With the addition of heart and liver transplant capabilities to an existing kidney transplant program, Northwell Health is looking to develop an institutional culture that fosters innovations in the selection, procurement and transport of donor organs, and maintains stellar outcomes for patients on Long Island and beyond.
Northwell Health has had a successful adult kidney transplant program for many years. Initiated by Ernesto Molmenti, MD, PhD, MBA, Vice Chair of the Department of Surgery and Director of Adult and Pediatric Kidney Transplantation at Northwell Health, the kidney program has provided a solid foundation for Northwell to expand into pediatric transplantation and add other transplant programs.
“We started about 10 years ago with adult kidney transplants,” Dr. Molmenti says. “Over the past two years, we’ve added pediatric kidney transplant. Last year, we added adult heart transplant, and we have been approved to start an adult liver transplant program very soon.”
The unwavering focus required during an organ transplant procedure
Lewis Teperman, MD, FACS, Vice Chair of Organ Transplant Surgery and Director of Organ Transplantation for Northwell Health, arrived two years ago to oversee the expanding program. Dr. Teperman, a longtime official with the United Network for Organ Sharing (UNOS), had previously visited the center for a site visit and advisory meeting, he recalls.
“I was at New York University at the time,” he says. “Hurricane Sandy came through and shut us down. We had to transfer patients, and a lot of them were relocated to Northwell. Later, New York University was not in a position to restore its transplant program as it needed to be. I started talking with Northwell and found that their vision, which was to put together the best transplant program in the Northeast, aligned with mine. My aim is to establish a program that includes all organs, as well as pediatric cases. We’ve already done a lot in a short period of time — achieved certificates of need, which is a rigorous process, and brought in new physicians and staff to oversee transplantation and patient care.”
New Physicians for a Transformed Program
Northwell has brought on nationally recognized transplant physicians to build out the new program. Among them is Brian Lima, MD, Director of Heart Transplant Surgery at Northwell Health and Associate Professor of Surgery at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Dr. Lima arrived with a twofold mission: to establish a heart transplant program and to oversee an expanded mechanical heart program.
Northwell Health SkyHealth helicopter — an intensive care unit in the sky
“I came from Baylor University Medical Center, the second- or third-busiest heart transplant center in the world,” Dr. Lima says. “Coming to Northwell was an amazing opportunity on so many levels, including the ability to bring the full-spectrum of advanced heart failure care to North Shore University Hospital. They saw my experience and innovations in the field, of course, but mostly the Northwell team wanted passion. They wanted someone who would leave a well-established heart transplant program to start a new program in arguably the most competitive market in the world.”
Demonstrating a Potential of Excellence
Drs. Molmenti, Teperman and Lima each have a difficult job in their respective areas of focus — ensuring their departments are regularly certified to perform transplants. The process is particularly onerous in New York, Dr. Teperman says.
A donor heart being transported to Northwell Health for a transplant patient transplant procedure
“We’re one of the few states in the U.S. that require a certificate of need,” he says. “Yet, we have thousands of people waiting for organs. The state is mindfully revamping the certification process. It takes a huge amount of time, paperwork and hearings — it’s a very rigorous process that also requires UNOS approval.”
Northwell has spared no effort or expense to attain certification. For example, the hospital is adding a new ICU to meet the needs of liver transplant patients. Operating rooms are being modified, and specialized nurses and physician assistants are being added.
“That’s what we did for the heart and pediatric program and now are doing the same for our liver program,” Dr. Teperman says. “We’ll have our final walk-through for certification during the first quarter of the new year.”
Even though Northwell was already an established kidney center — having performed more than 400 transplants — Dr. Molmenti says every new transplant program requires a host of changes as physicians and support professionals learn new skills, and the institution adapts to a patient population with different needs.
“We added pediatric kidney transplant over the past years,” Dr. Molmenti says. “The indications for pediatric transplantation are more diverse than for adults. They’re different because the causes for kidney failure in children are often different. Among pediatric recipients, there’s a greater incidence of congenital conditions associated with failure.”
Still, Northwell is meeting the challenge and, in fact, has capacity to grow.
“We’ve performed 400 transplants now, but we could do thousands more if we had the donor organs available,” Dr. Molmenti says.
The Difficult Gift of an Organ
That gap — between the need for organs and their availability — is one of the key challenges facing organ transplant centers nationwide and New York State in particular.
Brian Lima, MD, Director of Heart Transplant Surgery at Northwell Health and Associate Professor of Surgery at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, celebrates with a patient after a successful heart transplant.
“There are more than 300 people waiting for heart transplant in New York state,” Dr. Teperman says, giving an overview of the vast scope of the problem. “There are 1,200 people waiting for livers. We only have about 350 deceased liver donors annually, plus perhaps 5 percent of that number of living donors. That is a significant gap. We must increase organ donation and increase the viability of organs that would not otherwise be used. That is something we are working on at Northwell.”
In each program, physicians are making plans to increase donations, at every level from awareness-raising to donor organ preservation.
“Sadly, New York state is dead last in the country in the number of donor hearts available annually,” Dr. Lima says. “I was motivated to come here, in part, to change that metric. It’s a challenge. Often, hearts are turned down for reasons that are not well-established scientifically. People may think they need to wait for the perfect heart, but there’s no such thing. We have to have the clinical judgment and experience to find out which heart is less than perfect on paper but salvageable.”
Indeed, expanding the range of usable organs is important to members of the kidney, liver and heart transplant teams. Drs. Molmenti and Lima are involved in outreach to increase the donor pool. The hospital’s social media campaigns help to raise awareness in the community about the need for organs, the safety of live donation and the possibility of even an “imperfect” donor organ being just the right fit for a patient in need. Dr. Lima even has his own social media accounts devoted to promoting heart donation.
Physicians are also exercising extra scrutiny of organs from the deceased to identify those that might be rejected “on paper” but can be viable in real life, Dr. Lima says. To that end, he brought Syed Hussain, MD, from Cleveland Clinic to serve as Lead Heart Procurement Surgeon at Northwell Health.
“We don’t let a potential donor organ go without seeing whether there is something to be done to salvage it,” Dr. Lima says. “That’s why I recruited Dr. Hussain. He is of the same mindset. He is aggressive in approaching any given donor heart to see whether there is the option for reuse.”
Dr. Hussain’s experience allows transplantation to proceed smoothly, an important consideration in heart surgery, where donor organs have a limited window of usability. When Dr. Hussain visits a donor in another institution and calls back to Dr. Lima that the heart is viable, Dr. Lima can immediately begin preparing the recipient for transplant.
“We are in constant communication — myself on-site and Dr. Hussain at the donor hospital,” Dr. Lima says. “I don’t commit until he assures me the donor heart is good and on its way. That is why our close-knit team and tight communication are so essential. I don’t put the recipient under anesthesia until I receive word that the heart looks good in person. After Dr. Hussain says, ‘You may proceed,’ I can open the patient and remove any mechanical heart apparatus so that we are ready for transplant when the heart arrives in the operating room. When that happens, and we are sure the blood flow is mapped correctly, I perform one more check, the last of hundreds, and then I commit to taking the patient’s heart out and placing the new one in.”
Flying for Life
Even when donor organs are readily available, time is of the essence when retrieving them. Along with adding new areas of transplant, Dr. Teperman has worked to reinvigorate Northwell Health’s SkyHealth program. Historically, the aerial transport unit has moved critically ill patients to the hospital, but now it will be deployed for transplants, too.
“SkyHealth has a helicopter, but its range is limited to about 200 miles,” Dr. Teperman says. “We are looking into adding a jet, too. It’s hard to rent an airplane on short notice, but if an organ is taken out anywhere in the country, we want to be able to send our team via jet to retrieve the organ at a moment’s notice. It’s an innovative concept. With the support of Northwell administration, we will be the first hospital in the nation to take this step.”
The Best Medicine Can Offer
When a patient receives a donor organ, his or her journey has only just begun. Under Dr. Teperman’s guidance, Northwell Health continues to add professionals and procedures to ensure transplant success.
Lewis Teperman, MD, FACS, Vice Chair of Organ Transplant Surgery and Director of Organ Transplantation for Northwell Health, follows up with his patient post organ transplant surgery.
“We brought in laparoscopic surgeon Ahmed Fahmy, MD, who has performed well over 200 single-port operations on kidney donors,” Dr. Teperman says. “We are adding new surgeons in liver donation, too. Right now, living donation is a big part of the renal program and we are looking to add that piece to the liver program as well.”
In living liver donation, the donor organ is dissected in half, with one section remaining with the donor and one going to the recipient.
“We want that to be up and running quickly after we begin deceased donation,” Dr. Teperman says. “We are also strengthening our pediatric transplantation programs. We have three outstanding pediatric nephrologists, Pamela Singer, MD, Laura Castellanos Reyes, MD, and Christine Sethna, MD. Our adult transplant team operates in the pediatric venue. We only opened a year or so ago, and we are now gearing up to do a large number of pediatric transplants. I am very proud of the entire team.”
The influx of providers has led to a surge in creativity. As Dr. Teperman says, we are knocking down the doors in innovative technique.
“We use old drugs in new ways,” he says. “We are planning to use warm preservation devices operating on the principle of normothermic perfusion, meaning organs are perfused at body temperature. The relevant technology is OrganOx out of England. It is awaiting approval in the U.S., and Northwell is looking to use it as soon as it is approved. Our new transplantation tower has a preservation room, and we plan to have these devices maintaining organs in there.”
Both the well-established kidney transplant program and the nascent heart transplant program at Northwell Health boast high success rates.
A Northwell Health pharmacist reconciles various medications with a patient’s family member.
“Our Press Ganey scores are in the high 90s and some are in the 99th percentile,” Dr. Molmenti says. “As we advance and mature in our initiatives to reduce wait times for organs, we have achieved an increased level of national recognition.”
“The heart transplant program went live February 1, and successfully transplanted 11 patients in six months,,” Dr. Lima says. “We had only estimated performing 10 cases in the entire first year. We are one of the fastest-starting heart transplant programs ever. We’ve traveled as far as Wisconsin and Ohio to obtain organs. I’m really proud of what we’ve accomplished.”
Heirs to a Tradition
Organ transplantation is a relatively new discipline. Many senior practitioners can look back to Thomas Starzl, MD, who performed the first liver transplant surgeries, as their mentor and inspiration. Dr. Teperman and Dr. Molmenti, for instance, trained with Dr. Starzl at the University of Pittsburgh. Dr. Teperman intends for Northwell Health to carry forward Dr. Starzl’s traditions of courage and innovation.
Collecting blood samples for laboratory processing
“I went into transplantation because my medical school roommate’s mother died in need of a liver transplant,” Dr. Teperman says. “At the time, experimental operations were only being performed in Colorado. I went to train with Dr. Starzl in Pittsburgh and then went on to New York University for 27 years before coming here. It’s a tribute to the forward thinking of Mark Solazzo [COO, Northwell Health] and Michael Dowling [President and CEO, Northwell Health] that this will become a great transplant institution, differentiated from all the other transplant centers in the Northeast and the U.S.”
To that end, Dr. Teperman is eyeing such diverse innovations as transplantation as a cure for diabetes and lung transplants; new and innovative devices; and logistical changes such as drones for organ transport. It is truly an exciting moment in the history of Northwell Health.
Dr. Teperman runs a sessions meeting and reviews patient cases with the organ transplant board.
“Our work is never done!” Dr. Teperman says. “It is my intention that we become the greatest transplant center in the Northeast. Just give us five years!”
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