Transplant specialists at Vanderbilt University Medical Center were not shooting for another new record when they began planning a double-lung and liver transplant on February 16, 2025.
Yet, they faced a complex case that ultimately led to one. Their 60-year-old transplant candidate had myositis-related interstitial lung disease, liver disease, metabolic syndrome and cardiovascular disease. She also urgently needed a bypass of the left anterior descending coronary artery, which was 70% blocked.
The patient was too sick from her lung and liver disease to undergo a separate coronary artery bypass graft surgery before the upcoming transplant. Therefore, the team opted to perform it at the same time as her combined heart/liver transplantation in what became a 15-hour transplant surgery, and the first combination of this kind.
Konrad Hoetzenecker, MD, PhD, surgical director of the Vanderbilt Lung Transplant Program, led the operative procedure together with Seth Karp, MD, surgeon-in-chief; Martin Montenovo, MD, MMHC, surgical director of the Adult Liver Transplant Program; and Absi Tarek, MD, associate professor of cardiac surgery.
David Erasmus, MD, the medical director of the Vanderbilt Lung Transplant Program, coordinated the transplant teams and led the medical management of the patient.
“She’s just over six months out now and doing well,” Erasmus said of the patient. “Her lung, liver and heart functions are all very good.”
Foundations for Milestones
The Vanderbilt Transplant team performed their first combined heart, liver and double lung transplant in 2020. This was on the heels of more than 500 lung transplants performed at Vanderbilt since the lung transplant program began in 1990, including a record 99 lungs transplanted in fiscal year 2024 and 126 lung transplants in fiscal 2025.
Today, Vanderbilt has the busiest lung transplantation program in the Southeast, and the eighth highest volume program in the nation, leading in innovation in organ preservation and regeneration.
Criteria Met
Their recipient was a referred patient, evaluated by transplant specialists/hepatologists and pulmonologists in the Vanderbilt Interstitial Lung Disease Center.
“She had some muscle issues and possibly an autoimmune component to her lung disease,” Erasmus said. “We controlled these with immunosuppressive medication for a while, but then the medications were unable to keep her stable.”
In January 2025, her condition precipitously declined, leading to a hospital admission for high-flow oxygen. During this time she was evaluated for transplant and the LAD blockage was discovered.
“As sick as she was, receiving a coronary stent would have affected her place on the transplant list — a delay she was unlikely to have survived,” Erasmus said. “That forced our hand into asking whether we could do that surgery at the time of transplant. That’s ultimately where we landed.”
The patient’s precise condition played a key role in the decision.
“I think if the coronary disease had been much more extensive, it might have been too complicated,” Hoetzenecker said. “But it was located primarily in one vessel and the pump function of her heart was still good. Fortunately, that made it doable.”
Despite the near-failure state of her lung and liver, the patient retained enough muscle strength for the team to expect a good recovery.
“Every candidate has an extensive evaluation,” Erasmus said. “We needed to make sure she also had the grit required to go through what would be a very tough ordeal. Combined with support from family and caregivers, she met these more holistic criteria.”
“It’s an extensive evaluation everyone goes through. We needed to make sure she also had the grit required to go through what would be a very tough ordeal.”
Surgical and Support Teams
Performing surgery on three organs in a single operation required three separate surgical teams — made up of cardiology, thoracic and abdominal surgeons — working in tandem with Hoetzenecker, several nursing teams and anesthesiology specialists for each organ.
“Intraoperatively, we had to find a way to address each organ without damaging the function of the other organs, which is really complex,” Hoetzenecker said. “Every team had their most highly experienced people there, because we were doing something no one has ever dared to do before.”
The first order of business was to bypass the LAD lesion, which would relieve some of the stress on the heart, prior to the lung and liver transplant. To avoid significant bleeding during the transplant, they had to depart from the CABG protocol of full anticoagulation and a heart-lung machine.
“We did a veno-arterial, ECMO-supported bypass grafting, using only a very mild heparization, with the heart beating the whole time,” Hoetzenecker said.
“There were no major bleeding or complications. Having this bypass go smoothly set us up to move forward with confidence,” he said.
“Intraoperatively, we had to find a way to address each organ in a way that wouldn’t damage the function of the other organs, which is really complex.”
Plan B Enacted
The plan was to do the liver transplant next, but timing of organ arrival is often a wild card in transplant surgeries.
“The lungs had arrived, but there was an unexpected delay in getting the donor liver to Nashville, so we were on to plan B,” Hoetzenecker said.
Normally, they would do a lung transplantation through very small incisions from the side. In this specific case, however, they decided to perform a sternotomy (necessary for the bypass surgery) and use the same incision to implant the lungs.
“The liver transplant followed the implantation of both lungs, and it also went very smoothly. Our huge team was working hand-in-hand, and the overall blood loss was minimal,” Erasmus said.
After nine days in the ICU, the patient was transferred to a step-down unit, rehabilitation and then discharged, with continued support from family and visiting nurses.
“This patient is the kind of person who is so grateful for her life, for the additional time, and we will work with her closely to boost her odds of a long survival,” Erasmus said.
