Heart surgeons are experts on our most valuable organ. They know its chambers and arteries the way a mechanic knows an engine. And yet surgical interventions such as transplants — sewing once beating hearts inside unfamiliar rib cages — can be as fascinating and fearsome to surgeons as they are to the rest of us.
“Surgery is a legalized assault,” says Dr. Charles Fraser Jr., head of the Texas Center for Pediatric and Congenital Heart Disease at Dell Children’s Medical Center of Central Texas. “The premise is: I intrude on your body with something radical — a knife, tube, catheter — to take something out and put something in, repair something, all in the name of making you better. Distilled to its basic elements, the whole concept is radical.”
But the procedures entrusted only to the most punctilious limbs and minds bring a new hope for life to adolescents whose youths were seized by congenital heart defects. Patients wait in cardiac care units, sometimes for months, for the right organ to appear on the donor list.
For years, children in heart failure and in need of a transplant or mechanical assist device had two options for care in the entire state: Texas Children’s Hospital in Houston or Children’s Health in Dallas. In Central Texas, these kids would be flown by helicopter to one of the hospitals — a trip with a low probability of survival for an exhausted organ.
But in 2018, that all changed. The Texas Center for Pediatric and Congenital Heart Disease opened. The center is a partnership between Dell Children’s and UT Health Austin, the clinical practice of Dell Medical School at The University of Texas, and was created by Fraser and his team of hand-picked heart experts.
The first operative milestones came at an incredible speed for the young program. Since it was approved to list patients and perform transplants by the United Network for Organ Sharing in July 2020, the center has completed four heart transplants and implanted three ventricular assist devices, or VADs. Dr. Ziyad Binsalamah, the surgical director of heart transplantation and mechanical circulatory support, estimates they’ll be able to perform five to 10 transplants and assistive device implantations every year for the next three years.
“Everyone here is invested in making this a nationally recognized program, which is really amazing,” he says.
For Binsalamah, Fraser and the entire team, their young, ill patients are what matter most. What follows, the recollection of three milestone procedures and their recipients, are moments of time, precision, dedication and the utmost care for a child to have a normal life.
On Oct. 3, 2020, at 2:45 a.m., two cardiothoracic surgeons and a perfusionist burst from Dell Children’s in an ambulance headed for Austin-Bergstrom International Airport. In the whirring vehicle, a beige Yeti cooler labeled “Human Organ” in red lettering accompanies the medical team responsible for securing a donor’s heart several states away.
Methodical but rushed concentration calms the surgeons and perfusionist as each of their watches gains minutes. Every step of the day’s mission replays in their minds. Today, when they remove a donor’s heart to be placed within an 18-year-old soccer player named Gerardo “Junior” Ramirez Jr., time will be no friend.
The surgeons, Dr. Ziv Beckerman and Dr. Sara Mendoza Crespo, and the perfusionist, Richard Owens, board a six-passenger plane given first priority to take off and land. Upon arrival at the airport, the retrieval team takes a 20-minute ambulance ride to the hospital where the donor is being kept on life support.
While other retrieval teams wait for the donor’s liver and kidney, the Austin heart team is the first to go. Before they remove the heart, its strength is tested and an echocardiogram watches the heart’s function and structure. Confirming they have a strong organ, Owens stops its beating with medication. A piece of lymph node is taken to test for antibodies and put in a small jar.
The second the heart is clamped, the team has six hours to get it back to Austin and into the patient for the best chance of resuscitation. The donor’s heart and lymph node are secured in a bag filled with solution surrounded by ice in the cooler. At 9:20 a.m., the team and its fleshy cargo ride an ambulance to the airport and board the plane for Austin. The clock is ticking.
The Central Texas heart center was carrying on lifesaving work even before Ramirez’s surgery, which was its first transplant. On Sept. 24, 2019, the program implanted its first left VAD, a mechanical device inside the body that helps the heart circulate blood. Ventricle is another word for the pumping chamber of the heart, and the device helps when that pump is failing, Fraser says.
Twelve-year-old Grace Jennings went into cardiac arrest for two hours on Sept. 18, 2019, before a planned surgery to repair her leaking heart valve. In response, Grace was put on an extracorporeal membrane oxygenation machine, or ECMO, to pump blood to her heart and briefly save her life. But ECMOs are only a temporary solution, unless the doctor believes the heart is strong enough to regain function quickly and recover, and one with many complications: bleeding, infection and possible organ failure. The longest a patient can survive on an ECMO is about a month.
Grace ultimately needed a new heart, but the center had not yet been approved for the surgery or to list patients. Instead, Fraser inserted the VAD, another temporary solution but one that would keep her alive until a transplant. Then, on Jan. 26, 2021, now 13-year-old Grace became the second person to receive a heart transplant at Dell Children’s.
Fraser’s expertise draws from his longtime work as a world-renowned pediatric heart surgeon. He previously directed Texas Children’s congenital heart surgery program in Houston and helped build it into one of the largest heart centers in the country.
Midland-raised Fraser graduated from UT in 1980 with a degree in mathematics before attending medical school at the UT Medical Branch at Galveston. He later completed two residencies, surgery and heart surgery, at Johns Hopkins University in Maryland and was a pediatric heart surgery fellow under Dr. Roger Mee, one of the world’s best pediatric heart surgeons, at The Royal Children’s Hospital in Melbourne, Australia — an epiphanous experience, Fraser says.
Always proud of his alma mater, and with four kids who all graduated from UT, Fraser kept connections with the university and got to know former Dean Clay Johnston when the medical school opened. Fraser’s ties to UT, the opportunity to curate the best pediatric heart surgery program in the country and the benefits of being connected to a medical school influenced his decision to head the Central Texas heart center.
But despite all his experience, Fraser, who has participated in more than 18,000 cardiothoracic surgeries in his career, says that each transplant is as intense as his first in an experimental laboratory in 1986.
“You never get used to a heart transplant, and a surgeon should never get used to doing surgery,” Fraser says. “I have colleagues or trainees who will occasionally say something like, ‘Surgery is fun.’ I really bristle at that. Playing tennis is fun. Fishing is fun. Surgery is not fun. It’s very gratifying. It’s gratifying to do an operation and have someone be better. But I think a surgeon that considers doing surgery ‘fun’ is on the border of being dangerous, or is already dangerous, because that indicates a loss of reverence.”
On the morning of Ramirez’s heart transplant, his medical team gathers outside his hospital room at 8 a.m. to prepare for what would be one of the most significant and brutal events of his life. The retrieval team is still on its mission for the young man and in constant contact with the team in Austin by text message.
Ramirez had been in heart failure for nearly a year, and another hospital had rejected him for a transplant. He collapsed on a soccer field in 2017, and doctors discovered that he was born with an abnormal valve and also had Danon disease, which causes a thickening of the heart muscle and put him at risk for sudden cardiac arrest.
Before any operation, the surgical team has a briefing to discuss its strategic plan, and Fraser says surgeons develop a preoperative ritual to get them “in the zone.” Right before Fraser enters the operating room to start surgery, he collects himself during the act of thoroughly scrubbing his hands.
The life expectancy of a transplanted heart is about 15 years. For the parents of kids with heart failure and no permanent solution, the longevity and quality of their child’s life are unfaltering concerns. Fraser is accustomed to answering questions from parents, and as a father and grandfather, he shares their apprehension.
“My basic principle is always to speak to patients and families the way I would want to be spoken to, with objective language,” he says. “I certainly would never want to be guilty of under- or overpromising, and tend to be very blunt about things. If I or we as a body of practitioners don’t know, I tell people this is something we don’t really know what the outcome is going to be. I think that mostly works well for people.”
Even after a successful transplant, patients must continue to take anti-rejection drugs for the rest of their life. Successfully tracking the outcomes of patients’ operations and their quality of life has been a challenge for the medical community, Fraser says, because there is not a clear answer on how to best do so ultimately until death. The heart center wants to know things like how the patients are doing in school, how their developmental milestones are being met, how their intellectual capabilities are progressing, and whether they need remedial operations or ongoing care.
“We are listening to patients and families because historically, the medical community hasn’t been as good as it could have about looking at measures that are actually important to them,” Fraser says. “If you’re facing a life-threatening illness, just surviving is obviously paramount. But beyond that, we would like to think that we’re offering therapies that give people the best possible life. But if you’re not examining that, how do you know? So that’s not so easy, but we’re really expending a lot of effort and interest in that sphere.”
Dr. Carlos Mery, associate section chief of pediatric and congenital heart surgery, is at the heart center to find answers to these problems and build a program that supports families and patients in the long term — something he says the field does not do well. He is one of the center’s six congenital and pediatric surgeons and directs the health transformation and design in congenital heart disease program at Dell Medical. The program examines all clinical research, including outcomes and measurements, to redesign future care for patients.
“In line with the bold vision of the medical school, we’re looking for a program that really puts the patient at the center,” Mery says. “We want to build an infrastructure to support the patients and their families, not only from a medical standpoint, but from a holistic standpoint for their entire life.”