Pulling off one of the rarest of transplants required a surgical version of beat the clock.
First, Jennifer Martens was awakened in the middle of the night and told to get to an Edmonton hospital right away. Once there, she was brought to an operating room for a cesarean section; four hours later, in an operating room down the hall, surgeons anesthetized her newborn son and sawed open his chest.
While this was going on, a donor baby heart, packed in a cooler of ice, was being flown to Edmonton.
Talk about timing: The baby heart transplant that took place at Stollery Children's Hospital required precision co-ordination, but even the organ itself was a bit of a miracle. Ms. Martens's 37-week-old fetus was put on a transplant waiting list -- and an organ became available just three days later.
There's more: Xander Dolski, the baby in question, had to receive a heart within hours after birth or face certain death. And the donor heart needed to be transplanted within six hours of being removed from the deceased donor infant. Any longer and the heart would be prone to failure.
"It's a big scramble," said Yashu Coe, the pediatric cardiologist at Stollery Children's Hospital in Edmonton who treated Xander. "You want to time it so that the chest is open and the heart arrives. You don't want to be too late and have the heart arrive and sitting in a bucket."
The newborn heart transplant took place in December, but details were not released until this week.
"The real story is how well the team worked," said David Ross, the pediatric cardiovascular surgeon who performed the transplant on Xander. "Had any link not been strong, he wouldn't have done as well."
Xander's heart defect was picked up during an ultrasound in Winnipeg, where Ms. Martens lives, at 20 weeks gestation. It was a defect the size of the point of a ballpoint pen. It was thought to be a heart-valve problem, a serious condition to be sure, but one that doctors thought could ultimately be dealt with surgery in infancy.
"It was a little intimidating, but it didn't seem like a huge thing at that point," said Ms. Martens, 30, a zookeeper who works at Winnipeg's Assiniboine Park Zoo.
Except that as Ms. Martens's pregnancy progressed, it became apparent that her unborn child's heart defect could be lethal. By her 35th week of pregnancy, doctors told her there was no surgery after birth that could repair her baby's heart. Should a donor heart not become available, her baby would die hours after birth.
"When we came out here, we didn't know if we were going to come [to our Winnipeg]home planning baby showers or a funeral," Ms. Martens said. "That was a really hard time."
Xander's lethal heart problems were those of poor design: The aortic valve -- the outlet from the heart that sends the blood to the rest of the body -- was severely restricted. The muscle in the heart's main pumping chamber was weak and the hole between the chambers of the heart, that fetuses normally have, was also restricted. This meant the heart couldn't blow the blood out into the body and the blood inside the heart wasn't moving properly.
"Somehow, the heart got damaged along the way in development and it became ineffective," Dr. Coe said. "The major problem in any of these patients, is that the heart muscle is just so weak it cannot function effectively as a pump."
By early December, when she was 36 weeks pregnant, Ms. Martens and her mother, Brigitte Martens, flew to Stollery Children's Hospital.
There, a team of Edmonton specialists debated the best time to put the fetus on the waiting list. Too early and his lungs wouldn't be developed; too late and he risked not getting a donor heart.
"If we would have waited until he was born, the probability of getting him a heart would have been zero," Dr. Ross said.
During her 37th week of pregnancy, Baby Martens (fetus) was placed on the transplant waiting list.
The following day, Dec. 17, came good news: Ms. Martens's unborn baby was at the top of the North American waiting list. Factoring in the speed of aircraft, the organ could come from as far away as southern California, the U.S. eastern seaboard or Alaska.
All she and the baby's father, Walter Dolski, 40, could do was wait -- and hope. In order for their wish to be fulfilled, another set of parents would have to suffer a devastating loss.
"The really sad part of this is that you can only do this operation because someone has already lost a baby," Dr. Ross said. "It's horrible; it's very sad. But you can have one child die or two children die."
At 1:30 a.m. on Dec. 19, when she was 38 weeks pregnant, Ms. Martens was awakened by a telephone call. A donor heart was available and she would have to rush to hospital. Obstetricians from Royal Alexandra Hospital in Edmonton were also on their way to Stollery Children's Hospital to perform a cesarean section.
Although this was the moment she had waited for, she was panic-stricken. She quickly pulled herself together and raced to the hospital with her mother. Mr. Dolski was in Winnipeg.
At 4:45 a.m., Xander came into this world. Although Ms. Martens couldn't hold him, she managed to sneak in a soft kiss on his forehead.
At that moment, "he looked perfect," she recalled. "He was a healthy colour. He didn't look like he had any problems at all."
Outside of the womb, doctors examined Xander to determine whether there were other significant health problems that made him ineligible for a transplant.
"There's a limited supply of donors," Dr. Ross said. "We don't want to put a donor heart in a child who has some other lethal problem."
An examination revealed the six-pound, six-ounce boy was perfectly healthy, save for his heart. But three hours outside of the womb, blood was pooling in his legs and his heart was failing badly.
Xander was whisked to the operating room at 8:10 a.m., where he was anesthetized. By 9:15 a.m., he was put on the heart-bypass machine, a type of artificial circulation. His chest retracted open; he was there, waiting for a donor organ to arrive.
"It's a bit unnerving to look inside and see no heart there at all," Dr. Ross said. "The blood is circulating normally because it goes through the heart-lung machine, the baby is alive and well, but there's a big cavity where the heart should be."
When that organ came, it was a thing of beauty, with four working chambers. And following the transplant, Xander became proof that medical miracles aren't just the stuff of prime-time television, but of real life after receiving a transplant at the tender age of eight hours.
"The heart started pumping right away and he's never looked back," Dr. Ross said.
Under organ donor rules, no details can be provided about the heart, its location or the circumstances from which it came. Dr. Ross will only say the heart came from "some distance away."
Due to swelling, Xander's chest was left open for about a week. On Boxing Day, surgeons closed it and by late December, Ms. Martens and Mr. Dolski, also a zookeeper, were finally able to hold their son for the first time.
Today, eight weeks after his birth, the robust breastfeeding boy weighs 9 pounds, 1 ounce, and the ruler-straight scar that runs from the top of his chest to his midriff has already started to fade to mauve.
Although he was released from the hospital on Jan. 16, he will remain in Edmonton until late March for weekly doctor visits.
Xander is currently on 11 medications, three of them anti-rejection drugs, the latter of which he will have to take for life.
"An organ transplant is not a cure," said Dr. Ross, adding that 85 per cent of these babies are living five years after transplant. "Chronic rejection down the road would be something to be watched for."
These babies can start to experience chronic rejection problems 10 to 20 years after transplant, Dr. Ross said. That would necessitate another transplant.
Although there are no national figures on the number of fetuses placed on transplant waiting lists, Xander's was the second such transplant for Stollery Children's Hospital. The Toronto-based Hospital for Sick Children has put 24 fetuses on transplant waiting lists since 1997.
Of those, four transplants were done on babies delivered by cesarean section when a donor heart became available, 15 others were transplanted as infants and the remaining five went on to have surgical repairs, according to Anne Dipchand, cardiologist and head of the Heart Transplant Program and the Echocardiography Lab.
But placing fetuses on transplant waiting lists is rare. Many congenital heart defects detected during pregnancy hold the promise of being repaired surgically in the first few months of birth. Others who learn of the more lethal defects during ultrasound examinations will sometimes choose to terminate their pregnancies.
Parents of fetuses whose severe cardiac malformations were diagnosed through fetal echocardiography at the Hospital for Sick Children chose to terminate the pregnancy more than half of the time in 2005, Dr. Dipchand said. This percentage, she said, is even higher in Europe.
And yet, there has never been a better time to obtain a fetal heart in Canada. Research done by pediatric cardiologist Lori West of Toronto's Hospital for Sick Children has shown that donor hearts in infants do not require blood compatibility to be successful, like they do in adults. Because an infant's immune system is immature, it adapts to, not rejects, an organ that has been in the body of a different blood type.
While 17 to 20 centres worldwide have put her research into practice, many others have not. Consequently, many hospitals in the United States wait for organs with compatible blood types. That has meant more organs for Canadian babies, so much so that Dr. Dipchand said half of all donor baby hearts that come to Toronto Sick Kids are from the United States.
Newborn Xander's new heart
Jennifer Martens' fetus was 20 weeks old when she learned it had a heart defect. At 35 weeks, she learned the heart condition could be lethal. At 37 weeks, doctors performed a cesarean and Xander was brought into another operating room for lifesaving surgery.
Heart prepared for transplant
Once an incision has been made, the chest retractor is used to gain access to the heart. A scalpel is used to cut open the pericardium, the double-layered, fibrous sac that encloses the heart and the large blood vessels attached to it.
A tube leading from the heart/lung machine to the ascending aorta carries blood that has been oxygenated by the machine back to the body. Tubes attached to the superior vena cava and the inferior vena cava draw oxygen-depleted blood from the body. Clamps then isolate the heart from the rest of the body's cardiovascular system. The heart/lung machine has now fully taken over. The lower portion of the heart is cut away, leaving behind the back wall of the right atrium. The aorta between the clamp and the heart is cut, as well as the pulmonary artery at a location close to where it emerges from the heart. This leaves behind the back wall of the left atrium.
The donor's heart is placed on the baby's sternum. The back of the heart has been cut away and is ready for attachment. The back walls of the left and right atriums are connected to the donor's heart with a suture - a needle and polypropylene thread.
4. The baby's pulmonary artery and aorta are attached to the corresponding artery and aorta emerging from the donor heart. Removing the clamp on the aorta should initiate a heartbeat. Removing the remaining clamps allows the heart to fill with blood and the heart/lung machine tubes are then removed.