The Heart Healers (25 page)

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THE IDEA OF
surgically replacing a diseased heart had percolated in the musings of surgeons since the early 1900s when Nobel Laureate surgeon Alexis Carrel took the first step in demonstrating technical feasibility when he transplanted the heart and lungs of a small cat into the neck of a larger cat. Carrel reported that “The lungs became red and after a few minutes effective pulsation of the ventricles appeared,” and although it must have been a grisly scene, the recipient cat survived for two days. After World War II, eccentric Russian surgeon Vladimir Demikhov set the stage for future research when he succeeded in replacing one dog’s heart with another. His dog actually climbed the Kremlin steps on the sixth postoperative day, but soon thereafter died of cardiac rejection.

The development of modern cardiac transplantation, however, is the story of two men, a Tortoise and a Hare. Whereas most scientific developments follow the path of investigators building on the work of those who preceded them, the foundation for human cardiac transplantation was largely the work of one man, the Tortoise, Dr. Norman Shumway of Stanford University, who for more than two decades devoted his life to solving this tremendous challenge. In the 1950s Shumway, with his associate Dr. Richard Lower, initiated his program. Shumway had been inspired to pursue cardiac surgery research as a trainee of the great Walt Lillehei, whom we met during his tumultuous years in Minnesota. Shumway later said that Lillehei changed the course of his life.

Shumway was the most relaxed, irreverent, witty surgeon I have known. His humor turned on himself as often as it did on others. His endearing personality made him my favorite person among all the cardiac surgeons, and my feelings were shared by his colleagues, trainees, and patients. My favorite irreverent Shumway quip came at a get-together honoring his mentor Lillehei many years after Walt’s bout with the Internal Revenue Service and his subsequent resurrection. Lillehei, Shumway said, reminded him of Al Capone. “He killed a lot of people but the government could only get him on taxes.” Those training years at Minnesota set Shumway’s life’s course. “The atmosphere at Minnesota was unbelievable, it was electric,” he told his biographer David K.C. Cooper. “We used to say you had to invent an operation to get on the operating room schedule.”

As he set out on the long journey to human cardiac transplantation, Shumway faced three unknowns. The first was basic: would a heart, highly sensitive to both nervous and hormonal stimuli, be able to function normally after it had been separated from all its surrounding supportive tissue? Over a period of several years, he proved the long-term feasibility of the surgical procedure by auto-transplant, i.e., removing a heart from a dog and then transplanting it back in the same animal. Shumway’s dogs survived without a problem for several years.

Shumway’s answer led to a new question. How do you attach the donor heart to the recipient? The logical technical approach would seem to cut out the entire heart including a stump of the aorta and the major veins. This approach, however, performed in an era long before modern techniques of bleeding control were available, resulted in blood spurting from the aortic anastomosis (the site where two vessels are joined together by a surgeon). On each heartbeat, cells ejected into the aorta ripped at his suture line like an Oklahoma tornado, relented, then attacked again on the next beat. He needed to find a way to make his anastomosis under low pressure. Shumway finally found an ingenious solution. He cut out the donor heart leaving a cuff of right and left atrium behind. He did the same with the recipient heart. He then sutured the atria of the donor and recipient together. Because the pressure within the atria is only a tenth of the pressure in the aorta, he was able to create a stronger, leak-free anastomosis. Shumway had mastered the technical details of heart transplantation, but his dogs still died after a few weeks. He had arrived at transplantation’s greatest barrier, tissue rejection.

Rejection of transplanted tissue occurs when a recipient’s immune defense attacks the transplanted organ. It is the same process the body uses against foreign invaders like germs and poisons. The body’s immune system is activated when it recognizes proteins in the transplanted tissue called antigens. No two people, except identical twins, have identical tissue antigens. The more different antigens between donor and recipient, the more violent the rejection response.

Shumway soon discovered that suppression of the immune system using the few drugs then available to him created vulnerability to devastating infection. So he devised electrocardiographic methods for identifying the onset of rejection, and saved his powerful pharmaceutical guns for these episodes. Even so, immune suppression was desperately inadequate. Shumway had consumed a decade conducting research in the animal laboratory defining the best strategies for transplantation technique and for immune suppression. His was a lonely pursuit, since no one else seemed crazy enough to invest their entire career with the real possibility of eventual failure. He could perhaps take some consolation that if nothing else, he was the world’s acknowledged leader in cardiac transplantation research. By 1967 Norman Shumway announced that he was prepared to culminate his life’s work by attempting the world’s first human cardiac transplant. But now, with his moment of final achievement so palpably near, Shumway encountered a problem he could not solve.

In his animal research, Shumway had removed a beating heart from a donor dog, and immediately plunged it into an iced solution to preserve it until the moment of transplantation. But he could not use this method in humans. In the United States death was defined as absence of a heartbeat and respiration. Although physicians now recognized the irreversibility of brain death, it was not part of the legal definition of death. Hospital administrators were unwilling to allow him to remove a beating heart, even from an obviously brain-dead patient. Shumway was skewered on a catch-22. Shumway could hardly gather a group of surgeons at patient’s bedside watching for the last spike on a dying patient’s ECG, then plunge in to remove the heart.

On Sunday morning December 3, 1967, Norman Shumway and the world awoke to the stunning news that Dr. Christiaan Barnard, a cardiac surgeon in Cape Town, South Africa’s Groote Schuur Hospital, had performed the world’s first cardiac transplantation. As I sat flabbergasted over morning coffee at the death of Norman Shumway’s lifelong dream to be the first to successfully perform a human cardiac transplant, my thoughts flashed to the excruciating juxtaposition of victory with the agony of defeat, expressed by Walt Whitman’s poem on the death of Abraham Lincoln: “O Captain! my Captain! our fearful trip is done; / The ship has weather’d every rack, the prize we sought is won;” … “But O heart! heart! heart! / O the bleeding drops of red, / Where on the deck my Captain lies, / Fallen cold and dead.” Norman Shumway had weathered every storm during ten long years of research, and had victory snatched from him at the last moment. He had seen the triumph of cardiac transplantation, but someone else would receive the world’s accolades for what was the culmination of his life’s work.

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WHO WAS CHRISTIAAN
Barnard? Not one of us knew. Intrigued, I did a quick search of the published literature that revealed he had one publication dealing with a different topic in cardiac surgery and one publication on experimental renal transplantation. He was a complete academic unknown. Some cardiac surgeons knew him because he had served as chief resident on Walt Lillehei’s service at the University of Minnesota soon after Shumway left for Stanford. At the end of his training the chief of surgery Owen Wangensteen thought enough of Barnard’s skills to offer him a position on the surgical staff, but he chose to return to Cape Town to establish his own open heart surgery program. Wangensteen had used his connections within the U.S. government to get a heart-lung machine for Barnard. As part of his desire to remain current with the latest trends in cardiac surgery, Barnard had returned frequently to the United States and to England for medical meetings. He had visited surgeon Donald Ross during his last stop in London before his landmark surgery. Ross told a historian, “He had just seen some experimental work (in the United States) involving heart transplantation and said ‘Christ, Donny, I’m going to do that!’ I thought nothing more of it until, soon after, his historic operation was announced on the radio … I know he got the idea there during that visit … I’m not taking sides on this issue … but he had just seen Shumway or Lower’s group transplanting hearts in animals, and he came back determined to do it himself.”

Back home in Cape Town, Barnard had mixed reviews. His surgical outcomes in the new Cape Town program were quite good, so he had earned the respect of his fellow South African physicians, although his detractors carped that he had only average technical skills for a surgeon. He was the opposite of the relaxed, self-effacing Shumway. Barnard was legendary for his frequent angry operating room outbursts in which he blamed others for his surgical difficulties. Years later, fair or not, I flashed on Christiaan Barnard when a cardiac surgeon in a movie exploded: “I have an M.D. from Harvard, I am board certified in cardiothoracic medicine … So I ask you; when someone goes into that chapel and they fall on their knees and they pray to God that their wife doesn’t miscarry or that their daughter doesn’t bleed to death … who do you think they’re praying to?… You ask me if I have a God complex. Let me tell you something: I am God.”

When he returned to Africa to focus on being the first to transplant a human heart, Barnard prepared himself by practicing the procedure in the animal lab. When he was satisfied, he then performed a human kidney transplant, the only one of his career. When the kidney transplant patient survived, Barnard deemed himself ready to transplant a human heart. Why not? He was familiar with heart surgery and now he knew transplantation. His recipient would be Louis Washkansky, a fifty-seven-year-old diabetic who had sustained several prior heart attacks. Washkansky was undoubtedly a legitimate candidate. His heart failure was so severe and unmanageable that he could not leave the hospital. With a patient at the ready, Barnard attacked the barrier that had stopped Shumway: the definition of death.

South African law held that a patient was dead when declared so by a physician. Barnard consulted a medical ethicist, who informed Barnard that he was quite happy with brain death as a criterion. Barnard then wisely stipulated that to avoid subsequently political turmoil in the racially charged milieu of South African apartheid, both the donor and the recipient should be white. He turned down a suitable heart from a dead young male black donor. Two weeks later a woman in her mid-twenties who had sustained a devastating head injury in an automobile accident was brought to Groote Schuur Hospital. Shortly after arrival Denise Darvall was declared brain-dead. She had the same blood type as Louis Washkansky. Barnard would wait no longer.

Barnard placed Darvall in one operating room, with Washkansky in an adjacent one. Barnard wrote afterwards that as he entered the operating suites he thought, “I am not terribly religious, but I must pray today … I couldn’t say ‘Let me be a brilliant surgeon’ because I’m not a brilliant surgeon. Please help me to do this operation as well as I’m capable of doing it.’ I decided I would not take out Denise’s heart while it was still beating. I was scared I would be criticized … I disconnected the respirator myself. She didn’t breathe. After five or six minutes her heart went into ventricular fibrillation [in ventricular fibrillation the heart does move, but we define it as the absence of heartbeat]. I then said to my colleagues to open the chest and remove her heart.” Although Barnard gave this version of events many times, his brother Marius, a surgeon present at the operation, recalled this episode quite differently. Marius insisted that the heart was removed while still beating. I have wondered which version is correct, and I have wondered if Barnard’s anxiety about public reaction to him removing a beating heart explains this difference in their recollections. On the other hand we transport nonbeating hearts packed in ice, and restart them after transplantation, so either account is credible.

Although Barnard had practiced the technique of cardiac transplantation in his animal laboratory, his two assistants had never seen a transplant performed. The removal of Washkansky’s heart followed by the attachment of Denise Darvall’s to the remaining stump of recipient heart, using Shumway’s technique, consumed nine hours. When they were ready to come off the heart-lung machine, however, the donor heart would not start. “I was horrified,” Barnard recounted. He tried again. The heart was not doing well. “But on the third attempt, the blood pressure kept rising.” They had successfully completed the world’s first human heart transplant.

Barnard had told no one, neither the hospital supervisor nor the head of surgery, that he was about to perform the transplant. So there were no photographers memorializing the procedure, and when he emerged exhausted from the hospital, there were no reporters waiting. “I left the hospital at about 6 o’clock in the morning … sat down for breakfast, and “it was only an hour later when phone calls came in from all over the world … I don’t know how they got the information,” Barnard wrote. “On Saturday, I was a surgeon in South Africa, very little known. On Monday, I was world renowned.” I was so shocked that I still recall precisely what I was doing when I heard the news that Sunday morning.

Louis Washkansky recovered well after surgery. But late in the second postoperative week he developed pneumonia. Barnard and his team thought they were dealing with rejection. Their aggressive immunotherapy may have led to an accelerated spread of the pneumonia throughout his lungs. Washkansky died on the eighteenth postoperative day.

Barnard followed his initial technical success in cardiac transplantation with a second transplant twelve days after Washkansky’s death. Philip Blaiberg, a fifty-eight-year-old white Cape Town dentist, received the heart of twenty-four-year-old Clive Haupt, a black man who had died suddenly the preceding day on a Cape Town beach. The cross-racial transplant precipitated an almost comical debate. Author Marius Malan’s contemporary recounting of the debate includes this different-era insight from a white politician: “The relief of suffering knows no color bar … The heart is merely a blood-pumping machine and whether it comes from a white, black or colored man—or a baboon or giraffe, for that matter—has no relevance to the issue of race relations in the political or ideological context.”