Change of Heart

Groundbreaking surgeon Robert Montgomery has dedicated his career to making organ transplants more broadly available to those who desperately need them. Then it was his turn to be saved by a breakthrough in transplant surgery.

Photo by Brad Trent

Published in Hopkins Medicine - Spring/Summer 2021

The School of Rock cast had barely finished the opening number when Robert Montgomery collapsed in the audience. A cardiac defibrillator implanted in his chest, meant to revive him with a lifesaving jolt of electricity, had failed to do its job. His heart — and the Broadway theater — had gone silent.

His wife and children watched helplessly as an off-duty nurse swooped in to administer CPR, breaking multiple ribs as she performed chest compressions. He’s unsure how many minutes he managed to survive without a pulse, but when he regained consciousness, first responders were preparing to hoist him onto a stretcher. As they lifted him up, alive once again, the audience erupted into a standing ovation.

A groundbreaking surgeon, Montgomery transplanted more than 1,000 kidneys at Johns Hopkins Hospital between 1996 and 2016. He knew the tables could turn someday, and he would be the one in need of a new organ. He had lived for 57 years with an inherited form of dilated cardiomyopathy, a progressive disease that weakens the heart muscle and causes deadly arrhythmias. He had already outlived his father and older brother, who died of the same condition at the ages of 52 and 35, respectively. Despite his family history and the near-death experience on Broadway in 2017, his doctors told him he was still “not sick enough” to receive a transplant due to the limited supply of hearts available.

On average, 17 people die every day while awaiting a transplant. And the odds weren’t in Montgomery’s favor: More than 107,000 Americans were on the national organ transplant waitlist as of February 2021, but fewer than 39,000 patients received an organ last year.

As the former chief of transplant surgery and director of the Comprehensive Transplant Center at Johns Hopkins, Montgomery knew all too well that patients can wait months or even years for an organ from a compatible donor, if they receive one at all. In fact, he has dedicated more than two decades of his life to solving that very problem.

The Place Everybody Wanted to Be

Robert Montgomery was in his early teens when his father’s heart began to fail. It was the mid-1970s, and at age 50 he was too old to qualify for a transplant. Looking back, Montgomery believes the pain he felt while watching his father die in the hospital over a two-year period is what sparked his career in transplant surgery.

He studied medicine at the University of Rochester and joined Johns Hopkins as a categorical intern in the Department of Surgery in 1987. There were only four categorical spots that year, and he was one of the first students to be chosen from outside Johns Hopkins’ medical school in quite some time.

“I felt both special and also like a bit of an outsider when I first arrived,” he says. Above all, he was humbled to be at Johns Hopkins. “It was unparalleled. We had an amazing department of surgery. The cardiac surgeons were the best in the country, and each of the division chiefs were the world leaders in their field. It was the place everybody wanted to be.”

The idea of excellence appealed to Montgomery. As he progressed through his residency and got to know the attending surgeons, he felt confident that Hopkins was a place where he could make his mark in medicine. “If I work hard here,” he thought, “it will pay off.”

But less than a year into his training, he received news that threatened to end his career before it began: His 35-year-old brother had dropped dead while waterskiing. Subsequent tests confirmed that the heart condition responsible for his father’s death was genetic, and Montgomery had it too.

In the high-stress environment of an operating room, the risk of going into cardiac arrest in the midst of surgery was impossible to ignore. His doctors urged him to have a newly developed device called an implantable cardioverter-defibrillator (ICD) surgically placed in his abdomen and chest to shock his heart back into rhythm.

Levi Watkins Jr. — a notable Johns Hopkins cardiac surgeon, who implanted the first automatic defibrillator in a human heart in 1980 — performed the surgery on Montgomery in 1989. Montgomery was the first surgeon in the world to receive an ICD, and no one knew how it might interact with the sensitive electronics in the operating room, or whether it would be safe for a recipient to perform surgery. Doctors told him his surgical career was over and to look for a job outside of medicine.

Fortunately, he was never good at taking no for an answer. To illustrate that fact, he likes to retell the story of his second-grade Catholic school teacher, who wrote on his report card: “Bobby doesn’t think the rules apply to him.” The nuns may have disliked his nonconformist attitude, but as far as he’s concerned, it’s what makes him good at his job.

When it became clear that Montgomery had no intention of giving up surgery, Watkins and department chair John Cameron stood behind the 29-year-old resident. “The fact that they believed in me and wanted to do everything they could to make it possible for me to stay there was amazing,” he remembers. “I knew that there were a hundred people who would have loved to have my training spot.”

Creating a Transplant Revolution

Over the next 10 years, Montgomery focused on mastering his craft. He earned a Ph.D. in molecular immunology at the University of Oxford, returned to Johns Hopkins to complete his residency, worked as a postdoctoral researcher under renowned Hopkins geneticist Harry (“Hal”) Dietz, and finished a two-year multi­organ transplantation fellowship at Johns Hopkins’ Comprehensive Transplant Center. With his formal education and medical training complete, Montgomery joined the clinical staff as an assistant professor of surgery in 1999.

In September of that year, 45-year-old Joyce Roush became the second living person to donate a kidney to a stranger. The operation was performed in Montgomery’s unit at Hopkins and saved the life of Christopher Bieniek, a 13-year-old boy from Harford County, Maryland.

Roush, a mother of five from Indiana, said she made the decision to donate after learning about the laparoscopic nephrectomy — a minimally invasive procedure developed at Johns Hopkins in 1995 by surgeon Lloyd Ratner and urologist Louis Kavoussi (Montgomery, a transplant fellow at the time, also played a role in this historic innovation). By using multiple small incisions to remove the donor kidney, rather than one large cut, the new procedure made it possible for patients to leave the hospital after only three days. Today, it is the standard method for kidney removal throughout the world.

When Roush was interviewed a few days before her surgery, she told reporters that she hoped her donation would inspire more altruistic donors to come forward. “She was trying to create a revolution. It was all over the news,” remembers Montgomery. “Next thing, we had 50 people call to say they wanted to give a kidney too.”

This overnight surge in available kidneys made it possible for Montgomery to pioneer one of his greatest achievements: domino kidney transplants.

At the time, Johns Hopkins surgeons were already using a “paired-exchange” method, in which a willing donor and recipient — say a husband and wife — with incompatible blood or tissue types were matched with another couple in a similar predicament. By exchanging compatible kidneys between the pairs, it was possible to give two people successful transplants.

The domino method takes this idea one step further. Because an altruistic donor isn’t seeking a kidney for their loved one in return, they can give to a stranger in a mismatched pair, and the willing donor in that pair can offer their kidney to another eligible recipient, passing the gift forward indefinitely. This method also allows patients to receive organs that are better matched to their medical needs, thereby improving clinical outcomes.

In 1994, prior to the development of the laparoscopic nephrectomy and domino kidney transplants, only 3,000 living donors gave a kidney, according to data from the Department of Health and Human Services. By 2001, that number had more than doubled. These innovations also helped to boost the total number of U.S. kidney transplants from about 11,000 per year in the mid-90s to nearly 23,000 in 2020. Today, the National Kidney Registry uses the domino method to orchestrate more than 1,000 live donor transplants annually.

“When you make a major innovation, the impact is so much greater than what you can do with your own two hands in your lifetime,” says Montgomery, who oversaw the first 10-way open chain domino transplant in 2010 and earned a spot in the Guinness Book of World Records for transplanting the most kidneys in a single day. “I couldn’t have done any of this stuff on my own. It was an amazing moment in time, and Hopkins was an amazing place to be able to do it.”

The ‘Miracle Shop’

While solving the puzzle of donor matching, Montgomery’s team was also tackling kidney compatibility from an immunological angle. About one-third of patients seeking a kidney are considered “sensitized,” which means they have antibodies that make it difficult to find an organ that their body won’t reject. To solve the problem, the team invented a desensitization protocol that removes the unwanted antibodies from a patient’s blood before the transplant via plasmapheresis, a process that filters and replaces a person’s plasma supply.

“There are very few people in our field that are considered to be true geniuses, and Bob is one of them,” says Johns Hopkins transplant surgeon Dorry Segev, who worked under Montgomery from 2004 to 2016 and helped him transplant hundreds of kidneys in the operating room. “He can see what’s novel and what could really impact the patients we take care of.”

As the news of Montgomery’s work spread, desperate patients from all over the world poured into his Incompatible Kidney Transplant Program for treatment. People who had been turned away from countless hospitals due to rare diseases and immunological disorders posed an exciting challenge to Montgomery and his team. Segev says their mission to give a kidney to every possible patient had turned the transplant department into a “miracle shop.”

“It was wild. During those years, our transplant ward was like a laboratory,” remembers Montgomery. “We were seeing the firsts in all kinds of things. Every day, I would go into the operating room and do something I had never done before — that no one had done before. We were constantly innovating. It was just an amazing time.”

Despite his professional successes, Montgomery’s colleagues say he remained approachable, good-humored and down-to-earth. “You never felt like he was in a rush or too important for you,” remembers Segev. “He would sit at a patient’s bedside for an hour and talk to them about their family and make them feel better. He would just sit and laugh with them, even if it meant staying late because he had 23 more patients to round on.”

A Time of Reckoning

While Montgomery was focused on treating his patients, he had nearly forgotten about his ever-weakening heart. One night, after a long day performing a kidney swap and answering reporters’ questions at a press conference, he found himself wandering around the hospital parking garage for an hour, unable to remember where he had parked his car. He hadn’t been sleeping well and felt a strange, jittery feeling inside. After talking to his cardiologist, he learned the medication he was taking to keep his arrythmias at bay was causing his thyroid to go into overdrive, wreaking havoc on his body. The only solution was an operation to have the gland removed.

“That was a moment of reckoning in terms of my disease. I was in this phase of productivity, but at the same time, this disease was catching up,” he says.

Over the years, Montgomery had trained himself to stay calm under stress to avoid triggering his defibrillator — an experience he likens to a bowling ball being hurled into his chest. He knew he could never allow it to go off in the operating room, so dialing down his adrenaline became a top priority. The calm and even-keeled demeanor he cultivated at work gave his patients and colleagues no indication of the severity of the illness looming over him.

“I knew Bob had a family history, and I knew that he had a defibrillator device, but I was not aware of any kind of timeline or that he would necessarily need a heart transplant,” recalls Hopkins transplant surgeon Niraj Desai, who worked under Montgomery from 2009 to 2016 as surgical director of the kidney and pancreas transplant program.

Desai was also unaware of how his own research would come to directly affect the life of his supervisor.

Like Montgomery, Desai was constantly exploring new solutions for connecting patients with lifesaving organs. In 2013, he pitched an idea that involved transplanting kidneys infected with hepatitis C into patients without the virus — thereby giving them the infection — and then curing them using novel antiviral drugs.

“We were discarding almost a thousand organs a year in the U.S. that were perfectly transplantable, other than the fact they had Hep C,” says Desai. The virus is the most common chronic bloodborne infection in the country, and about 1 percent of the adult population lives with the illness, which causes dangerous inflammation of the liver. The opioid epidemic and associated overdose deaths have increased the availability of organs with Hep C, as sharing needles can spread the virus.

Montgomery liked the idea, but he thought it was too risky to use the antiviral drugs that were available at that time. He kept an eye on the drugs’ evolution over the next two years and, finding no cause for concern, gave Desai his blessing to pursue a clinical trial.

Working together with Associate Professor of Medicine Christine Durand, who specializes in infectious diseases, Desai recruited 10 Hep C-negative trial participants and successfully transplanted them with Hep C-positive kidneys — making Hopkins the second hospital in the country to undertake the procedure. Using the protocol developed by Desai and Durand, the antiviral medication was shown to be 100 percent effective at wiping out the infection. Today, Desai estimates that over 1,000 transplant recipients are benefiting from Hep C-positive organs that would have been discarded just five years ago.

A Transplant, at Last

After more than 25 years at Johns Hopkins, Montgomery left in 2016 to become the director of New York University’s Langone Transplant Institute. The university tapped him to pioneer the same type of innovative protocols that had put Johns Hopkins’ Transplant Center on the map. However, about a year after stepping into the new role, his heart stopped cooperating.

His first near-death experience happened while traveling in a remote part of Patagonia. Before leaving New York, he had unknowingly picked up a superbug that appeared while abroad as a case of bacterial pneumonia, sepsis and ultimately cardiogenic shock — a life-threatening condition wherein the heart fails to pump enough blood. He spent nearly three weeks in a coma in a tiny hospital in Argentina before stabilizing enough to be medically evacuated back to the United States. It took him three months to recover and return to work, but his heart was never the same.

The next scare occurred on that October night in 2017 while watching School of Rock on Broadway. And the next came the following summer in Matera, Italy, where he was attending a medical conference. He went into cardiac arrest and collapsed onto the stone floor of his hotel room, splitting his forehead open. His wife, celebrated opera singer and Peabody Conservatory faculty artist Denyce Graves, rushed to his aid and called for an ambulance. Sixty seconds later, she breathed a sigh of relief as his defibrillator revived him. But his heart stopped yet again as they waited for the ambulance to arrive, and twice more in the local hospital, where a Catholic priest wasted no time giving him the last rites.

After being shocked back to life four times in a single night, there was no more disputing it. Robert Montgomery was finally sick enough to join the heart transplant waiting list.

He signed out of the hospital against medical advice and boarded a commercial flight back to New York. He already knew that his blood type and 6-foot, 1-inch height would make him a tough match for a compatible heart, and his doctors warned that he could spend a year waiting in the hospital for the right donor to come along.

“I said, ‘Look, I would certainly take a heart from somebody who died with a needle in their arm and had hepatitis C,’” he recalls. His surgeon phoned two weeks later and said it was as if Montgomery had incarnated his donor. Less than three weeks after sidestepping death in Italy, he received the heart of a 25-year-old man with Hep C, who had died of a heroin overdose. And, by following the protocol developed by Desai and his team, Montgomery walked out of the hospital completely virus-free.

“I was very amazed to see all that unfold the way it did,” says Desai. “Professionally, it feels great to see anyone benefitting from that protocol. But personally, to see someone that I’m close to, like Bob, benefiting, is just an amazing feeling — just knowing this work had an impact on someone who was not only my boss, but my close friend, who I respect and admire.”

Still Trailblazing

Today, Montgomery is back at work serving as chair of surgery and Transplant Institute director at NYU, and he no longer needs to worry about his defibrillator going off in the operating room. Thanks to his new heart, he’s even been able to go jogging for the first time since 1988. And, despite all the physical challenges he’s endured over the last five years, he still looks like the same vibrant surgeon that became the face of Johns Hopkins’ kidney transplant program — with one notable exception. Hospital masking requirements brought on by COVID-19 forced him to shave the flowing horseshoe mustache that has been his defining feature since the 1990s.

Living in New York hasn’t stopped Montgomery from doing trailblazing research with his former team at Johns Hopkins. He’s currently participating in a novel clinical trial, led by Segev, on how transplant recipients are responding to the COVID-19 vaccine. (The findings indicate a sluggish immune response, likely due to the immunosuppressant drugs that transplant recipients are required to take.) The two surgeons are also researching ways to improve the immunologic matching process in order to make transplanted organs last longer — it’s not uncommon for recipients to need a second transplant decades later — and to minimize the amount of medication patients need to take long term.

Montgomery hopes the work he and fellow researchers are doing will ensure that future generations have an easier medical journey than he has had. His daughter, oldest son and two nieces inherited cardiomyopathy as well, and they already have defibrillators implanted. If nothing else, he tries to live by example, so others know they can live a normal — if not extraordinary — life, regardless of what their diagnosis may be.

“Living from one heartbeat to the next, I knew I had to get it right and nail my life,” says Montgomery, “and in that regard my disease was a blessing.”

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