On March 18, 2020, the anguished parents of 6-month-old Nathaniel Capelo sat in his hospital room at The Mount Sinai Hospital facing the grim reality that he would die within days if he did not receive a new liver. One week earlier, the COVID-19 pandemic had begun to grip the nation and widespread lockdowns were taking place. But at 10:30 that night, the couple received a phone call from Mount Sinai’s transplant team that offered tiny Nathaniel a potential lifeline: the family of a shooting victim in his early 20s, who had just died in another state, were willing to donate his liver—epitomizing the “good news/bad news” world of organ transplants.

At the time, operating rooms throughout New York City were being converted into intensive care units to house severely ill patients with COVID-19 who were beginning to strain the city’s health care system, and many hospitals had started suspending their transplant procedures altogether. The hospital where the donor had died told Mount Sinai’s Recanati/Miller Transplantation Institute that its surgeon Chiara Rocha, MD, and her team would have to bring their own personal protective equipment to wear while extracting and retrieving the donated liver to bring back to New York. Charter airline companies were shutting down flights and Mount Sinai’s administrators worked their magic in securing a Learjet to fly Dr. Rocha and her team hundreds of miles to and from the donor hospital in the middle of the night.

“The stars lined up,” says Sander S. Florman, MD, Director of the Recanati/Miller Transplantation Institute. “This was as logistically complicated as anything we have ever done and in a child where everything was stacked against him.”

To this day, Nathaniel’s doctors do not know what caused his rapid liver failure. But now, the inquisitive 20-month-old toddler “is going to do great,” says Dr. Florman. Three-quarters of the liver he received was transplanted into an adult patient at Mount Sinai, who is also doing well.

Members of Mount Sinai’s Liver Transplant team include, from left: Antonios Arvelakis, MD, Associate Professor of Surgery; Marcelo E. Facciuto, MD; Sander S. Florman, MD; and Chiara Rocha, MD.

The liver is the only organ in the body that can regenerate and grow. “But what most people don’t know is that if the liver is too big for the body it can shrink down,” says Dr. Florman. This is significant because at the time of his transplant surgery Nathaniel weighed only 11 pounds, representing “the extreme technical complexity” of what was possible, he adds.

Most children requiring a transplant would receive 20 percent of an adult liver—a size much too large for Nathaniel. Before the transplant could take place, Marcelo E. Facciuto, MD, Professor of Surgery at the Icahn School of Medicine at Mount Sinai, had to cut the donor liver down to the “smallest anatomic segment” possible, says Dr. Florman. But even that was too big. Following the seven-hour surgery led by Dr. Florman, the team left Nathaniel’s abdomen open for four days in order to shrink the liver to a size that was able to fit inside his tiny body.

After conducting more than 4,500 transplants during its 32-year history, Mount Sinai’s program has encountered a challenging surgery like Nathaniel’s only a dozen or so times, says Dr. Florman. “You’re talking about sewing an artery that’s just a couple of millimeters with sutures that are as fine as your hair. You are connecting the artery, the veins, and the bile duct, and it is all done with what we call a loop—glasses with a built-in microscope lens because it’s too small to complete with just your eyes.”

He adds, “Transplant is the epitome of a team sport and you can’t do this without having a tremendous team or without an institution that has unbelievable depth. Only a small number of transplant centers in the country would have been willing to take on a child this small. Even in the best of times this would have been a great triumph and a great case. This was even more so considering the time in which it happened.”

In fact, March 2020 marked the busiest month ever for Mount Sinai’s liver transplant program, which conducted 23 transplants, some of which were referrals from other programs that had just shut their doors.

Today, at 20-months of age, Nathaniel is on track to hit all of his milestones. He is walking on his own, beginning to talk, and able to eat tiny pieces of solid food.

Nathaniel recently celebrated the one-year anniversary of his life-saving surgery, and his prognosis is good. Each month that goes by lowers the chances that his body will reject his transplanted liver. He has been weaned off of all but one of his 13 medications.

“Dr. Florman and his team were just amazing,” says Nathaniel’s father, Dennis Capelo. He and Nathaniel’s mother, Alexandra Ramos, remained at the hospital with their child during the five-month ordeal. Nothing could have prepared them for “the scariest time we ever had to deal with,” says Mr. Capelo, who has a 3-year-old son and 10-year-old daughter from a prior relationship.

He says, “We try to cherish every moment we have. We spend as much time as possible with all of the kids and each other and hope for the best.” He and Ms. Ramos have remained close to Nathaniel’s former Mount Sinai nurses and send them photos and videos to mark their toddler’s milestones, including his first steps. “They became like family to us,” Mr. Capelo says.

One of Nathaniel’s physicians, Ronen Arnon, MD, Professor of Pediatrics, Hepatology, and Liver Transplantation at the Icahn School of Medicine at Mount Sinai, remembers how “Nathaniel struggled to survive. The first months of his life were spent in a hospital bed rather than at home, and his first friends were his doctors and nurses. He suffered from eating and breathing difficulties and he could barely move due to his swollen abdomen.”

Another of his physicians was John Bucuvalas, MD, Chief of Pediatric Hepatology, Professor of Pediatrics, and Director of Solid Organ Transplant Outreach, Jack and Lucy Clark Department of Pediatrics, and Mount Sinai Kravis Children’s Hospital. “Today, Nathaniel is an active toddler and exploring his world. He won’t remember the transplant,” Dr. Bucuvalas says. “But for his parents, the Intensive Care Unit, P5 (Pediatric floor 5) teams, and the liver team, the series of events are etched in our memory and remind us of why we do what we do.”