At 9:30 p.m. Oct. 2, Dr. Chesney Castleberry got the call.


A new heart was being offered to 18-year-old Gerardo, who had been in heart failure for almost a year and had been turned away from being listed by another hospital in Texas.


She called his family that night and told them to be at the hospital at 5 a.m., that she was 90% sure he would get the heart transplant they had been praying for the next morning.


"Please give us this opportunity to have him a little bit longer," his mom, Myrna, remembers praying.


"It was a gift from God," she says, and the best birthday present for her. His family prayed and lighted a candle for him. They could not sleep.


Gerardo’s family didn’t know he had a heart condition until he collapsed on the soccer field at school in 2017. Doctors discovered he was born with an abnormal valve, but he also had a thickening of his heart muscle caused by Danon disease, which was affecting both sides of his heart. Danon puts him at risk for sudden cardiac arrest, and Castleberry says that when she meets boys with Danon disease, they are automatically talking about a heart transplant.


The family knew a transplant was going to be needed, but they thought they had more time. Last fall, he didn’t have any energy and wasn’t eating (and this was a kid who would take six trips to the buffet line). He was officially in heart failure.


On Aug. 1, he passed out twice in a shopping center parking lot and was taken by ambulance to Dell Children’s Medical Center. Since then, he has been in the cardiac care unit.


"This poor young man was dying," says Dr. Charles Fraser Jr., chief of the Texas Center for Pediatric and Congenital Heart Disease at Dell Children’s and UT Health Austin, the clinical practice of Dell Medical School at the University of Texas.


Because of Gerardo’s heart, his liver and kidneys also were getting sicker.


"He was on the cusp of being too sick for transplant," says Castleberry, the medical director of the pediatric heart transplant team, a joint program of Dell Children’s and UT Health Austin. Within a week, if he had not received the heart transplant, they would have had to put in two ventricular assist devices, one on each side, she says, to help his heart do its job.


When Castleberry got that call Oct. 2, she had been watching the listing of this heart, but didn’t think it would go to Gerardo. Another hospital was going to take it for another patient, but that team passed on it. That happens when they don’t think it’s a good enough match for their patient.


Usually transplant medical directors only get about 20 to 40 minutes to decide whether they want a heart, which is why she has her phone with her at all times.


Castleberry acted quickly. Accepting the heart set the transplant team in motion to perform its first heart transplant at Dell Children’s.


Growing a new program


Dell Children’s has been going through massive growth in many aspects, including cardiac care. Dell Children’s Heart Failure, Ventricular Assist Device and Transplant Program began two years ago when Dell Children’s, UT Health Austin and Dell Medical School brought Fraser to Austin from Texas Children’s Hospital in Houston to build the Texas Center for Pediatric and Congenital Heart Disease.


On July 22, the program was approved to list patients and perform heart transplants by the United Network for Organ Sharing.


"The heart transplant is the bellwether for a developing heart program," Fraser says. From his arrival to transplant happened faster than he initially predicted.


Once launched, the transplant part of the program has grown faster than Castleberry expected, too.


Four patients have been approved to be listed for transplants, and three are actively on the list through Dell Children’s. Two others could be listed at any time. They expect to do two heart transplants this year, building to 10 a year.


Castleberry is evaluating one to two new patients every two weeks. "It’s triple what I’m used to," she says. "I didn’t expect this many kids listed this fast."


She still has to get through more referrals of kids as well as babies about to be born, "babies we would have had to ship out," Castleberry says, to another children’s hospital in another city.


Fraser says the growth and pace has been driven by the needs of Austin’s patients and the ability to build a transplant team here quickly. Having the connection to a medical school was crucial to being able to recruit an experienced transplant team.


Fraser began at Dell Children’s on Sept. 1, 2018, and the stretch since then has been the longest time in his career when he couldn’t perform a heart transplant.


"It’s like fighting with one arm tied behind your back," he says. He had to send patients elsewhere. "I unapologetically will be shouting from the rooftops with my last breath that Austin cannot accept anything other than cutting-edge medical care," he says.


The hospital has gone through massive upgrades to make this program happen, including opening the cardiac care unit in June 2019, with 24 beds and a dedicated staff. The rooms are all being upgraded with new lights, screens, floors and doors, which makes performing emergency bedside surgery more of a possibility.


It also has upgraded two operating rooms with new lights and screens and all the features needed to be able to see what’s going on from every angle in the room.


At the same time, Dell Children’s is undergoing a $700 million expansion in the next three years, which includes a Specialty Pavilion for the cardiac, neurosciences, blood and cancer centers, as well as a new fetal center. That $113 million four-story building next to the hospital will open in April.


The hospital also has a $209 million expansion to build a fourth tower, which will add 72 beds and is expected to open in December 2023. It also is building a $191.8 million second hospital with 36 beds and a medical building at 183-A tollway and Avery Ranch Boulevard. This is expected to open in November 2022.


A heart for Gerardo


All of the work of the last two years came to fruition on Oct. 3.


At 2:45 a.m., cardiothoracic surgeons Dr. Ziv Beckerman and Dr. Sara Mendoza Crespo, and perfusionist Richard Owens, leave Dell Children’s by ambulance and travel to Austin’s airport.


They bring with them everything they need for the operation, from surgical equipment to gowns to the beige Yeti cooler that says "Human Organ" in red lettering.


They board a six-passenger plane from a company that specializes in this kind of transport and head to another airport. These planes are always given priority to take off and land.


Once the retrieval team touches down, they take a 20-minute ambulance ride to the hospital where the donor is being kept on life support.


The donor’s name, age, gender and location are all kept anonymous from the public, and Gerardo’s family has opted to make public only his first name and age. The team double-checks multiple times that this is the correct donor and on the other end that this is the correct recipient.


At the donor’s hospital, another team is waiting for the liver and kidney, but the heart team always goes first. Before they remove the heart, they test to see how strong it is and do an echocardiogram to watch the heart’s function and structure.


Once the heart is clamped, the clock starts. They have six hours to get the heart back to Austin and into Gerardo for the best possible outcome.


"We look at the heart preservation as the most important key to success," Beckerman says, which is why Dell Children’s brings its own perfusionist, an unusual move. "If the heart you are going to procure is not preserved and protected the best way possible, it’s not going to be successful."


They stop the heart with medication and remove it from the body. They take a bit of lymph node as well to test for antibodies and put it in a small plastic jar.


The heart and the lymph node will be kept cool in a bag filled with a special solution surrounded by ice and go into the cooler. Beckerman will keep it with him the entire journey.


"The second we clamp the heart, we were out of the hospital within 25 minutes, which is really fast," Beckerman says.


The team at the donor hospital and the one at Dell Children’s are in constant communication by text messaging.


At 9:20 a.m., this team and its new carry-on ride the same ambulance to the airport, board the plane and take off. They try to rest, eat a little something and get ready for the next part of this heart’s journey. They are watching the clock.


Preparing for transplant


The team in Austin is gathered outside Gerardo’s hospital room at 8 a.m. to prepare for what will be a long day.


A crowd of doctors, nurses, technicians and his parents follow Gerardo as he is wheeled from his room on the cardiac intensive care unit down the hall to operating room 3.


His mom takes off her glasses, wipes away tears and leans over to say to him, "Everything will be OK."


His father, Gerardo Sr., gives him final words of love in Spanish and tells him: "We love you so much; all your family loves you. We are going to be waiting for you."


One of the team tells him: "You are safe. Take a breath."


A member of the team leads the parents to a consultation room outside the cardiac care unit. They will get hourly updates from a nurse throughout.


The rest of the team follows Gerardo through the double doors into the operating room hallway and into the operating room.


As members of the anesthesiology team help him move from his hospital bed to the surgery bed, they announce the time he arrived in the operating room: 8:39 a.m.


Anesthesiologist Dr. Erin Gottlieb points to the pillow on the operating table. "This is our pillow. It’s not very fancy." The white pillow is plain compared with the X-Men pillow Gerardo has been sleeping on.


"There you go," she says as he moves from his hospital bed to the table.


They call out his name and patient ID numbers to verify the right person is getting the heart transplant.


"We got a lot of sticks for you, man," Gottlieb says, as she slowly begins to anesthetize him and put in IVs and catheters. Because of the degree of his illness, she needs to go much slower in anesthetizing him than in an otherwise healthy person.


As she and fellow cardiac anesthesiologist Dr. Anthony Zapata work on preparing him for the surgery, she talks to Gerardo in reassuring tones.


"How are you doing, Junior?" she asks him at one point.


The team at Dell Children’s is racing to get Gerardo onto the heart bypass machine, which will do the work of a heart when they remove his heart and put in the donor’s heart. They won’t remove Gerardo’s heart until the donor heart is in the room with them and they have checked its condition. If something happens, he will still have his old heart, and they possibly could put him on an assistive device until another heart becomes available.


They take one more echocardiogram of Gerardo’s heart to make sure no one sees anything new that would stop the procedure.


"Are we good?" Dr. Fraser asks the team, which will grow to more than two dozen people.


The answer is yes.


Getting Gerardo ready


Gerardo is now asleep. Gottlieb points to Gerardo’s chest. You can see his heart physically moving his chest up and down with every heartbeat. His heart is working hard to keep up.


Of the 50 to 60 heart transplants Gottlieb has worked on, she says Gerardo’s case is the worst. His heart is enlarged to about the size of a basketball.


It’s 9:35 a.m., and Fraser wants to make his first incision at 10:10 to get Gerado on bypass by 11 and receiving plasma by 11:30 at the latest. Before they can put the new heart in, they need an hour of exchanging Gerardo’s plasma with donor plasma to trick his body into not reacting to the new organ.


The new heart is expected to arrive at 12:30 p.m.


"We’re on the clock, so everyone is moving faster than normal," says perfusionist Blake Denison, who will be operating the heart bypass machine. "Everything is very methodical."


It is methodical, but there’s a sense that they are behind.


"I don’t want to delay anything," Gottlieb says. "Keep moving."


The team goes over the plan again as each person in the room states their name and role.


At 10:30 a.m., Gottlieb is watching all of Gerardo’s vital signs and growing concerned. She knows all the medications she is having to give to support his blood pressure.


She goes just outside the operating room where Fraser and Dr. Carlos Mery, the surgical director of the heart transplant program, are scrubbing their hands for surgery, and she tells them to hurry up.


She returns and continues to monitor Gerardo’s vitals. He is struggling.


Calmly, she tells cardiothoracic surgeon Dr. Lok Sinha to start CPR. In less than a minute, Gerardo’s heart is beating again.


"It’s uncommon," perfusionist Kellen Rosten says of having to do CPR while preparing a patient for heart transplant in the operating room, "but it happens. It’s a good day if we don’t."


Kids like Gerardo, who have been sick in the hospital for months, "they’re so unstable," Rosten says. "They are just so frail."


When things change just a bit, he says, "the heart decompensates."


The team returns to preparing Gerardo to go on bypass and getting the room fully ready. They cool the room all the way down.


By 10:35 a.m., Fraser makes his incision into the chest.


Gottlieb calls the relationship between the surgeon, the anesthesiologist and the perfusionist the "triangle of trust." Fraser, Gottlieb and Denison are in constant communication.


Fraser orders a drug to be given, Gottlieb echoes it, and Denison confirms it. Denison gives out stats for Gerardo’s blood, such as the clotting factors and blood gases. They begin to hook up Gerardo to the bypass machine.


The time before a patient is on bypass and then when he is taken off are the most critical in the procedure.


"To get him on bypass is huge," Gottlieb says. "Especially when you have to work so hard to get there."


Getting him off the bypass machine, she says, "you worry about (the new heart) not being able to overcome," Gottlieb says. "We have medicines for that."


At 11:34 a.m., they test putting Gerardo on bypass.


"Open," Fraser says and Denison repeats the request while skillfully moving knobs on the bypass machine.


"All circuits turned way up," Fraser says.


They watch all the levels and the blood moving into the machine and back into Gerardo’s body.


At 11:42 a.m., Fraser asks, "Good to go?"


"Good to go," Denison confirms.


He begins to increase the flow, calling out percentages, "75%, 80%, 90%, 100%."


Gerardo’s heart is no longer doing any of the work. He is on bypass. The sound of the heartbeat on the monitor is silenced.


They begin to see improved numbers on the monitor screens. The machine is moving the blood in a much more efficient way than Gerardo’s heart could.


"He’s suddenly feeling better," Fraser says.


They start the plasma and wait.


A new heart in sight


At 12:22 p.m., the text message arrives: The donor heart has landed in Austin. The team is eight minutes away by helicopter.


At 12:30 p.m., the heart and its team lands on the helipad near the emergency room. They opted to take a helicopter instead of an ambulance because of traffic concerns. It’s a UT football game day.


The donor heart team is greeted with a crowd of people welcoming them with clapping. They take the stairs to the operating room on the second floor to not risk getting stuck in an elevator.


By 12:32 p.m., the heart has reached the room.


Fraser says he always pauses to give a little whisper of thanks when a heart arrives. "I remind everybody, on the other end of this, there's a human tragedy. ... On this end, there is great joy, but on the other end, great sorrow."


Fraser tells Beckerman to scrub in and take the heart out, but before he can do so, Fraser asks him, "You’re happy with it?" Beckerman confirms he is.


The teams verify the donor information and the patient information again. Then they begin to remove the heart from the plastic drawstring bag.


By the time the heart arrives, it is 4 hours, 15 minutes and 19 seconds since the heart has been out of the donor’s body. Castleberry keeps a clock running on her phone. It will help her know how close to the six-hour window they are.


Behind where Fraser is working, Beckerman and his team are preparing the donor heart. They’ll trim off any excess and assess how well it did during the transport.


The donor’s lymph nodes will be sent by courier to San Antonio for cross-matching against Gerardo’s to see if there are any reactions. They'll know by 5 p.m. what kind of medication they might need to give Gerardo to counteract those reactions.


Fraser removes the old heart and puts it on a bowl on a table near Gerardo’s feet. It is oversized compared with a normal heart. The donor’s heart is about one-third the size.


By 1 p.m., Fraser is beginning to sew in the new heart from back to front.


Once a section is sewn in, Fraser begins poking the heart to wake it up. He applies electrical paddles. The heart starts beating right away. "Sometimes it takes a while," he says.


It’s 1:45 p.m., and the new heart begins to find its rhythm in a new body. Everyone in the room is glued to watching the EKG monitor as well as the image of the heart through a camera on Fraser’s head.


"The EKG looks great," Mendoza Crespo says.


Gottlieb points to the way this heart is beating. It’s no longer leaping from Gerardo’s chest. "It’s different," she says. It is normal.


Fraser continues to sew in the heart.


At 3:40 p.m., doctors look again at an echocardiogram, this time of the new heart inside Gerardo. It’s looking good.


Slowly, Denison begins to reduce the flow of the bypass machine. "90%, 75%, 50%, 25%, 20%, off pump," he calls out.


The heart is now moving all the blood in Gerardo’s body by itself.


The doctors continue to watch it.


They remove his pacemaker and the wires connecting it. They put in drains to remove excess fluid. They begin to close the opening in Gerardo’s chest.


By 4:50 p.m., the chest is closed with metal sutures. The heart is beating 98 beats a minute.


"We got a nice heart, a perfect heart," Fraser says.


It was only out of a body for five hours and four minutes.


The team begins to move Gerardo back onto his hospital bed from the surgery table. Gottlieb grabs syringes of medication and wraps her stethoscope around her neck just in case something happens on the way back to the cardiac care unit.


As Gerardo enters the unit with the entire surgery team following him, nurse manager Laura Morton blows a kiss from her station. It’s 6 p.m., about 10 hours after he left the unit to go into the emergency room.


When Gerardo wakes up the next night, he asks, "When are they going to put in the new heart?" his mom remembers.


A period of recovery


The next weeks are pretty active for the team caring for him. The new heart has to work harder once the anesthesia wears off. The first five days, Gerardo receives big doses of anti-rejection drugs.


Nine days into his recovery, they do a biopsy of the new heart to test for rejection and check all the sutures and connections. "You can treat rejection early," Castleberry says. If you wait, it’s more difficult, she says.


It looks good.


Gerardo’s recovery has been more difficult than they expected it to be. He had to go back on a ventilator to give his new heart a break, and he’s on dialysis to help his kidneys process all the medications.


Sometimes, heart transplant patients can go home in as little as two weeks, but Castleberry anticipates Gerardo’s recovery will take four to six weeks,


"His discharge day will depend on his progress," Mery says.


He is doing better and better every day, Castleberry says.


His parents agree. He is letting his parents know that he’s tired of being in the hospital. He wants to go home, and he wants to graduate from high school.


His family cannot help but think of the other family, the one who lost their family member. "We are really sorry for that family," his dad says. "That heart is really strong. It’s keeping my kid alive. He is really good."


When Gerardo leaves Dell Children’s, he won’t have many restrictions. "I want them to live their lives," Castleberry says.


He will continue taking anti-rejection medicine, and the life expectancy of a transplanted heart is about 15 years. He will continue to be monitored.


When it comes to the actual surgery and the choreography of the day, Fraser says, "It doesn’t go any better than that."


Even though everyone on the team has performed heart transplants before, this one felt a bit different to Beckerman. They had done simulation after simulation, but you’re never quite sure, he says.


"Until you really see that the ambulance is there, the plane is there, the chopper is there, everything is in place to do what you want to do, you have that little doubt in your heart," Beckerman says. "That is really stressful."


It worked perfectly.


The day of the transplant, "is always a testament to how strong teamwork can be," Castleberry says. "We mobilize these teams at the drop of the hat. ... This is why they went into medicine, to help kids."