Recently, in what can be termed an incredulous development, a 63-year-old Babu Micheal underwent a coronary bypass and a liver transplant, both, simultaneously. This speaks about advancements in medicine and highlights the immense incredible possibilities, especially when it comes to complex surgeries and transplants.
Jaslok Hospital & Research Centre in Mumbai successfully performed a simultaneous coronary artery bypass graft (CABG) surgery and deceased donor liver transplant (DDLT), a first-of-its-kind multidisciplinary collaboration, with advanced surgical techniques. The case also underscores the growing challenge of managing coexisting cardiovascular and liver diseases, a trend on the rise globally.
Michael's medical journey began with a diagnosis of cirrhosis seven years prior, secondary to non-alcoholic fatty liver disease (NAFLD), a condition affecting one-third of India's population and increasingly linked to liver cancer. In 2021, he underwent a focused radiation therapy (SBRT) for liver cancers, a treatment he required again in April 2024. While the tumours were partially controlled, his liver function began to decompensate, necessitating a liver transplant. During his pre-transplant evaluation, it was detected that he had significant blockage in his left main coronary artery.
Dr Rahul Chhabria, Associate Director, Emergency Cardiology opined that the coronary blockages required revascularization with surgery prior to his liver transplant and that he was not a candidate for angioplasty as he had complex anatomy of his left main vessel and also it would have postponed his liver transplant.
This presented a complex dilemma: delaying the transplant to address the heart condition risked further cancer progression and liver deterioration while performing either surgery alone carried significantly elevated risks due to the combined impact of both diseases. The initial plan considered a live donor transplant, but after careful evaluation, prioritizing donor health and recognizing the potential for recipient instability during such a complex procedure, the team decided against this approach.
Michael was then placed on the waiting list for a (DDLT), understanding the uncertainties and potential wait times associated with cadaveric donation. Hope arrived unexpectedly with the selfless generosity of the family of a 47-year-old deceased donor, turning their tragic loss into a life-saving gift for Michael. This prompted a rapid mobilization of the hospital's resources, with intensive care units and social workers working tirelessly to facilitate the complex logistical and medical preparations.
The intricate surgical process began with the cardiac surgeon performing a beating heart, off-pump CABG. This technique aimed to minimize surgical trauma and optimize Michael's condition for the subsequent transplant. Dr. Bhalerao emphasized the high-risk nature of the procedure and the need for meticulous precision to ensure Michael's readiness for the liver transplant.
Following a period of close observation to ensure stability and the absence of bleeding, the green light was given for the liver transplant. The transplant team then commenced the complex procedure. The anaesthesia team played a crucial role in maintaining hemodynamic stability and managing Michael's physiological parameters throughout both surgeries, performed within a time duration of 12 hours.
Remarkably, Mr. Michael tolerated both procedures well. He was taken off the ventilator on the second day and made a steady recovery, being discharged home after two weeks with both his heart and new liver functioning normally. "This is one of such cases wherein a simultaneous very high-risk dual surgery were performed by a multidisciplinary team effort, careful planning and flawless execution. Babu can live a normal life and we all feel satisfied about it ” commented Dr Aabha Nagral, Director of Gastroenterology, Chief Hepatologist & Liver Transplant Physician at Jaslok Hospital who managed the patient over the last 7 years.
“This pioneering case underscores the importance of thorough pre-transplant evaluations, multidisciplinary collaboration, and the life-saving potential of organ donation. It also highlights the increasing need for innovative approaches to manage complex cases involving coexisting conditions, particularly in the context of the rising prevalence of NAFLD and cardiovascular disease” stated Dr Shailesh Sable, Director Liver Transplant Program.
“After knowing the extent of his liver and heart problem, we thought it is impossible for him to survive with a good life. The team at Jaslok has put in a herculean effort to get his heart fixed and liver transplanted. We are extremely grateful for the support and effort and sincerely admire the dedication and team effort. We are also thankful to the donor's family for their noble act," expressed Babu’s daughter.