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February 12, 2020

'A big risk': After getting a new heart, this transplant surgeon faced a rocky road back to the OR

Daily Briefing

    Robert Montgomery, a lead transplant surgeon at the NYU Langone Transplant Institute, in 2018 underwent a heart transplant from a donor with hepatitis C—and now, he's back at work serving as an example for patients who want to re-enter the workforce after receiving transplants, the Wall Street Journal's Sumathi Reddy reports.

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    Montgomery's transplant

    Montgomery suffers from familial cardiomyopathy, a genetic disease that affects the heart's electrical pathways. The disease can cause cardiac arrhythmias that result in heart attacks.

    At age 29, Montgomery had a defibrillator implanted in his heart. The device saved his life multiple times, but Montgomery continued to experience life-threatening arrhythmias and decreased heart function, which made him an urgent transplant candidate.

    A donor heart became available in 2018, but the heart came from a heroin user who had died of an overdose and had been infected with hepatitis C—meaning the organ also was infected with the disease. Montgomery, who for years had advised his transplant patients to accept hepatitis C-infected organs, accepted the heart and underwent a successful transplant. He later tested positive for hepatitis C, and took oral medication for eight weeks until his infection cleared.

    Montgomery said he accepted the heart to serve as an example for his patients. "This was an opportunity to both use an organ that we probably wouldn't have used and to kind of morally align myself with what I believed and had been telling people," Montgomery said.

    Montgomery quickly returned to work—but a new issue kept him out of the OR

    Montgomery returned to work part-time two weeks after his heart transplant, and three months later, he was back to seeing patients. However, the immunosuppressant drug Montgomery was taking to prevent his body from rejecting his new heart gave him a tremor, which prevented him from performing surgery.

    According to Reddy, tremors are a common side effect of the standard immunosuppressant drug tacrolimus. "Most people learn to live with it," Montgomery said. "Unless your profession is a watchmaker or a surgeon. Then it becomes an important thing."

    A risky solution

    Eager to return to work, Montgomery set out to find an immunosuppressant that didn't cause tremors. He eventually found an experimental protocol at the Mayo Clinic in Rochester, Minnesota, that gave heart transplant patients an immunosuppressant drug called rapamycin.

    According to Sudhir Kushwaha, a Mayo cardiologist who developed the medication, the drug is intended to improve long-term survival rates for heart transplant patients. Research has shown that patients who switch to rapamycin within six months of receiving a heart transplant have survival rates that are almost double the rate of patients using a standard immunosupressants, and at least one study has found transplant rejection rates are about the same as those receiving standard care.

    However, outside of Mayo Clinic, most surgeons do not prescribe rapamycin to transplant patients, Reddy writes. That's in part because some studies have shown higher rejection rates among patients taking rapamycin, Reddy writes. Some physicians on Montgomery's medical team had concerns about the rapamycin protocol, saying they believed Montgomery should stick with the standard treatment.

    But Montgomery was eager to return to work in the OR, so in June 2019 he started himself on a two-month transition to rapamycin. By the end of August 2019, Montgomery's tremor was gone and he was able to assist on a surgery.

    However, within one month, heart biopsies showed Montgomery's body was beginning to reject the organ. Montgomery then adjusted his medication to a combination of rapamycin, low doses of his old immunosuppressant drug tacrolimus, and high doses of a steroid to prevent rejection—a regimen that's been working so far.

    "I think we've found the right alchemy that will hopefully keep me from having more rejection but will allow me to operate," he said.

    Back in the OR—and to being an example for patients

    Montgomery said going against some of his medical teams' opinions was tough.

    "It wasn't an easy decision. I feel like I made the decision in a very informed and methodical way. … But it still is a big risk. I'm not on the optimal drug regimen that is accepted by the field," he said.

    Still, Montgomery said he's confident he made the right decision for him and, today, he's back in the OR and serving as an example for his patients.

    According to Reddy, just about 20% of patient who receive kidney transplants go back to work. And Montgomery said the percentage of heart transplant patients who return to their jobs might be even lower.

    "That's really important to me, to serve as sort of an example, or to try to advance that idea" of being able to return to work, Montgomery said.

    Now, Montgomery is establishing a team at NYU Langone that provides early interventions intended to help transplant patients go back to work. "Transplant patients don't want to be marginalized. They want to really be able to turn that page and really get back to their lives," he said (Reddy, Wall Street Journal, 2/10; Reddy, Wall Street Journal, 1/28/19).

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