Man recovering from multi-organ transplant at University of Md.
A 28-year-old man flown to Maryland six months ago with a failing heart and liver expects to soon return to his Georgia home with healthy new organs, both transplanted during a surgery performed only a dozen other times this year across the country.
The rare effort by University of Maryland doctors means David Krech, who was born with a heart defect and has endured many other procedures, may soon be planning a future as a schoolteacher.
"The previous operations were stopgap measures, not a cure. The transplant is a cure," said Dr. Erika Feller, medical director of the Heart Transplant Program at the University of Maryland Medical Center and an assistant professor of medicine.
Transplants in general are now a regular remedy for failing organs — more than 19,000 have been performed so far this year nationwide. But multi-organ transplantation is still evolving, and heart-liver combinations remain among the least common.
Doctors at several institutions say that there is less need for multiple organs than single ones. But they also say there's also less expertise, and willingness, to transplant more than one because of the complexity and risk.
There have been just 90 heart- liver transplants since the 1980s, according to data from the United Network for Organ Sharing, a nonprofit organization that manages the nation's organ transplant system for the federal government.
That system doesn't even have a waiting list for heart-liver patients. Krech was put on separate organ lists and got both when a donor also had a second suitable part. A network spokeswoman said officials are constantly retooling policies on how to allocate scarce resources, now based on severity of illness, geography and other measures.
The group reports that more than 200 centers perform transplants, but only 26 have undertaken a heart-liver procedure — Maryland, which has performed three, is one of just a few on the East Coast. Maryland and Johns Hopkins University in Baltimore also have performed other multi-organ transplants.
There are generally long wait times for all. Krech matched more quickly than many others at five months because he has a rare blood type that meant less competition. More than 100,000 people are currently waiting.
At the University of Pittsburgh Medical Center, where 13 heart-liver transplants have been performed, doctors have been trying to increase use of flawed organs that may be rejected elsewhere, said Dr. Jay K. Bhama, a cardiothoracic surgeon. He also said they are more aggressive in selecting patients in need of more than one organ. Most have survived surgery well, he said. For transplants in general, national statistics show about 90 percent survive the first year.
"We've found if we get them through the surgery they enjoy the same survival rates as patients with the isolated organ transplant," he said. "Other institutions are still more hesitant because it's a big operation and they believe the risk is too high or they don't have the resources."
He and others said positive results may prompt more centers to step up. That would mean less travel for people like Krech.
At the University of Chicago Medical Center, doctors have worked to advance a surgical method specific to multi-organ transplant, including a procedure used at Maryland. It involves opening the chest for the new heart and leaving it open for the liver team. Heart doctors can then ensure there isn't bleeding, a common surgical complication, before closing.
Dr. J. Michael Millis, director of the Chicago hospital's transplant center, said successes have prompted doctors there to perform heart-liver-kidney transplants.
"We're trying to raise the bar, while making sure not to waste two or three organs," he said. "We don't want to look back and say the person wasn't a good candidate and we shouldn't have done it."
Millis and Maryland doctors said they consider more than just failing organs. They need transplant teams to effectively communicate and form a single plan. And because the patient must take anti-rejection medications for the rest of his life and return for care regularly, he and his family must demonstrate commitment.
Krech's family helped cement the decision to operate at Maryland, said Dr. Bartley P. Griffith, chief of cardiac surgery at the University of Maryland Medical Center and professor of surgery.
Griffith, who performed the heart transplant, said scarring from past procedures made surgery challenging. Two main arteries had fused, making extraction of the old heart difficult. He was aware many other centers wouldn't have done the surgery, seeing less risk in giving the organs to two other patients.
"I think we struggle with taking risks today, even though we had a great kid who deserved a chance," he said. "But everyone here was on board."
David Krech's operation started with a call to Feller in the transplant program from Krech's doctor in Thomasville, Ga. He knew transplant was the only hope for Krech, who was born with pulmonary atresia, a rare form of congenital heart disease where the pulmonary valve does not form properly and blood from the right side of the heart cannot get into the lungs to pick up oxygen. He also had a related hole in the wall that separates the heart's right and left ventricles.
He'd had his defective valves replaced at age 10 and 11 and again in 2007. In May, he got sick once more. By October, his heart was failing and he was dangerously low on sodium, which helps regulate blood volume and pressure, among other functions. His bad heart had also wrecked his liver, causing cardiac cirrhosis and a lot of fluid retention.
By the time he was flown on a medevac jet 1,000 miles to Maryland — 36 hours after the first contact with the transplant program — he was delirious.
Doctors stabilized him. A few days later, the transplant committee put him on the list for new organs. Krech and his mother and father, Lavinia and Bill Krech, who are divorced, moved into a rowhouse in South Baltimore to wait for a donor together. Krech stayed on the intravenous medications and had little energy.
He'd come to the hospital regularly to see doctors and have fluids drained from his belly. Then, the morning of Oct. 15, the hospital called and said a suitable heart and a liver were available. A bit scared, and sad for the anonymous donor's family, he and his family prepared for 10 hours in surgery.
"I thought I'd rather die trying," he said. "I felt like it would go well, but if it didn't, I'd lived a good life."
By the next day, he was sitting up in a chair — a recovery doctors said was uncommonly quick. He was released from the hospital a few weeks later.
Lavinia Krech, who retired early from her government job to move to Baltimore, said her son clearly has more energy and improved circulation: "He never had rosy cheeks before."
Bill Krech, a salesman who has been squeezing in work by phone, said he'd known since his son's birth that he would need a heart transplant some day and felt lucky to be able to come to Baltimore.
If all goes well, the family will be able to leave Baltimore in a few months. Doctors will be watching to ensure Krech's anti-rejection medications work, his organs function normally and he avoids infection. He hopes to return soon to Southwest Georgia Technical College to study early childhood education. He also hopes to again live on his own.
For now, he and his family will enjoy his health, and a little sightseeing in Baltimore.