OR Talk: Triple Organ Transplant

The surgical team responsible for the success of a recent heart-liver-kidney transplant talks shop.

After a decade battling sarcoidosis, Valence Sams Sr. was gravely ill. He faced nonischemic cardiomyopathy, congestive hepatopathy and kidney failure-a veritable death sentence.

His only chance at survival was a triple transplant of the heart, liver and kidney. The stars aligned in the spring of 2023, and Sams became one of only 37 patients nationwide to receive this kind of triple organ transplant since the United Network for Organ Sharing began tracking them in 1987.¹

Here, the Cedars-Sinaisurgeons responsible for his successful transplants describe the experience in their own words.

The Road to a Triple Transplant

Justin Steggerda, MD: It is very rare that a patient needs a triple organ transplant. Unfortunately, even for those in need, the answer of whether to pursue a triple transplant is frequently "no."

Tyler Gunn, MD: You need to have a very rugged recipient who can undergo 20 hours of surgery. These are three organs that could have gone to three different people. If the surgery results in a bad outcome, you've affected four people.

Irene Kim, MD: If a patient is unlikely to survive a triple organ transplant, then we should not attempt it, because then we are not being good stewards of the precious gift of life.

Nicholas Nissen, MD: The problem with transplanting just a single organ is that the other failing organs will compromise that new one. If you only transplant the heart and the patient is in liver failure, they are not going to survive-and you've thrown that heart away. You either have to say no to everything or allow the patient to have more than one organ. We take the burden of that decision very seriously and must carefully weigh the likelihood of success. Either we fix all of the organs, or we don't fix any.

JS: You also need a healthy donor-someone who doesn't have intra-abdominal injuries, who is young, and who has good liver and renal and heart function. These organs take hits over the course of our lifetimes. Once you add the hit of a transplant-you take the organs out of the body, put them on ice, transport them and put them in someone new-not every organ will work.

TG: Mr. Sams had sarcoidosis, an infiltrative disease that mostly affected his heart and over time led to heart failure and kidney damage. He developed liver disease, which is usually irreversible. Often, patients with these health conditions can't get transplanted, and they usually pass away. But Mr. Sams was young and fit, and we thought he could undergo the procedure.

JS: I think the most important thing was that he continued to prove throughout the entire evaluation process that he wanted it. He always had his family by his side. He was always optimistic and always motivated, and he didn't want to settle for anything less.

NN: You're very much obligated to treat the patient whose life is in your hands at that moment, sitting in front of you. We had a moral and ethical obligation to consider him for a triple transplant. Data showed he should survive and have good outcomes. In his case, we felt it was a well-meaning use of resources.

IK: A triple organ transplant is a significantly more complex and challenging case than a single organ transplant, and it requires dedication from all involved transplant programs. As a center that is quite comfortable performing dual organ transplants and has high transplant volumes, our team is experienced in considering these transplants after careful selection.

JS: The process starts when we get an offer for the organs. The heart team has to believe it is a good enough heart, the liver team has to believe it's a good enough liver, and the kidney team has to believe that it's a good enough kidney. If all align, you accept the organs and move forward. This donor was in Arizona, so the case involved coordinating multiple flights, perfusion teams and surgeons who procured the organs with the operating room and surgeons back at Cedars-Sinai, who were simultaneously working to have the patient ready for surgery when we arrived.

Read: A Kidney Transplant and a Visit from Rampage: Jordan Kirkland's Story

In the OR as a 20-Person Team

TG: Triple organ transplants are so rare because they are so complex. You need to perform three separate surgical procedures back-to-back. First is the heart transplant, which is completed in a similar fashion to a single heart transplant, but then the process deviates. Instead of closing the chest and sending the patient to the ICU after six hours, you leave the patient with an open abdomen and the new heart and move on to the liver transplant, which takes another six or seven hours or longer. Then you get to the kidney, which adds another three to four hours. When all was said and done, this case took about 20 hours in and out of the operating room. During that time, the patient is critically ill.

NN: The process can be compared to an orchestra, with surgeons and 20 other team members all playing their parts. Once the heart is transplanted, we begin the liver transplant, and we can't move forward unless the heart is doing fairly well. That adds a bit of extra pressure, because all of our surgical maneuvers and decisions have to factor in the minute-to-minute function of a brand-new heart. One of the critical elements to this entire process is the collective effort of multiple anesthesia teams, each expert in their own area and together functioning seamlessly and flawlessly.

JS: There was constant communication regarding how the patient was doing with each transplant as it progressed. It is important that each surgery-but particularly the heart and liver transplants-go well. From a logistics standpoint, throughout the case, we were always checking in to see how the patient was doing. We monitored his heart and then his liver function, what was going on with his bleeding, and whether we could proceed with the next step of the operation. We ensured everyone was satisfied along the way before the next part began.

Outcomes and Looking Ahead

JS: As a patient, Mr. Sams did phenomenally well and was discharged home within two weeks. The success of this came down to communication and the fact that we have practice at it, having already performed multiple heart-kidney, liver-kidney, heart-liver and heart-lung transplants.

TG: Within any single transplant operation, there are many steps. If one goes wrong, it can derail everything. To perform three in a row, there are hundreds to thousands of things that have to go right, and they did. I think the reason it went so well is that we have such high transplant volumes at our center, so for each of us, it wasn't much different than a normal surgery. It was just much longer!

NN: In a carefully selected patient, I think triple transplant is a good option. Cases like this will make centers think, "Should we?" or "Could we?" We're not on any podium, but for this young man, it was absolutely the right thing to do. It saved his life.

JS: I feel very fortunate to be a part of this. I think this definitely gives us confidence that we can perform such a surgery successfully again; we just have to be wary of becoming overconfident.

IK: We will proceed judiciously, and I think it is likely we will attempt another triple organ transplant.

TG: We always need to thank the donors and advocate for organ donation. It's that wonderful gift of life that allows us to do this and really affects people's lives, like Mr. Sams. He recovered quickly and is doing very well.

JS: It's been a high-risk, high-reward experience. People become surgeons for all sorts of different reasons, but a common thread is that we want to help people and we also appreciate the challenge. From a physiologic standpoint, this is one of those procedures that's pushing the boundaries of what we can do in medicine. I think the teamwork aspect is an exciting part of it, too.

NN: This wasn't foreign territory to us. I don't mean to put it lightly, but it was just like any other day in the operating room-working together to save lives.

Read: Cedars-Sinai Patient Receives Rare Triple Organ Transplant

1. Adjei MA, Wisel SA, Steggerda JA, Mirocha J, Mavis A, Esquivel CO, Kim IK. Incidence and Outcomes of Simultaneous Thoracoabdominal Triple Organ Transplantation in the United States. Transplant Proc. 2024 Jan 8:S0041-1345(23)00767-4. Epub ahead of print.