Hard Cases: Tennessee’s First Heart-Lung Transplant

This article is part of LinkedIn's Hard Cases series, where medical professionals share the toughest challenges they've faced in their careers. You can read more about it here and follow along using hashtag #HardCases.

One month after Christmas, in 1987, my surgical team and I prepared for Tennessee’s first heart-lung transplant. A determined mother, desperate to live, was flying to Tennessee to receive the heart and lungs from a young woman in Nashville whose own life had ended too soon.

It was a bold step for our patient, the surgical team, and the brand new Multi-Organ Transplant Center at Vanderbilt University.  

I had just left Stanford to move home to Nashville and start the Multi-Organ Transplant Center at Vanderbilt University Medical Center (VUMC), with the goal of creating a world-class transplant program. At that time, heart-lung transplants were still quite rare; fewer than 100 had been performed worldwide. It was a challenging operation that would give even the most experienced surgeon pause. Remove all the organs between the neck and the diaphragm, leaving the chest cavity bare. Transplant a donor heart and lungs. Put everything back together. The long-term prognosis of transplanted lungs was unknown.

It was a nascent field. The procedure was still considered experimental in 1987, and most insurers would not cover it. So before we could take on a heart-lung patient, several things needed to happen. First, I needed a guarantee to finance the operation. The cost of transplantation, which often totaled $100,000 or more, was one of the big social and ethical issues confronting the field at that time. We didn’t want this life-saving treatment to be available only to the very wealthy, but without insurance covering the procedure hospital systems struggled with how to absorb the hefty cost. 

I had already left one program at Massachusetts General when they decided (mistakenly and shortsightedly I believed) in 1980 not to pursue heart transplantation because of the price tag. In starting the multi-organ transplant center, Vanderbilt agreed to open its doors to the patients in greatest need, not just those who could afford to pay. Eventually our center would need to pay its own way, but during those early years when insurers failed to cover the procedure – we would. 

I also needed to train our surgical team. I had participated in a number of these operations at Stanford under the tutelage of Dr. Norm Shumway, the pioneering father of heart transplantation. Now I hoped to bring this new medicine to Tennessee and the Southeast. For months our surgical team meticulously trained on the new procedure, culminating in a simulated heart and lung transplant under anesthesia and in the operating room in sheep, whose anatomy is similar to ours. Based on my experience at Stanford both in the lab and in the operating room, I detailed to the team the critical aspects and common pitfalls: minimize dissection around the trachea, carefully avoid damage to the phrenic nerves in the dissection, spend at least 30 minutes drying up the field before sewing in the specimen, minimize manipulation of the fragile lungs.

Our team was finely tuned and ready. That’s when Jean Lefkowitz called, a young woman who was dying, her only hope being this exceptionally rare, new procedure. 

Jean suffered from primary pulmonary hypertension, a fatal disorder that causes cells to grow and clog blood vessels in the lungs. She had done her research and knew the risks involved with heart-lung transplants – the long-term success rate was still nowhere near that of hearts alone – but this surgery was her only chance at a longer life with her children.

When I first spoke to Jean, she explained that she was very ill, and was considered a good candidate by another transplant program in Pittsburgh but she couldn’t raise the six-figure sum necessary to cover the cost of the operation. 

“I have raised some money from bake sales,” Jean said. “I’ve made appeals to the newspapers. I’ve written to hundreds of businesses asking for money. I’ve asked everyone to help. I’ve looked into other programs, like the one in Arizona, but they’ve done so few. Stanford is just too far away for me, and the waiting list is too long. I’ll die before they get to me.” 

Jean insisted our fledgling program at Vanderbilt was her best hope. 

She was determined, optimistic, and had a strong will to live. I was committed to not attaching a price to patients’ like Jean’s lives. We agreed to accept her for transplantation.

But would a donor become available before Jean died?

I placed Jean on the transplant waiting list around January 1, 1987, letting her know it could take months for an appropriate match. There was, and still is, a vast shortage of donor organs for the number of patients waiting for the life-saving transplant procedures. Too many of my patients, suitable and waiting for transplants, died while waiting for an organ. 

I arranged transportation for Jean through a company who volunteered to fly her on a chartered plane at a moment’s notice. Jean would be flying from her home in Florida because in transplant surgery, every minute counts. Donor heart and lungs can be outside the body for a grand total of four hours. It was imperative she got to Vanderbilt as soon as a match became available to ensure the highest probability of success.

In a matter of weeks, Jean had taken a turn for the worst and was at death’s door. I hoped for her sake that a match would become available soon, but also knew that someone would die before Jean would have a chance to live. 

That chance came 24 days after I had listed Jean. A teenage girl in Nashville shot herself in the head and was pronounced brain dead. It was a terrible and incomprehensible tragedy, and my excitement for Jean was tempered by the knowledge that a family had just lost a beloved daughter. The girl’s family unselfishly wished to honor their daughter by offering donation of her organs to give new life to others in dire need (As many as 12 recipients can be given better and new life from a single donor.). After receiving permission from the girl’s mother and running tests, it was confirmed that she was a suitable match. She had the same blood type and a similar chest size. We entered her donor information into the national computer network and it was confirmed that Jean was next in line for the donor heart and lungs. The girl’s death gave Jean her only chance for more years with her two young children. 

I rushed to the hospital to prepare for the complicated procedure. The operation took many hours, but our months of disciplined preparation paid off. Jean’s surgery was a success, and she was wheeled off to the ICU to begin her long recovery. 

This story, though dramatic in narrative because of the nature of the radical operation and the stakes of life and death, is actually just an example of how medical science advances today to treat diseases in ways that only a few year ago were impossible. 

Three decades later, VUMC is home to the second busiest heart transplant program in the country – with nearly 100 heart transplants performed last year – and ranked No. 1 in the Southeast region for volume for its combined adult and pediatric procedures. The center also performs a number of dual-organ transplants, including heart-kidney, heart-liver, and heart-lung. This year we celebrated our 1000th heart transplant. Nothing made me happier than celebrating with my colleague surgeon Dr. Walter Merrill, and especially with our friend and patient Jimmy Moore, who at age 29 was our fourth patient at the center in 1986 – and is now the center’s longest living heart transplant recipient at age 60. He is truly one of our medical miracles. 

Jean, sadly, was not at our celebration. Despite her surgery’s initial success, six months later she succumbed to complications resulting from a lung infection. She was a favorite among our team and her passing was tough on all of us. 

At the time, others in the hospital questioned whether the investment we were making in multi-organ transplants was worth it, whether those funds could be better used to help other patients. Was the time and money justified when the long-term prognosis of these patients was still unknown? 

Years later, it’s clear that the investment at the time and the decision to continue to develop heart and lung transplantation was the right one. Those that survive the first year after heart-lung transplantation today can expect to enjoy a decade of life or more. With heart transplants, life expectancy is even longer, and some like Jimmy Moore continue to thrive over 30 years after his transplant. 

 I am proud that instead of shutting the doors on potentially life-saving surgery because of prohibitive costs and challenging rejection rates of transplanted hearts and lungs, we continued to innovate. We learned from one another and carefully and ethically developed cutting-edge therapies that soon became standard therapy.

Jean did not get the new lease on life that she had hoped for, but her courage and tenacity paved the way for thousands of others who will.