an unfortunately common combination for congenital heart patients,” Moguillansky said.
For Barber, multiple organ failure manifested in subtle ways. More trouble getting around. Feeling tired. Then, eventually, not feeling much of anything.
“I grew up sensing I was different from other kids,” said Barber, now in his 50s. “I was no stranger to hospitals and doctor visits because of my heart. But the waiting period prior to my transplant was something else.”
Lonely. And long.
Due to the severity of his illness and how much it had progressed, Barber was hospitalized for months leading up to his procedure. During this time, his bodily organs were sustained by three separate forms of mechanical circulatory assist devices. Dr. Eric Jeng, the surgical director for UF Health’s Mechanical Circulatory Support Program, upgraded Barber’s support platform from an axillary intra-aortic balloon pump to the Impella 5.5 heart pump, and subsequently the highest level of circulatory assist, venoarterial extracorporeal membranous oxygenation, or ECMO. Barber was the first case in the nation to be supported long term with the Impella 5.5, and successfully bridged to a triple-organ transplantation.
In short: Getting him to the procedure was as much of a landmark event as the surgery itself, and spoke to the prowess of the adult heart failure team and the UF Health Congenital Heart Center team members involved.
“He was actually quite sick going in,” Moguillansky said. “He made it to transplant by the skin of his teeth. He survived to the time of transplant, but if those organs hadn’t been available that day, he probably would not have survived that much longer.”
Barber’s rehab, treatments, medications and transplant preparation played out against the backdrop of the COVID-19 pandemic, which meant that his visitors were limited.
“I’m not going to lie, it was hard,” Barber said. “But I got through it. I was always hopeful.”
Barber’s numerous previous operations left souvenirs of scar tissue in his chest, making the already delicate process of heart transplantation even more complex. At the same time, he was on anticoagulants, a medication that impacts how blood clots.
This made the liver transplantation, already known as one of the bloodiest procedures among surgeons, like threading a needle.
“When you do a double-organ transplant or triple-organ transplant, you’re not just multiplying the complexity of the operation by two or three,” Beduschi said. “You’re multiplying it by 10 or 20 because you are adding a variety of new possible complications.”
To minimize some of those complications, both heart and liver were perfused together, a process that joins the organs’ blood flow, which shortened the operative time by almost half. The kidney was transplanted the next day. Both operations used a single incision from Barber’s neck to his abdomen, minimizing the lengthier recovery time associated with the traditional transverse incision through the abdomen, which involves cutting muscle.
The landmark triple-organ transplant was a success. In August 2020, the UF Health team stuck the landing.
“I’m still expecting a long road ahead, but for the first time in a while, I feel like I have a lot to look forward to,” Barber said.
So do other patients. The number of abdominal transplant surgeries has grown exponentially since Beduschi took over as chief of the division.
“We closed 2020 with more than 200 abdominal organ transplants,” Beduschi said. “We are successfully transplanting some of the sickest and more complex patients with extremely short waiting times so others can be on their way to recovery and increase the chances of a normal life.”
And Barber is slowly, and steadily, on his way to a new normal.
“Six years ago, he came to us and they were thinking they’d do a transplant,” Bleiweis said. “Instead, we performed a valve reconstruction and got him those additional six years. But now, after this? He’ll have a lifetime.”