Changing the world of organ transplants while fearing he could die waiting for one
The first time he went into cardiac arrest and died, briefly, Dr Robert Montgomery was hiking in Patagonia, near the southernmost tip of South America. He felt his heart racing as he lagged behind his son John and their guide. Then he collapsed, face down into the snow. Seconds passed before a medical device implanted in his chest delivered a shock that restored his heartbeat and saved his life. It was 2010, and Montgomery, then 50, recovered quickly. But it was becoming painfully clear he needed a new heart. The one he was born with was failing. The odds of him getting a heart transplant were grim and Montgomery knew this because he was a transplant surgeon himself. In Ireland, there are approximately 660 people currently waiting for an organ transplant. Earlier this year The Irish Times reported that most were on the waiting list for a kidney transplant, with approximately 100 on the list for other organs. Of these, six patients were waiting for a heart transplant. At the time of his Argentina trip, Montgomery was leading one of America’s premier organ transplant centres, at Johns Hopkins Medicine. As a child, Montgomery wanted to be a veterinarian. It was only when, at age 14, his father developed symptoms of dilated cardiomyopathy that he reconsidered. The rare disease causes the heart’s chambers to stretch and enlarge and can lead to heart failure, irregular heart beats or arrhythmias, cardiac arrest and sudden death. His father became increasingly debilitated and eventually needed a feeding tube after suffering brain damage from a cardiac arrest. People ‘My youngest child will probably be bearded before the national children’s hospital opens’ By the time his father died in 1976, Montgomery, then 16, had decided to become a doctor. Eleven years later, he had just started a surgical residency at Johns Hopkins Medicine when he got the worst phone call of his life. His brother Rich, a 35-year-old father of two, had died that morning. Pathologists discovered that Rich also had dilated cardiomyopathy, likely caused by a genetic mutation. Robert was evaluated and learned he had the condition too. Suddenly, his career was in doubt. Surgical training was gruelling, and a cardiac arrest or fainting episode could endanger patients. When medication failed to keep his arrhythmia in check, Montgomery opted for a new medical device called an implantable cardioverter-defibrillator, or ICD, that could shock the heart back into a normal rhythm. Unsure if he could complete his residency, Montgomery and his wife at the time moved to England so he could study immunology. He decided to pursue a doctorate, just in case surgery didn’t work out. Montgomery returned to Johns Hopkins in 1992. He wanted to specialise in transplant surgery. His own illness was a motivator. “I didn’t think I would live a normal lifespan – I knew I would need a heart transplant or I would die – so I was in a hurry, and I was hyperfocused.” Irish Guide Dogs at 50: ‘He made the difference of being able to leave the house or not’ So few heart transplants were done in the early 1990s that becoming a full-time heart transplant surgeon wasn’t an option. Montgomery focused on kidneys, the most commonly transplanted organ. At Hopkins, he helped develop a minimally invasive surgical technique for retrieving kidneys from healthy living donors, which doctors hoped would lead more people to donate a kidney. It did. Over the next few years, “we transplanted all the kids on our paediatric list”, Montgomery said. In 2001, realising he could increase the number of patients who got an organ if kidneys were swapped between incompatible, donor-recipient pairs, Montgomery started a programme to do just that. Soon, he and his team were doing domino donations. An altruistic donor gave a kidney to a stranger, whose nonmatching donor gave a kidney to a second recipient and so on. “He was seen as a bit of a cowboy,” said Brigitte Sullivan, the transplant administrator who Montgomery described as his “fellow visionary”. In 2016, NYU Langone Health recruited Montgomery to build an organ transplant programme, and he moved to Manhattan with his wife, opera singer Denyce Graves, and their daughter (Montgomery also has three children from previous relationships; his first marriage ended in divorce). He had met Graves on a flight to Paris. By the time the plane landed, she had invited him to hear her sing and he had invited her to watch him operate. Despite his earlier near-death experience in Patagonia, Montgomery returned to the same spot in 2017. He wanted to spend time with his sons John and Max, but he went into cardiac arrest again. The closest hospital was nearly an hour away and John did chest compressions on him in a Jeep as they raced to it. When he emerged from a medically induced coma more than a month later in New York, where he had been flown, Montgomery had to learn to walk, talk and eat again. “As I was having more of these near-death experiences, it became really clear to me that the likelihood of me getting a heart transplant was less than of me dying before I got on the list,” he said. A few months later, his heart stopped in the middle of the Broadway show, School of Rock. He received CPR in the aisle. At a medical conference in Italy, in September 2018, he experienced four cardiac arrests, one after another. The upside, he realised, was that he was now so sick he could finally join the waiting list for a heart. A mother stalking her 19-year-old online is demented – but not in the way you think Just before dawn on September 20th, 2018, he got a call that a heart was available – if he wanted it. The donor, who had died of a heroin overdose, was infected with hepatitis C. There was reason for pause. The hospital’s heart transplant programme was brand-new; Montgomery had started it less than a year earlier. And transplants with hepatitis C-positive hearts were so novel that he would be part of a clinical trial if he received one. “A lot of my colleagues thought I was crazy,” Montgomery said. But he believed in the programme and had encouraged his own patients to consider organs with hepatitis C, which could be cured with medication. “So why not me?” he said. After a six-hour surgery, Montgomery had a new heart. Two days after the operation, he was sitting up in bed, reviewing cases. After his experience, Montgomery began to see all the work he had done to find more viable organs as insufficient. “It’s never going to be able to provide enough organs for people with organ failure,” he said. It was time for a radical move. Experiments had proved that organs from genetically modified pigs could be transplanted into monkeys. The next step was to build a case for transplants to humans. Montgomery decided to try it first in a patient who was brain-dead, something that had never been attempted. In 2021, Montgomery announced he had for the first time transplanted a kidney from a genetically modified pig into a human. Scientists at United Therapeutics, which produced the pig, had knocked out a gene involved in an aggressive organ rejection response. Not only was the kidney not rejected, but it functioned, making urine and excreting waste for 54 hours, the limit set by a hospital ethics panel. Over the next few years, Montgomery’s team and others in Maryland and Boston transplanted pig kidneys and hearts into a small number of living patients who were terminally ill and had exhausted other treatment options. The patients died of underlying conditions within months, but none of them mounted the kind of devastating immune rejection that destroys an organ – a major accomplishment that showed that pig organs could be transplanted safely and function properly in humans. Last year, the Food and Drug Administration in the United States gave a green light to clinical trials of pig organ transplants in very ill patients who aren’t likely to get a kidney any other way. Montgomery is leading two of them. Since his surgery, he has gone salmon fishing in Alaska with his son John, travelled to Africa with Graves to celebrate her retirement and assisted kidney surgeons in Ukraine. Every morning, to protect his new heart, he walks 3km to work. He sets out before 6am, to make it in time for patient rounds. – This article originally appeared in the New York Times