Two pediatric surgeons tell the story of the first split-root domino heart transplant ever done at NewYork-Presbyterian and share how major advances in pediatric heart surgery will allow for more living valve transplants.
On this episode of Advances in Care, host Erin Welsh talks to Dr. Andrew Goldstone and Dr. David Kalfa, pediatric cardiac surgeons at NewYork-Presbyterian and Columbia, about their groundbreaking heart transplant that saved the lives of three separate children. It was the first time doctors at NewYork-Presbyterian Morgan Stanley Children’s Hospital performed a split-root domino partial heart transplant. In this procedure, one child was transplanted with a new heart and their original heart was used to donate living pulmonary and aortic valves to two separate recipients in need.
Dr. Goldstone, Dr. Kalfa and the rest of the team at NewYork-Presbyterian and Columbia had previous experience with a handful of domino partial heart transplants where one patient is transplanted with a new heart and another receives a valve from the explanted heart. Those experiences helped prepare for the split-root domino, which took nearly 24 hours of extremely coordinated care. In addition to their efforts to increase the number of domino heart transplants being done, physician-researchers at the institution are leading new studies that are also helping improve living valve procurement and storage, allowing more children to receive heart valves that will grow with them and require less surgeries.
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Dr. Andrew Goldstone is the Surgical Director of Heart Transplant and Mechanical Circulatory Support and Director of the Valve Transplant Program at Columbia and NewYork-Presbyterian. He has been recognized nationally and internationally for his clinical and basic science research. In the lab, he focuses on mechanisms underlying collateral artery formation and cardiac regeneration. His long-term goal is to continue adding high-level evidence to better inform the surgical treatment of pediatric and adult cardiovascular disease.
Dr. David Kalfa is a Board-certified cardiothoracic surgeon with a subspecialization in pediatric cardiac surgery. He is also a researcher focusing in the field of growing heart valves and growth accommodating heart valves.
For more information visit nyp.org/Advances
Dr. Andrew Goldstone: I remember I was on call. I had gotten a call for an offer for a heart, a whole heart. It was around two in the morning or something.
This is Doctor Andrew Goldstone - a pediatric and congenital heart surgeon at NewYork-Presbyterian and Columbia. And the call he’s talking about took place back in the spring of 2023.
Dr. Andrew Goldstone: After a call like that, it's very hard to go to sleep again. You know, you're sort of awake and you're thinking about the transplant that you're gonna do. And so I was just checking my emails and I was looking through the case conference schedule for the next day.
While Dr. Goldstone sat thinking about the donor heart he would soon be transplanting, a different case caught his eye - an infant patient in heart failure who needed a truncal valve repair.
Dr. Andrew Goldstone: I saw this patient who had truncus arteriosis and had already had a truncal valve repair - so her heart was failing because the truncal valve wasn't working well still. And so in my mind I was like, you know, I have a similar size patient who's getting a heart transplant.
Dr. Goldstone and the team at NewYork-Presbyterian Morgan Stanley Children’s Hospital were on the verge of a unique opportunity. They had one patient – an infant that was about to receive a donor heart transplant, and another infant patient who needed a new heart valve.
Dr. Andrew Goldstone: At our case conference we were all talking about how it would be great if we could do this partial heart transplant for that child who needed the truncal valve. And so I said, well, I'm doing a heart transplant later today. The valves work. Maybe we could do it as a domino.
A domino partial heart transplant. The doctors would transplant a new donor heart into the first patient, and then use the working valves from that patient’s explanted heart to perform a valve transplant for the second patient. Saving two lives in the process. A domino partial heart transplant had never been done before on infants. But it was something that Dr. Goldstone and the rest of the team were prepared to try.
Among that team was Dr. David Kalfa – another pediatric cardiac surgeon at NewYork-Presbyterian and Columbia.
Dr. David Kalfa: It really takes a village to make this happen, right? You have to coordinate a lot of things. You have to involve a lot of people, you know, surgeons and cardiologists, anesthesiologists, perfusionists…
Dr. Andrew Goldstone: The whole team really rallied together. It was truly a remarkable exhibition of teamwork and determination to get it all together and a little bit of faith too in each other to organize this and innovate like this.
Together with an expansive team of medical professionals, Dr. Goldstone and Dr. Kalfa performed the first infant domino partial heart transplant ever done. It was a landmark moment in pediatric cardiac surgery and one that profoundly changed the lives of two small children.
Dr. David Kalfa: It was an incredible feeling. To be honest with you. Especially, you know, when you go out of the OR and then you meet with the parents to update them on how the surgery went. That was just an incredible moment.
Dr. Andrew Goldstone: It led to two lives saved in the same day, which was incredible. And, you know, that was the first of many we've done now.
I'm Erin Welsh and this is Advances in Care, a podcast about groundbreaking developments in modern medicine.
That first procedure was only the beginning. Since the initial domino they performed in May of 2023, Dr. Goldstone and Dr. Kalfa have continued to think creatively about how to make the most of every organ and improve children's outcomes.
Today, both doctors share the story of their most recent transplant - a split root domino. Like the first domino transplant, it involves transplanting a new heart into a pediatric patient. But this surgery takes the innovation even further. It uses a donor heart and the aortic and pulmonary valves from the explanted heart to save the lives of not just two, but three patients.
In this episode, Dr. Goldstone and Dr. Kalfa walk us through this groundbreaking procedure, and share how these surgeries are revolutionizing pediatric cardiac care.
Dr. Goldstone didn’t set out to become a pediatric cardiac surgeon but life has a way of changing the best laid plans...
Dr. Andrew Goldstone: I had job offers in adult cardiac surgery, and I was supposed to be an adult cardiac surgeon. And then I had to make it complicated and toward the end of my training, decided actually I want to do pediatric heart surgery,
What really pushed me toward that is that, you know, my own child needed surgery and I saw the gift that you could give to a family. And I'm reminded of that every day I see my own son.
Like Dr. Goldstone, Dr. Kalfa was drawn to the profession by the incredible impact cardiac surgery can have on children throughout their lives.
Dr. David Kalfa: When I first saw the case of a pediatric cardiac surgery in a small child that was for a replacement of one of these cryopreserved homografts. That was already the fourth operation that this child had to undergo. And based on this experience, I decided to really focus my whole career on that.
Dr. Kalfa leads the Pediatric Heart Valve Center and has gone on to focus on finding new options for living valve transplants in children. As it stands today, the most common solutions are cryopreserved homografts - or frozen human heart valves, tissue valves - which are cow and pig valves, and mechanical valves. But all three of these options lack one very important quality…
Dr. David Kalfa: All these options, you know, the mechanical valve and the tissue valve, all these options do not have any growth potential.
When heart valves are unable to grow with a patient it means that many more surgeries are required throughout a patient's life which increases morbidity and mortality. That's why Dr. Kalfa and Dr. Goldstone were so keen to embrace a new solution that can use living valves - the domino partial heart transplant. And it’s why the split-root domino is so incredible.
Doctors have known for some time that living valve transplants are possible, but they come with their own set of challenges.
Dr. David Kalfa: In the sixties, in the seventies, some surgeons were actually implanting fresh homografts, which mean that they are using this living tissue coming from a person, who passed away or coming from a heart that is explanted at the time of a transplant.
These early living valve transplants did not use immunosuppression, which made it much more likely that patients would reject the living valves after transplantation.
Dr. David Kalfa: The other difference was that they didn't necessarily rush to implant this valve, which meant that some of this valve had a long ischemic time before being reimplanted in the patient.
Not surprisingly, ischemic time is very important to maintaining the health of living valves. It’s also important when it comes to transplanting donor hearts.
Dr. Andrew Goldstone: So in general, the heart, we try to get it from the time that we're stopping the blood flow to it in the donor to the time that the recipient is giving their blood to this heart and perfusing it, we try to have that happen within four hours.
Coordinating two complex transplants at once while optimizing the health of the valves is a major hurdle when it comes to doing partial heart transplants. It can be difficult to locate and move valves from one hospital to another within the necessary time frame to still consider them living. That’s one of the major advantages of domino heart transplants – when they’re done at one institution, like NewYork-Presbyterian, the valves are ready right after they’ve been explanted from the first patient who is receiving a full heart transplant.
Even then, it takes an extensive team of experts who understand how to properly transplant living valves and a department that’s ready to move on the opportunity as soon as a donor heart becomes available. Lack of access to this expertise, the necessary equipment and a sizable team prepared to move swiftly are the major reasons domino partial heart transplants aren’t being done more frequently.
After completing eight domino partial heart transplants since their first procedure back in May of 2023, Dr. Kalfa and Dr. Goldstone realized that their team was uniquely situated to take on a new challenge that would help even more children – the split-root domino partial heart transplant. And in the summer of 2024, they got word that another heart was about to become available.
Dr. Andrew Goldstone: Dr. Kalfa was on call. He received the offer for the heart for one of my patients.
Dr. Goldstone and Dr. Kalfa quickly realized that this heart presented an extraordinary opportunity.
Dr. Andrew Goldstone: We had a situation where we had patients that needed separate valves. One needed just an aortic valve and one needed just a pulmonary valve. And so we had a donor who was the right size and had the right size valves for each of these patients. And we said, well, we could potentially set off a cascade where we help three kids with one heart transplant.
After years of preparation and training, this would be the first time that the team at NewYork-Presbyterian would do a split-root domino partial heart transplant.
Dr. David Kalfa: We already had some discussion with the parents of patient A to know whether or not they would be interested in potentially donating the valves from their baby to help other babies. And so we knew that once the heart of patient A would be explanted at the time of the heart transplant, we could use the aortic valve to replant the aortic valve of patient B. And the pulmonary valve to help patient C who needed a pulmonary valve. So that's the concept of a double domino, right? Or a split root heart valve transplant. So you split the roots so that you can, you know, implant them in two different patients.
As soon as they received the call, they needed to begin preparing for the three back-to-back transplants they were about to do.
Dr. Andrew Goldstone: Usually from the time that you get the call, you have anywhere from like eight to 24 hours that you're sending your team out to go procure the donor heart organ.
Once their procurement team was in motion, they needed to reach out to the families of each of the three patients.
Dr. Andrew Goldstone: If we're planning to do the domino, we need to then start setting the teams in motion to start talking to the families about it. A lot of these patients that are living with valve disease are not hospitalized, so they need to come in and sometimes they don't live that close, so we need to let them know so they can mobilize.
The team had to work quickly to ensure all three families were ready to go for this tightly coordinated sequence of events to unfold as smoothly as possible
Dr. Andrew Goldstone: To get a child through heart surgery requires a tremendous number of people. And they all have to work together well for this shared common goal of doing what's right by the patient. And so even in the operating room, there may be 10 people in the operating room making that function, you know, including the anesthesiologist, the perfusionists who run the heart and lung machine, the surgical assistants, the nurse, the scrub nurse who's handing the instruments, applying the instruments, a circulating nurse, trainees. So there's a lot of people in there to make this work.
In addition to assembling and preparing all the medical professionals needed to execute these transplants, the team would need two separate operating rooms next to one another, and three intensive care beds ready for the patients post surgery. Once the team was mobilized and the patients had arrived, Dr. Kalfa scrubbed in to begin the first heart transplantation on Thursday at 8am.
Dr. David Kalfa: I performed heart the transplant on patient A. So we brought patient A in the operating room knowing that I would explant this heart and then I would harvest, you know, first the pulmonary valve and this pulmonary valve would be implanted in patient B.
While Dr. Kalfa was in the operating room performing the heart transplant, Dr. Goldstone entered a different operating room next door. He began preparing his patient for their valve transplant.
Dr. Andrew Goldstone: I was doing the first valve transplant simultaneously as Dr. Kalfa was doing the heart transplant.
Dr. Kalfa had to work quickly, so that he could transfer the first valve to Dr. Goldstone with as little ischemic time as possible. First Dr. Kalfa explanted his patient's original heart and transplanted her with the new donor heart. Then he had to split off the pulmonary valve for Dr. Goldstone, who had already begun operating on his patient.
Once Dr. Kalfa finished, the team transferred the pulmonary valve to Dr. Goldstone’s operating room so he could transplant it. The explanted heart with the remaining aortic valve needed by the final patient was placed in a device which helped maintain temperature until the heart transplant was completed.
Dr. Kalfa wrapped up the heart transplant by 2:00pm, taking about six hours and Dr. Goldstone’s valve replacement wrapped up by 4:00pm taking about eight. Dr. Kalfa was the first to wrap up which meant, according to the team’s plan, he would take a brief break and then begin the final valve transplant.
Thankfully, Dr. Kalfa was prepared to refuel before his final operation.
Dr. David Kalfa: Thank God I have a few bananas in my office.
Dr. Kalfa did not rest long. Soon it was time for him to transplant the aortic valve in the third and final patient. He began, but soon ran into a complication.
Dr. David Kalfa: So at the time of the implantation of the aortic valve patient, we actually figured out that the donor of the aortic valve has a congenital malformation of the coronary arteries. These coronary arteries are these small arteries, coming from the aorta to bring some blood and some oxygenation to the myocardium.
Sometimes you can have an abnormal origin of the coronary artery, right? So this is something that we treat, you know, by doing a surgery that we call a coronary unroofing, an unroofing of the coronary artery.
At the time of the implantation of the aortic valve, I actually was surprised to see that, you know, patient A had donated an aortic valve with an abnormal coronary artery to patient C. So I also had to do this unroofing and deal with this little surprise.
But thanks to years of experience in the operating room and the in-depth planning that goes into double domino procedures, Dr. Kalfa was prepared.
Dr. David Kalfa: You deal with this type of situation in cardiac surgery, that's a specialty where you really, you encounter some surprise, right, and so you have to adapt and change your plan or do other additional procedures. So that's not something which is very infrequent, to adapt your surgical plan in the operating room.
At 4am the next morning, more than twenty hours after they began, Dr. Kalfa completed the final valve transplantation.
Dr. David Kalfa: So that was a pretty long day. That was a very, very long day actually. You know, it was almost like a 24 hour adventure.
As with any surgery, Dr. Kalfa and Dr. Goldstone went to see their patient's parents after they finished to let them know it was a success.
Dr. David Kalfa: And actually I become kind of a little bit of emotional after talking to the parents of patient C because it had been a long day. And everything went as smoothly as possible. And also, I had operated on patient C in the past. So as a surgeon, you know, especially a pediatric cardiac surgeon where you know that you may have to re-operate right in the same patient, you kind of create a relationship with the parents. And so I already had this relationship, right, with these parents who are incredible, fantasy parents. And so adding that to, you know, the whole story makes it very particular for me.
Dr. Andrew Goldstone: The patients all did outstanding. You know, they did really well. The heart transplant went very well. The heart worked well. The pulmonary valve recipient has done great and the aortic valve recipient did fantastic as well.
The opportunity to have these living valves grow with the children will continue to be monitored throughout their lives. But based on discoveries made from the first domino partial heart transplants, these innovations are already paving the way as a new approach to valve transplant and are reducing the need for repeated surgeries.
In the wake of the success of the split-root domino heart transplant other institutions have been reaching out to the team at Columbia to learn how they can start doing living valve transplants.
Dr. Andrew Goldstone: We as a field are trying to work together to make sure that we understand the outcomes as a group, right? Because not everyone has done that many valves. And so individual center experience is important, but it's gonna be more important as a group experience to understand this new approach to valve replacement.
But there are significant challenges to procuring living valves.
Dr. Andrew Goldstone: There's issues like at the regulatory standpoint because a valve is not declared an organ, right? It's considered tissue at the FDA level. And so the organ procurement organizations are not, technically, it's not under their jurisdiction, so they don't, they're not obligated to call for valves in unused hearts. And so it's not so easy to get those calls. We don't get that many calls despite, you know, reaching out a lot.
This has not deterred the team at NewYork-Presbyterian from looking for solutions. Or from creating the solutions themselves.
Dr. David Kalfa: So we are in the process of setting up this heart valve registry in collaboration with the CHSS, who is the Congenital Heart Surgeon Society, and we are moving along with this project pretty well. So that's very, very exciting.
A heart valve registry would create a list of all patients needing valves much like physicians use donor registries when they have patients in need of transplants. Once it's in place and widely used it will help more patients get access to the valves they need.
And for his part, Dr. Kalfa has been hard at work finding innovative solutions for storing living valves.
Dr. David Kalfa: We are working in my lab here at NYP Columbia to set up a system, bioreactor system that helps us storing, preserving, and then even potentially rehabilitating some valves in vitro for an extended period of time, right? So now we are able to store them and to keep them alive for almost two months, which is already a huge game changer.
The future of living valve transplants looks very promising thanks to the dedicated teamwork of the members of the transplant program at NewYork-Presbyterian and Columbia.
Dr. Andrew Goldstone: It comes down to a culture of determination, a culture of innovation and a culture of teamwork, right? And everyone here is dedicated to our patients and trying to do what we feel is best for them and what is best for the families working with them and what their goals of care are. And that is for me, what has made NYP and Columbia such a special place to work, and why I think this endeavor so far has been successful.
The impact of these transplantations has gone far beyond the operating room. The family of one of the patients recently shared a very important and very furry life update with Dr. Goldstone.
Dr. Andrew Goldstone: They appreciated the procedure so much. They actually, they got a dog and they named their dog Domino, which is incredible. And to see their kid growing up and running around now after this procedure is awesome.
Dr. David Kalfa: When we did this double domino valve transplant, you know, there is absolutely nothing that can be more rewarding than helping three patients at once. Having such an impact on the life of children is magical.
Thanks to Dr. Goldstone and Dr. Kalfa for taking the time to share their story about the split-root domino partial heart transplant they performed.
Their work has forever changed the lives of many pediatric patients and will continue to revolutionize how the medical community approaches living valve transplants in children.
I’m Erin Welsh.
Advances in Care is a production of NewYork-Presbyterian Hospital. As a reminder, the views shared on this podcast solely reflect the expertise and experience of our guests. To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts. And to learn more about the latest medical innovations from the pioneering physicians at NewYork-Presbyterian, go to nyp.org/advances.