Transplant surgeon's brush with death spurs pig organ revolution

Dr Robert Montgomery collapsed face-first into snow near the bottom of South America in 2010, his heart racing wildly as he fell behind his son and their guide on a hike through Patagonia. A device implanted in his chest delivered an electric shock that brought him back. He was 50 years old, and he already knew what the collapse meant: his heart was dying, and the odds of getting a replacement were brutally thin.

Montgomery knew those odds intimately because he was a transplant surgeon himself, leading one of America's premier organ transplant centres at Johns Hopkins Medicine. He understood the mathematics of scarcity. In Ireland alone, roughly 660 people were waiting for an organ transplant, with only six waiting specifically for a heart. The shortage was not a problem that would solve itself, and it was about to become his problem in the most personal way.

His path to this moment had been shaped by loss. When Montgomery was 14, his father developed dilated cardiomyopathy, a rare disease that causes the heart's chambers to stretch and enlarge until the organ fails. His father became increasingly debilitated, eventually requiring a feeding tube after suffering brain damage from cardiac arrest. By the time his father died in 1976, Montgomery had decided to become a doctor. Eleven years later, while Montgomery was beginning his surgical residency at Johns Hopkins, he received the worst phone call of his life: his brother Rich, 35 years old and a father of two, had died that morning. Pathologists found that Rich also had dilated cardiomyopathy, likely caused by a genetic mutation. When Montgomery was evaluated, he learned he carried the same condition.

He pushed through his residency, eventually specializing in transplant surgery. The work became urgent. Montgomery did not expect to live a normal lifespan—he knew he would need a heart transplant or he would die—so he was hyperfocused, racing against his own failing body. He developed minimally invasive techniques for retrieving kidneys from living donors, work that increased donation rates dramatically. In 2001, he pioneered kidney-swap programmes, arranging domino donations where an altruistic donor gave a kidney to a stranger, whose incompatible donor then gave a kidney to a second recipient, and so on. His colleagues called him a cowboy.

But the cardiac arrests kept coming. In 2017, hiking again in Patagonia, Montgomery collapsed a second time. His son John performed chest compressions in a Jeep racing toward a hospital nearly an hour away. When Montgomery emerged from a medically induced coma in New York more than a month later, he had to relearn how to walk, talk, and eat. A few months later, his heart stopped during a Broadway performance of School of Rock; he received CPR in the aisle. At a medical conference in Italy in September 2018, he experienced four cardiac arrests in succession. The grim irony was clear: he was finally sick enough to join the waiting list for a heart.

Just before dawn on September 20th, 2018, he received a call. A heart was available. The donor had died of a heroin overdose and was infected with hepatitis C. The hospital's heart transplant programme was brand-new—Montgomery had started it less than a year earlier—and accepting a hepatitis C-positive organ meant joining a clinical trial. Many of his colleagues thought he was reckless. But Montgomery had encouraged his own patients to consider such organs, knowing hepatitis C could be cured with medication. After a six-hour surgery, he had a new heart. Two days later, he was reviewing cases from his hospital bed.

The transplant saved his life, but it also clarified something urgent in his mind. All the work he had done to increase the supply of human organs—the techniques, the programmes, the domino donations—would never be enough. The shortage was structural, permanent, unsolvable through incremental innovation. He needed to think radically. Experiments had already shown that organs from genetically modified pigs could function in monkeys. Montgomery decided to attempt something that had never been tried: transplanting a pig organ into a human patient who was brain-dead.

In 2021, Montgomery announced the first transplant of a kidney from a genetically modified pig into a living human. Scientists at United Therapeutics had knocked out a gene involved in aggressive organ rejection. The kidney not only survived—it functioned, producing urine and excreting waste for 54 hours, the limit set by the hospital ethics panel. Over the following years, Montgomery's team and others transplanted pig kidneys and hearts into a small number of terminally ill patients who had exhausted all other options. The patients died from their underlying conditions within months, but none experienced the devastating immune rejection that typically destroys transplanted organs. The proof was clear: pig organs could work in human bodies. Last year, the Food and Drug Administration approved expanded clinical trials of pig organ transplants in very ill patients with no other options. Montgomery is leading two of them. Since his own surgery, he has gone salmon fishing in Alaska with his son John and travelled to Africa with his wife, opera singer Denyce Graves, to celebrate her retirement.