12-year-old’s unique heart surgery

FDA gives Stanford doctors special permission

When Lizneidy Serratos’ mother took her to the hospital at 1 a.m. Aug. 4, she thought wildfire smoke near the family’s Reno home was the reason the 12-year-old was struggling to breathe. But after a series of tests, doctors said Lizneidy’s heart was failing.

“Her heart function was at only 10 percent,” said Lizneidy’s mom, Maricela Alvarado-Lazarit. “It was a shock.”

After receiving a ventricular assist device, Lizneidy Serratos plays in the Dunlevie Garden at Lucile Packard Children’s Hospital Stanford.
Courtesy of Maricela Alvarado-Lazarit

On Aug. 12, Lizneidy underwent surgery at Lucile Packard Children’s Hospital Stanford, becoming the youngest and smallest person in the country — and one of the smallest in the world — to receive a specific type of heart pump which kept her alive until she received a heart transplant in early December. She was saved by the heroic behind-the-scenes work of her doctors and nurses, who petitioned the Food and Drug Administration for permission to use a medical device that had not yet been approved for children. They got a compassionate-use exemption in about 24 hours.

Too sick to walk

“When Lizneidy came to us, she was very, very sick,” said Katsuhide Maeda, MD, associate professor of cardiothoracic surgery at the Stanford School of Medicine. Lizneidy had dilated cardiomyopathy, a leading cause of heart transplants in children. “She was vomiting and nauseated, and could not eat at all,” said Maeda, who performed the surgery to implant her ventricular assist device. And she couldn’t walk because her heart was so weak.”

In late July and early August, as wildfire smoke drifted into Reno, Lizneidy’s family noticed she was breathing less easily. Then, just after midnight on Aug. 4, Alvarado-Lazarit found Lizneidy sleeping in a strange position.

“I was criss-cross applesauce, with my head down at my feet,” Lizneidy said. (Though Alvarado-Lazarit didn’t know it, people with heart failure can often breathe better if they sleep sitting up.) Alarmed, she woke her daughter and took her to the nearest emergency room. Doctors transferred Lizneidy to the pediatric intensive care unit at another Reno hospital, Renown Children’s Hospital, which has a pediatric specialty care partnership with Stanford Children’s Health. Lizneidy was then transferred by an emergency medical flight to Packard Children’s.

Lizneidy received medications that stabilized her for a few days. But her heart was not recovering. As in most cases of dilated cardiomyopathy, the physicians did not know why her heart was failing.

“It appeared she was getting worse and was going to need a ventricular assist device,” said Christopher Almond, MD, associate professor of pediatric cardiology at the School of Medicine. A VAD is a surgically implanted pump that helps a patient’s failing heart move blood through the body.

Almond told the family that Lizneidy would probably need a heart transplant, and that she would receive surgery to implant a pump that could keep her alive until a donor heart became available.

The best pump

The Packard Children’s cardiology team wanted to give Lizneidy a pump called the HeartMate 3, which is small enough to implant in the chest. Patients with the pump must wear an external battery pack, but can leave the hospital, walk freely and perform many normal activities. In rare cases, heart pumps allow children’s hearts to regain enough function to avoid a transplant.

Heart failure made Lizneidy too weak to walk or eat. After the pump was implanted, she enjoyed a meal with her family at a restaurant near the hospital.
Courtesy of Maricela Alvarado-Lazarit

However, the HeartMate 3 had one drawback in Lizneidy’s case. To implant it, Maeda needed to create a hole in the girl’s left ventricle, the largest pumping chamber in her heart, and suture a washerlike device called a sewing ring onto the heart to anchor the pump. But the sewing ring that had been approved by the FDA was too big for Lizneidy. There was a smaller ring, but it was approved only in Europe.

“The problem with the larger sewing ring is that Dr. Maeda would have had to sew across one of her most important coronary arteries,” Almond said. Closing the artery would have permanently severed the blood supply to part of Lizneidy’s heart muscle, cutting off the possibility of avoiding a transplant.

“Because she had a chance of recovery, we didn’t want to sacrifice the main artery supplying blood to her heart,” Almond said.

So on Aug. 9, Almond asked the FDA for a compassionate-use exemption. He wrote a letter to the FDA and the device manufacturer, Abbott, requesting permission to use the smaller, unapproved sewing ring; contacted Stanford’s ethics team to get its permission for the unusual surgery; and arranged for another cardiologist to provide an independent second opinion to the FDA. On Aug. 10, as hours ticked by and paperwork stacked up, people in several locations across the country — including FDA staff — stayed late at work to help.

“The process for getting compassionate-use approval is a bit complex,” Almond said, noting it can take days or weeks. But everyone recognized the urgency of Lizneidy’s case. “The hospital, the FDA and the company did a phenomenal job supporting this medical request on such short notice.” 

“Everybody was so good, keeping us informed of what was going on and what to expect,” Alvarado-Lazarit said.

By 9 p.m. Pacific time on Aug. 10, the approval was complete. In one more bit of serendipity, Almond learned that the small sewing rings — which were commercially available only in Europe — are manufactured 30 miles from Packard Children’s, in Pleasanton, California. 

The sewing ring arrived at the hospital the following morning. That evening, Lizneidy was growing worse. It was time for surgery.

A medical pioneer 

On Aug. 12, Lizneidy’s family came to the hospital early. She was calm as she was wheeled into the operating room, listening to favorite songs on her phone. The small sewing ring worked just as the doctors had hoped: In the five-hour surgery, Maeda kept Lizneidy’s coronary arteries intact. Lizneidy became the first person in the United States to receive a small sewing ring and, at the time of her surgery, the youngest and smallest person in the country to receive the HeartMate 3 ventricular assist device.

The pump made an enormous difference. Lizneidy’s breathing tube was removed the next day, and she soon began eating again.

“Having her just talking and laughing and asking for things was great,” Alvarado-Lazarit said. “When she started being able to get up, it felt like, ‘She’s going back to normal.’”

Since the surgery, the smaller sewing ring has received FDA approval for commercial use, enabling more patients to benefit from the device.

Lizneidy’s medical team — which also included pediatric cardiologist David Rosenthal, MD, professor of pediatrics at the School of Medicine, and nurse practitioner Jenna Murray — monitored her for three months before deciding in early November that a transplant was her best long-term option. Maeda and cardiothoracic surgeon Teimour Nasirov, MD, performed her heart transplant on Dec. 4. Lizneidy and her family are now staying at the Ronald McDonald House near Stanford while she recovers from the transplant.

Throughout the fall, living with the VAD, Lizneidy was relaxed and cheerful, attending seventh grade at the hospital school and accepting her challenges with a dose of tween humor. The battery pack for her heart pump was always at her side, housed in a tote bag she wore over her shoulder.

“It’s like an annoying best friend, always there,” Lizneidy said in September. “But I’m OK with it.”