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Organ Transplantation

Our Expertise

Heart Transplantation

Our pediatric heart transplant program dates back to 1984, when the world's first successful pediatric heart transplant was performed at Columbia Presbyterian Medical Center on a four-year-old boy with complex congenital heart disease. Since then, our surgeons have performed over 265 heart transplants in children making NewYork-Presbyterian one of the largest pediatric heart transplant centers in North America and the world.

Our Pediatric Heart Transplant Program specializes in transplanting children with end-stage congestive heart failure due to cardiomyopathy and children with complex congenital heart disease who are not candidates for palliative or corrective surgery. We have also successfully pioneered transplantations in high-risk patients who are not offered heart transplants elsewhere, including patients with severe, elevated pulmonary resistance.

By applying new surgical techniques and expanding the donor pool, NewYork-Presbyterian Morgan Stanley Children's Hospital continues to make strides in pediatric heart transplantation, and was the first hospital to perform heart transplants in an effective, single-lung physiology in children and also in adults.

Morgan Stanley Children's Hospital is also the first institution in the United States to perform ABO-incompatible heart transplants (donors and recipients have different blood types) in pediatric patients. By following a specific protocol, survival is the same as in children who receive ABO-compatible hearts.

An evolving area of surgery is the use of ventricular assistance devices (VADs) in pediatric pre-transplant patients to support the heart and stabilize the pre-transplant patient, a process called "bridging," until an appropriate heart that is located.

Center for Pediatric Cardiomyopathy, Heart Failure and Transplantation

The Center for Pediatric Cardiomyopathy, Heart Failure and Transplantation calls on the expertise of pediatric cardiologists, pediatric cardiac surgeons, and a wide range of health professionals with expertise in cardiology and heart transplant. Pediatric patients are cared for by a multidisciplinary team, with parents as key members. Parents help the team understand their child's particular medical issues, as well as emotional and practical needs, which guide the overall treatment plan.

This team approach has set the standard of care for children with end-stage heart failure-achieving 84 percent overall long-term survival after hospital discharge. Team members include:

• Pediatric cardiologists
• Pediatric cardiac surgeons
• Medical consultants, including pediatric electrophysiologists, neurologists, and endocrinologists
• Nurse specialists in cardiology and transplant
• Research nurses
• Genetic counselor
• Pediatric cardiology social workers
• Child psychiatrists
• Child life specialists
• Physical therapists
• Pharmacist

Since pediatric cardiomyopathy and heart failure can be progressive, the heart may deteriorate past the help of medication, mechanical treatments, or surgery. When a patient no longer responds to other treatments, has persistent severe symptoms of heart failure, or suffers severe disability, a heart transplant is offered as a procedure of last resort.

Cardiomyopathy is the leading reason for heart transplantation in children. Roughly 20 percent of infants and children with symptomatic cardiomyopathy require a transplant within the first year of diagnosis.

With the combined expertise of the members of our pediatric cardiology team, we help families learn whether they have looked at all possible treatment options before considering a heart transplant. As a research center, we may be able to offer treatments unavailable elsewhere.

Children who are considered candidates for transplant usually:

• Have hearts that are so weak or diseased that the flow of blood throughout the body is dangerously low. When the heart does not pump blood well, too little oxygen circulates to the child's body. Without oxygen, tissues and organs may be damaged;
• Have very complex congenital heart disease that is not correctable with surgery;
• Have dangerous heart rhythms that compromise the amount of blood entering and/or leaving the heart;
• Have little ability to enjoy or participate in ordinary childhood activities, including playing sports, visiting friends, or even attending school;
• Have trouble keeping up with their schoolmates or siblings. They are often much smaller than other children their age. Infants may exhibit developmental delays in sitting, crawling, and standing; they are often very poor feeders; or
• May have been well all their lives and only recently became severely ill with acute myocarditis or cardiomyopathy.

The process of transplantation for a child of any age has a profound impact on the entire family. The proper education, including age-appropriate activities such as play therapy, tours of the hospital, and talking with other parents and children prior to hospitalization, can turn this experience into a positive one. This education includes siblings of the recipient whose lives are very affected by everything their brother or sister is going through. We urge families to communicate openly with the transplant team and their own support systems. The transplant nurse, social worker, and child life specialist will provide more information about available resources and support groups.

In addition to providing outstanding patient care, the Pediatric Heart Transplant Program stands at the forefront of pediatric heart failure research, including investigations of new strategies for post-transplant management. The Pediatric Heart Transplant Study Group, founded at Morgan Stanley Children's Hospital and comprised of 23 institutions across North America, is responsible for a significant proportion of today's published research related to pediatric heart transplantation.

Liver Transplantation

The Hospital's liver transplantation effort is distinguished by surgical and medical advances, with one-year survivals in pediatrics in the mid 90th percentile, and five-year survivals in the low 90s. The national standard is in the mid-80s.

The Liver Disease and Transplantation Center is a comprehensive program dedicated to treating all forms and stages of liver disease in children and adults. When treatments are unable to save a damaged liver and transplantation becomes necessary, our program offers surgical and postoperative care that reflects the great progress achieved in liver transplantation. While patients await transplantation, our team provides the medical intervention necessary to improve the success of the transplant postoperatively.

Our hepatologists take care of patients with mild liver disease to major illnesses requiring transplantation. Among the conditions we treat that could lead to the need for transplantation are:

• Acute liver failure
• Alagille syndrome
• Alpha 1 antitrypsin deficiency
• Ascites
• Biliary atresia
• Cholestasis
• Cirrhosis
• Hepatitis
• Hepatoblastoma
• Hepatomegaly
• Jaundice
• Liver disease
• Liver injury
• Liver tumor
• Neonatal hepatitis
• Portal hypertension
• Portal vein thrombosis
• Splenomegaly
• Tyrosinemia
• Variceal bleeding
• Wilson's disease

The Center cares for patients from the pre-operative phase through post-transplant recovery. As a medical-surgical service, our surgeons and hepatologists are readily available to answer any parent and patient concerns. The Center also includes a social worker, nurse practitioners, and a financial assistant who helps families with insurance.

Our pediatric patients have access to clinical trials that address the latest therapies in immunosuppression, including novel adult therapies that may be appropriate for older teenagers.

Many of our pediatric liver transplants are performed in children with biliary atresia, whose care is maximized by the collaboration of general pediatric surgeons and transplant surgeons.

NewYork-Presbyterian Hospital is a world leader for living donor transplantation, which involves the removal of a portion of the donor's healthy liver into a recipient. This is possible because of the unique ability of the liver to regenerate. A living donor offers the possibility of earlier transplantation to those in need before their health deteriorates to life-threatening status. Very often a family member or parent is a suitable donor for the child. In addition, we can split donor livers - making a liver available to two children at one time.

Lung Transplantation

The leading indications for pediatric lung transplantation are:

• Cystic fibrosis
• Bronchiolitis obliterans
• Focal nodular hyperplasia
• Inadequate lung development
• Interstitial lung disease
• Primary pulmonary hypertension
• Pulmonary vascular diseases
• Surfactant protein deficiencies

Morgan Stanley Children's Hospital has major programs in pediatric pulmonary vascular disease, pediatric congenital heart problems, and pediatric cystic fibrosis. These programs collaborate closely with our lung transplant specialists.

NewYork-Presbyterian Hospital has taken a leadership role in perfecting techniques and patient selection criteria for lung transplantation in patients with cystic fibrosis (CF). As a result, the Hospital is home to the largest adult CF lung transplant program in New York City, and has now expanded the program to include patients under the age of 18 years.

Although current management strategies reasonably control the disease into adulthood in most pediatric patients, lung transplantation may offer extended survival in pediatric patients with advancing disease who have severe and irreversible airflow obstruction. As part of the expanded program, there is no age limit, and children will be considered for transplantation as early as necessary.

Pediatric patients who are considered for transplant typically have irreversible disease that has rendered them dependent on supplemental oxygen. Other signs of advancing disease, such as frequent exacerbations, high blood levels of carbon dioxide, and pulmonary hypertension, are also usually present. CF is the reason for transplant in approximately 20 percent of the lung transplants performed at NewYork-Presbyterian/Columbia. Outcomes to date have been similar in children and adults.

The one-year survival for lung transplants overall has been 96 percent, and the three-year survival is 90 percent. In contrast, the national data from UNOS (United Network for Organ Sharing) is currently reporting one-year survival of 83 percent and three-year survival of 67 percent.

Additionally, the transplant program has been very active in studies of the pathophysiology of graft rejection, including early detection of genetic signals of an impending rejection episode. Their efforts to provide sufficient immunosuppression to prevent rejection episodes while minimizing the complications of these agents are critical to extending graft and patient survival.

Because of the challenges of transplantation for patients, early referral of patients with advancing CF is critical, whether they are adults or children. This provides time to perform tests on a timely basis, but also to prepare the patient both physically and psychologically for transplant if it becomes necessary.

Renal (Kidney) Transplantation

A kidney transplant can transform the lives of children with end-stage renal disease and kidney failure - freeing them from dialysis and enabling them to enjoy full, active lives. Medical and surgical advances over the years have greatly improved the success rates of kidney transplantation. At Morgan Stanley Children's Hospital, the renal transplantation program offers expert and comprehensive pediatric renal care for children and adolescents.

Our surgeons are skilled at transplanting adult kidneys into children. These larger kidneys have more reserve and usually function better than pediatric donor kidneys. The transplant surgeons and pediatric nephrologists have expertise in immunosuppressant therapies and other medications that address the immune response and medical issues of young patients.

Our pediatric nephrologists are important members of the renal transplant team, offering expertise in the diagnosis and treatment of rare and progressive conditions that can lead to end-stage renal disease in children, as well as kidney malformations in infants and toddlers. Often, they follow their patients for years during the progression of the illness to the point of transplant. The Hospital is equipped to provide both peritoneal dialysis and hemodialysis as temporary measures until the child can receive a kidney transplant. Many of these children will have a parent who is eligible to be a donor. The nephrologists evaluate the child for medical suitability for transplantation and manage the post-transplant care in collaboration with the transplant team.

Small Bowel Transplant

Small bowel transplantation is an important treatment option for intestinal dysfunction or short bowel syndrome in which children do not have enough small bowel to absorb nutrients.

Care for small bowel syndrome involves the integration of expertise by pediatric gastroenterologists, pediatric transplant surgeons, and pediatric surgeons. The condition generally appears within a few weeks of birth, brought on by a congenital disorder or an early onset inflammatory bowel condition. Prognosis can often be predicted by the location and length of the bowel, and intestinal rehabilitation should be considered in patients capable of absorbing oral nutrients. Transplantation remains reserved for patients with irreversible intestinal problems associated with life-threatening complications.

Approximately 20 percent of patients with small bowel syndrome are candidates for small bowel transplantation, and 80 percent are generally candidates for rehabilitation. Patients may need to receive supplemental nutrition through a central intravenous line-total parenteral nutrition (TPN)-a form of nutrition delivered into a vein for patients unable to absorb nutrients through the intestinal tract. If this proves unsuccessful or has complications, small bowel transplantation may be recommended.

In some patients, taking an aggressive nutritional approach via TPN will restore bowel health and avoid transplantation-the goal of intestinal rehabilitation.

Our experience with small bowel transplant spans two decades, including surgery on a four-month old girl, who today, at 18, is the longest survivor of a small bowel transplant in the world.

In addition to treating short bowel syndrome, the expertise of our gastroenterologists and transplant specialists include the following conditions:

• Gastroschisis
• Ileal atresia
• Intestinal atresia
• Intestinal pseudo-obstruction
• Jejunal atresia
• Malabsorption
• Necrotizing enterocolitis (NEC)
• Short bowel syndrome (SBS)
• Volvulus

It is important to make sure that patients are as nutritionally sound as possible before transplantation to prevent post-transplant complications, including sepsis, clotting, liver problems, the development of an abdominal fistula (a wound that does not heal), an ostomy, or a nasogastric (NG) tube.

When indicated, our surgeons provide pre-transplant surgical management involving longitudinal intestinal lengthening-a bowel-lengthening procedure, called serial transverse enteroplasty or STEP-that is performed prior to transplant with promising surgical and nutritional outcomes. This procedure enables food to move more quickly through the repaired bowel and nutrients to be more quickly absorbed. At Morgan Stanley Children's Hospital, the procedure is performed by a team of pediatric gastroenterologists, pediatric surgeons, and pediatric transplant surgeons to ensure the best outcomes.

Our pediatric transplant surgeons can perform small bowel transplantation for specific sections of the colon, such as the large bowel. We also can combine liver and small bowel transplantation, as well as liver, small bowel, and colon transplantation if necessary. For some patients, our surgeons rebuild the colon to avoid any permanent colostomy. They can also perform a multi-visceral transplantation-the transplantation of more than four organs: stomach, small bowel, pancreas, liver, and large bowel.

The Bianchi procedure, in which the bowel is cut in half and one end is sewn to the other, is used to treat short bowel syndrome when the intestine is stretched beyond its normal dimensions (symmetric bowel dilatation).

Following surgery, patients are referred to a pediatric rehabilitation center for after care to further the recovery process prior to going home. The Hospital's social workers meet with our transplant team frequently to develop the most appropriate discharge plan and address any concerns families may have.

Ongoing research continues to explore therapeutic interventions to optimize adequate digestion and absorption of nutrients. Our physicians are pursuing clinical research related to treatment of liver complications-particularly cholestasis jaundice-as the result of TPN management.