A Transplant Surgeon Is Operating Again—With a New Heart

By Sumathi Reddy
Published on February 10, 2020

Robert Montgomery has resumed performing surgery after receiving a heart transplant from a donor with hepatitis C. But his journey back hasn’t been without complications.

Robert Montgomery was performing his first kidney transplant as the lead surgeon since his own heart transplant in September of 2018.

“I’m super excited, totally excited,” the 60-year-old surgeon said shortly before operating on a recent Friday morning.

His patient, Daniel Flori, had had a heart transplant about 12 years ago, and the two swapped stories about their experiences before the kidney operation. Mr. Flori, who is 59 and lives in New Hyde Park, N.Y., asked how Dr. Montgomery, the director of the NYU Langone Transplant Institute here, was doing with his new heart. Dr. Montgomery asked about Mr. Flori’s son, who donated a kidney in January to a stranger to set off the fast-moving donor chain that ultimately brought his father a kidney.

“We trust you. I feel like there’s an extra layer of trust, too, because you had the heart transplant, so you know,” says Mr. Flori’s daughter, Alexandra.

Four hours later, Dr. Montgomery reassured Mr. Flori’s family: “It went great! Beautiful kidney.”

Dr. Robert Montgomery shakes hands with his patient, Daniel Flori, before performing a kidney transplant at NYU Langone Transplant Institute in Manhattan on Jan. 31. CAITLIN OCHS FOR THE WALL STREET JOURNAL

In 2018, Dr. Montgomery received a heart transplant after a series of cardiac arrests and life-threatening arrhythmias. The heart came from a heroin user who died of a drug overdose and had hepatitis C. Dr. Montgomery wanted to encourage patients to accept such organs, more than half of which used to be discarded.

Hepatitis C is a virus that causes liver infections. In recent years treatments have been more than 95% effective so patients like Dr. Montgomery who receive hepatitis C-positive organs are cured of the disease within a few months.

Dr. Montgomery has familial cardiomyopathy, a genetic form of heart disease that affects the electrical pathways of the heart muscle. The ailment killed his father at 52 and a brother at 35. When he was 29, he had a defibrillator implanted, unsure if he could become a surgeon because it wasn’t clear back then whether the device would interfere with operating-room equipment. The defibrillator saved his life many times and he went on to become a surgeon who pioneered numerous advancements.

“Surgery is so important to me,” Dr. Montgomery said. “The operating room is the place where I feel kind of the most at home. I fought really hard to become a surgeon…and stay in the game and now I had this second challenge and it was really important that I overcome that.”

Two weeks after his transplant surgery, Dr. Montgomery returned to work part-time. Three months later, he resumed seeing patients. He was taking tacrolimus, an immunosuppressant drug that kept his body from rejecting a new heart. But one side effect was a tremor. “Most people learn to live with it,” he said. “Unless your profession is a watchmaker or a surgeon. Then it becomes an important thing.”

He found an experimental protocol at the Mayo Clinic in Rochester, Minn., where heart-transplant patients are treated with a different drug, rapamycin. Sudhir Kushwaha, a Mayo cardiologist who focuses on heart transplants, developed and began using the rapamycin protocol with heart-transplant recipients in 2002. The goal, he said, is to improve long-term survival rates.

His research shows that if patients switch to rapamycin within six months of their transplant, their survival rate is nearly double that of those on the standard drug. Other benefits, he says, are a lower likelihood of developing cancer as well as improved kidney function. Most importantly for Dr. Montgomery, tremors aren’t a side effect,

At Mayo, about 70% of heart-transplant recipients take rapamycin. Dr. Kushwaha said the clinic has used it in about 400 patients without seeing any difference in rejection rates compared with the standard treatment.

The rapamycin protocol isn’t used widely outside Mayo, Dr. Montgomery said, with one studyshowing rapamycin has a higher rate of rejection than the standard treatment. (Dr. Kushwaha said the study used a different derivative of rapamycin and started patients on the drug earlier than they do at Mayo, which increases the risk of rejection.)

In June, Dr. Montgomery started a two-month transition to rapamycin from tacrolimus. By August the tremor was gone and at the end of the month, he assisted on his first surgery. But heart biopsies in September and October showed his body was starting to reject his heart. After several tense conference calls between his Mayo and NYU teams, he decided to stay on rapamycin and resume low doses of tacrolimus, along with high doses of a steroid to treat the rejection. “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.

Not everyone on Dr. Montgomery’s medical team agreed with the alternative protocol. Some said they thought he should have stuck with the standard one. But that would have meant focusing on administrative duties and research—and not returning to work in the operating room.

“I think what they didn’t understand was how important this was to me,” Dr. Montgomery said. “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.”

In December he assisted Bonnie Lonze, a transplant surgeon and assistant professor at NYU Langone, on two kidney transplants. Dr. Montgomery trained Dr. Lonze at Johns Hopkins when she was a fellow there.

Dr. Lonze says she has done more than 100 surgeries with Dr. Montgomery both during and after training. “When he wanted to get back into the operating room after going through everything he went through, it was as if not a day went by,” Dr. Lonze said. “He didn’t skip a beat.”

This month, just three days after Mr. Flori’s transplant, Dr. Montgomery performed a 10-hour operation, removing two kidneys that had cysts and putting in a new one.

Dr. Montgomery wants to be a role model for transplant patients. Only about 20% of kidney-transplant patients return to work. The numbers for heart-transplant recipients may be even less, he says. Many are on disability when they get a transplant and are afraid to lose their Medicare coverage.

“That’s really important to me, to serve as sort of an example, or to try to advance that idea,” Dr. Montgomery said.

He is assembling a team at the hospital to look at early intervention with recipients to help them resume working. “Transplant patients don’t want to be marginalized,” he said. “They want to really be able to turn that page and really get back to their lives.”

This article was originally published here:
https://www.wsj.com/articles/a-transplant-surgeon-is-operating-againwith-a-new-heart-11581346948