It had been less than two weeks since giving birth when a coronary artery in Adriana Rodriguez’s heart burst.
The sudden tear interrupted an early December breakfast with her mother in Bellingham, and within minutes her chest started tightening. A wave of nausea weakened her body. She wanted to curl up into a ball.
The ambulance ride and first few days at PeaceHealth’s St. Joseph Medical Center jumbled into a blur.
The 31-year-old didn’t know at the time that the rupture had triggered a monthslong medical journey that would eventually lead doctors in Seattle to attempt a double heart and liver transplant — working in a context that had never been seen at the hospital or anywhere in the U.S. Some research around the concept exists, but it hadn’t been tested in someone who was as sick as Rodriguez, and with the same immunologic obstacles.
But options were limited, so a handful of UW Medicine doctors urged the hospital to take a leap of faith.
“I didn’t know if it would save Adriana’s life, but this was the best chance I’d ever seen,” said Dr. Shin Lin, one of Rodriguez’s primary cardiologists in Seattle, and one of the main proponents of the procedure.
Eight months later, there are still many unknowns about the surgery, but doctors say the experience illuminated what might be possible in the future of heart transplant science.
An unusual patient
Before Rodriguez ended up in the hospital late last year, she had been preparing to welcome a third child — her first girl.
Junior and Adrian, 12 and 11, were looking forward to their sister’s arrival. Near the end of the month, the family had plans to take a Christmas road trip to Mazatlán, a seaside town in Mexico.
When Rodriguez first ended up at the Bellingham hospital, she hoped she’d be able to return home soon. She had no idea she would spend much of the following year in Seattle.
The rupture, or dissection, in her heart was severe — something doctors say is uncommon but not unheard of during or after pregnancy. The increased stress and hormonal changes play a role in risk, but in the best-case scenario, the heart heals on its own, said Dr. Jay Pal, surgical director of UW Medicine’s heart transplant program.
When Rodriguez was transferred to UW Medical Center last December, Bellingham doctors had already added a balloon pump — a shorter-term mechanical device that helps pump blood — near her heart to support it.
Her care team in Seattle quickly found her heart would need more. Six days later, Rodriguez was connected to a heart-lung machine, known as an ECMO machine, that oxygenates a person’s blood outside the body and recirculates it. The method is generally reserved as a last-resort option for a hospital’s sickest patients, doctors said.
“[The ECMO machine] has a knob on it showing how much support to give,” Lin, her cardiologist, said. “When we turned support down, it didn’t seem like she was going to make it.”
The care team started talking about the possibility of a heart transplant, a reasonable next step for a patient with heart failure, Pal said.
Then Rodriguez’s care became even more complex.
“Adriana’s level of antibodies were well beyond anything we’d seen before in other patients,” Pal said.
In other words, she was “highly sensitized” — meaning her body for some reason had developed a large number of protective proteins, which normally would be helpful in fighting off bacteria and infections. But preformed antibodies also attack other new tissue, including transplanted organs. That put Rodriguez at significant risk of a rejection.
“If someone has one or two preformed antibodies, it’s not hard to avoid [rejection],” Pal said. “She had many — to the point where she would only be able to accept about 1% of donated hearts.”
Some members of the care team pointed to an option for longer-lasting mechanical heart support, known as a left ventricular assist device or LVAD, but Lin didn’t love the idea. Rodriguez’s heart was smaller than usual and he was worried she would run into long-term problems.
The group struggled over a path forward for several weeks. It was late December when Lin stumbled on the idea of the heart-after-liver transplant.
A domino decision
The cardiologist of seven years was at home catching up on some reading from the International Society for Heart and Lung Transplantation. Rodriguez’s case was fresh in Lin’s mind, but he wasn’t intentionally hunting for a solution that day.
The organization had recently published an updated set of guidelines, and one section stood out. It reported more double heart-liver transplants are being done, and that the liver transplants seem to provide some sort of immunoprotection and decrease the rate of heart rejection, though the concept wasn’t fully understood.
“It was a bit of a serendipitous moment,” he said later. “I thought, ‘Wait a second. This could help our patient.’”
Lin did some more research and pulled together a couple of other examples that suggested transplanting a liver, along with a heart, could help lower antibody levels. None, however, confirmed success.
The operation had also only been tried on patients with bad livers that needed to be replaced. In this case, Rodriguez’s liver was healthy. Would the procedure still work in lowering her antibody levels enough for her body to accept a new heart?
When Lin finally pitched his idea to the heart transplant committee, he envisioned a set of falling dominoes.
Surgeons would first remove Rodriguez’s healthy liver and transplant a new one from the donor. The new liver would absorb antibodies that would otherwise attack the donor heart, and filter them out of the bloodstream. Then, after the liver, it’d be safe for surgeons to transplant Rodriguez’s new heart — also from the same donor.
Meanwhile, her healthy liver would go to another patient in need.
The team was skeptical at first.
The method hadn’t been tested widely and never before in a situation like Rodriguez’s. Teams from the liver and kidney transplant departments weighed in on daily conversations about her care, as did others throughout the hospital. Many thought the plan was too high-risk.
Another dilemma: Was the healthy donor liver most useful in a tricky transplant procedure, or was it better to use it somewhere it was sure to save a life? Organs are scarce and there’s a responsibility to be “good stewards for liver donor utilization,” said Dr. Mark Sturdevant, the hospital’s surgical director of liver transplantation and one of Rodriguez’s surgeons.
Lin stood firm. He felt the double transplant was the best option.
Pal, also one of Rodriguez’s main heart surgeons, helped Lin advocate for the surgery, but new roadblocks — ranging from limited research to expensive medications — seemed to emerge each week.
“There were several times where this concept looked dead,” Lin said. “Too many doors had shut. But the patient was still upstairs, and she needed a solution.”
The weeks in the hospital were hard on Rodriguez, who badly missed her children and found relief in their frequent visits. Her mother, who also lives in Bellingham, rented an Airbnb in Seattle to be close, along with her aunts, who helped with child care. Her father, in Olympia, moved to Seattle temporarily so he could visit every day.
“I don’t think I would’ve made it without them,” Rodriguez said. “My kids were my reason to keep pushing.”
It was early January by the time Lin and Pal had persuaded enough doctors to support the heart-liver transplant they had in mind. A consensus still hadn’t been reached, but because the procedure had the approval of Pal, who leads the surgical side of the department, and Dr. Daniel Fishbein, who leads the medical side, the team began to move forward.
Meanwhile, Rodriguez had been waiting on the donor transplant list. After four weeks, a match became available.
17 hours of surgery
On the morning of Rodriguez’s surgery, her care team had a checklist. Every detail had been planned out. Still, nerves kept Lin, who would be watching the surgery afar, from sleeping the night before.
“Transplants are not a simple procedure,” he said. “A lot of things can go wrong. And this wasn’t going to be one transplant, it was going to be two.”
The surgery team began at 8 a.m. on a Saturday in mid-January. After they removed Rodriguez’s liver and heart, liver surgeons Sturdevant and Dr. Ramasamy Bakthavatsalam hurried down the hall to transplant her healthy liver into another patient, someone struggling with advanced liver disease.
About 17 hours later, Rodriguez was out of surgery. She had a new heart and liver.
“The next thing I remember is waking up and Dr. Pal coming to see me,” she said later. “When I saw him, I just thought, ‘I made it. I’m alive.’ I tried to grab his hand to say thank you.”
Although surgery went well, a couple of more weeks passed before Rodriguez and her care team felt optimistic about her condition. She was feeling better every day.
In mid-February, Rodriguez was discharged from UW Medical Center’s Montlake campus, though her doctors asked her to stay in Seattle for initial weekly follow-ups.
It was a relief to leave the hospital, Rodriguez said, but they weren’t in the clear yet. Months after the surgery, Lin pointed to a chart of her antibody levels following the procedure, noting that most of them had significantly plummeted, a good sign. But some weren’t going down.
Then, on Day 65 — more than three months after the operation — reports returned confirming all antibodies had dropped to “unmeasurable” levels.
“That was the day I could actually breathe freely,” Lin said.
Back to Bellingham
At Rodriguez’s most recent checkup in Seattle in August, Lin listened to her new heart with a stethoscope. Everything sounded normal.
After chatting about diet changes and ongoing medications, the two made plans for next month’s appointment. Lin said he was hopeful Rodriguez would be able to resume “as normal a life as possible” within the year.
Rodriguez has been recovering slowly over the past few months. While still in Seattle, she completed a 12-week course of weekly physical therapy and got used to short walks in the hallway of her Airbnb. It took her awhile to lift or pull anything, and for months she couldn’t hold her new baby, Analia, on her own.
She and her children finally returned to Bellingham in early May, deciding to move into her mother’s home for extra support.
“It felt weird to be back here,” she said recently. “It had been five to six months since I’d been home.”
Since then, she’s added grocery shopping and cardiac rehabilitation, a medically supervised exercise program, to her routine. Because her immune system is still fragile, she tries to avoid crowds. She used to work as a server at her mother’s downtown Bellingham restaurant, Señor Lopez, but hasn’t thought about returning to the job just yet.
And she’s still getting used to the daily medications and now monthly drives to Seattle for her post-op appointments — which will likely continue in some form for the rest of her life.
Her family accompanies her to each one.
After her most recent appointment, Rodriguez stepped outside the hospital to rejoin her father and kids, waiting in a car by the curb. She smiled as she picked up 8-month-old Analia — something she can do easily now. Junior and Adrian popped their heads out to greet their mother.
The family’s Christmas trip to Mexico, canceled last year, has been rescheduled for this December. They can’t wait.
“I hope that if this happens again to someone, this [experience] will make them not as scared of the surgery,” she said, expressing gratitude for her “amazing” doctors and nurses. “There’s a success story behind it.”
At UW Medical Center, doctors are also still reeling from the experience. Rodriguez’s care team has since published their work in a peer-reviewed journal and has started working with other patients at the hospital who might benefit from the same procedure. UW Medicine has also opened conversations with other regional health care systems about working with more highly sensitized patients in the Pacific Northwest.
“These patients have presented very big problems for programs in the past,” Lin said. “They’re patients we had written off as not transplantable, but now there may be some hope.”
There are still complicated questions about the surgery, Pal said, but “knowing Adriana did well is really encouraging and hopefully allows us to apply this therapy more broadly.”