Girl Who Got New Organs After Botched Duke Transplant Dies

A 17-year-old Mexican girl, who survived a botched heart and lung transplant at Duke University Medical Center long enough to get a second set of donated organs, has died.

Jésica Santillán, a Mexican immigrant who came to America three years ago seeking medical treatment for a life-threatening heart condition, had been engaged in a desperate battle for life since February 7, when doctors at Duke transplanted a set of organs into the girl that were a mismatched blood type.

As her body mounted a massive attack against the organs, sending her into a coma-like state, the girl suffered a heart attack on February 10, and was placed on life support.

Jésica never recovered consciousness and was near death when, against all odds, she got a second donated set of heart and lungs said to be "an incredibly good match" transplanted into her small body on February 20.

Hopes briefly ran high that a miracle recovery might occur. But while the new organs worked well, Jésica's brain began swelling and bleeding shortly after the second surgery, causing severe and irreversible brain damage, doctors said.

The end formally came on February 22, when doctors reported that all brain activity had ceased. Jesica was declared brain dead at 1:25 pm. Her heart stopped at 5:07. Doctors removed her from a respirator at 5:10, said Duke University Medical Center spokesman Richard Puff.

Ironically, the distraught parents, who did not want their daughter removed from life-support, declined Duke's request to donate Jésica’s organs after days of pleading for others across the country to donate organs so their daughter might have a second chance at life, the hospital said.

But Jésica's death was hardly the final chapter in the mystery of how organs from a person in New England with Type A blood could have been sent to North Carolina to be transplanted into Jesica, who had Type O blood.

The United Network for Organ Sharing, which operates a registry that matches donor organs as they become available to prioritized patients on the waiting list, said that when the organs became available in New England, Jésica did not appear on the "match run" -- a computer-generated list of potential recipients who were medically compatible with the donor (see UNOS statement).

Two other Duke University patients, however, did come up on the match run for the heart, and the New England Organ Bank called Carolina Donor Services to offer the organ to Duke.

When Carolina Donor Services contacted Dr. James Jaggers, the Duke surgeon for the first Type A patient, he told them his patient was not medically ready for transplant. But he told them he had a second patient, Jésica, who needed both the heart and a pair of lungs. Carolina Donor Services said it would call him back.

Carolina Donor Services then called another Duke surgeon, Dr. Duane Davis, who asked about the size of the heart and decided it was not right for his patient.

Both the computer's initial choices -- which had been screened for blood type and other details -- had been eliminated. Carolina Donor Services then transmitted the request for a heart and lungs for Jésica to New England Organ Bank (see Carolina Donor Services statement).

Why Jaggers would have requested the organs for a patient with a different blood type than his patient for whom the heart was offered, and why New England Organ Bank would have decided to give the organs to a patient not on the "match" run, remain a mystery.

Duke University Medical Center officials accepted responsibility for "a tragic error," but failed to fully explain how the system broke down in a letter sent Friday to UNOS (see Duke letter).

Jaggers released a statement saying: "I am ultimately responsible for the team and for this error," but did not explain how the error occurred (see Jagger's statement).

Officials at the New England Organ Bank said the donor's Type A blood was clearly presented along every step of the process.

"We have gone through our files, and the most important thing is that the donor's blood type was on there -- it accompanied the organs to [North] Carolina," said Sean Fitzpatrick. "The information had been sent down previous to the organs arriving."

Even though Jaggers immediately told the family after surgery that there had been a blood-type mix-up, Jésica's family and friends charged that Duke was slow in making the error public -- a delay some attributed to the hospital's concern over its reputation.

Duke Hospital officials indeed did not publicly acknowledge the error until more than a week later, and the family fumed that the delay may have cost precious days in locating organs for a second transplant.

But heart and lung transplants are, at best, rare for teenagers. In the last two years, there have been only eight in the United States for children between the ages of 11 and 17, according to UNOS records.

Duke Hospital now faces a variety of regulatory investligations. North Carolina state officials dispatched seven investigators to the hospital to determine whether the blood-typing error represented a larger problem that could jeopardize Medicaid and Medicare patients, and the agency that accredits North Carolina hospitals also is launching a probe.

Other Sources: Raleigh News Observer, UNOS