The First Heart Transplant

Dr. christiaan barnard will

(always be remembered as the heart surgeon who performed the first successful heart transplant using a human donor heart. He attended medical school at the University of Cape Town, South Africa, where he received training in general surgery. Then, in 1956, he received a two-year scholarship to study surgery at the University of Minnesota in Minneapolis.

"I actually went to Minneapolis to study general surgery," Barnard recalled. "I was working in a laboratory one day in general surgery when I walked past one of the labs where Dr. Vince Gott was working with a heart-lung machine. [Gott later became professor and cardiac surgeon-in-charge at Johns Hopkins University.] He looked up and said, 'Listen, I'm working and I need a pair of hands. Do you mind scrubbing and giving me some help?'

"It immediately fascinated me that we now had the ability to work inside the heart. I switched to cardiac surgery, and that's how I got involved in heart surgery. I trained under Dr. C. Walton Lillehei in Minneapolis, and I often went to Rochester, Minnesota, to watch Dr. John Kirklin work."

When his training was over, Barnard returned to South Africa, where he performed the world's first human-to-human heart transplant. In 1999, Barnard recalled that famous operation:

"When I was ready to take the heart out of the donor, who was brain dead, I disconnected the respirator and waited until the heart went into ventricular ^fibrillation (a fatal rhythm)

and see how we were going to monitor and treat rejection."

Indeed, cardiac surgeons were clearly successfully tackling the demands of heart transplantation. Only three days after Barnard's first transplant, the second human heart transplant using a human donor was performed on a child by Dr. Adrian Kantrowitz in Brooklyn, New York. Kantrowitz' patient died of a bleeding complication within the first twenty-four hours.

Washkansky, meanwhile, died on the eighteenth postoperative day. At autopsy, the heart appeared normal, but pneumonia was present, possibly because of the methods used to treat rejection.

Barnard performed his second heart transplant on Philip Blaiberg on January 2, 1968. Blaiberg was discharged from the hospital and became a celebrity for the several months he lived after the transplant. This highly visible success signaled that a heart transplantation was possible for humans suffering from endstage heart disease.

In the first year after Barnard's first heart transplant, about one hundred heart transplants were performed by cardiac surgeons around the world. However, by the end of 1968, most groups abandoned heart transplantation because of the extremely high mortality related to rejection. Despite the lack of interest, Shumway, Lauer, Barnard, and a few others persevered both clinically and in the laboratory. Their eventual discovery of better drugs for suppression of the immune system response established heart transplantation as we know it today.

before I opened the chest and took out the heart.

"The only moment that was an eerie moment was when I had taken the heart out of the recipient. That was the first time that I saw a human being without a heart but alive because he was kept alive by the heart-lung machine. That was the only moment of the operation I really, really remember.

"We did not consider the operation a big event. We realized we were doing a different operation, but we had done different operations before. We did not take a single photograph of the operation. In fact, I didn't even inform the hospital authorities that I was doing the operation that night.. I only told them afterwards, and we didn't have press or anybody around. It was only the next day that the media found out that we'd done the operation."

The celebrity surrounding that event changed his life and, in his own words, he found the publicity surrounding that event "disturbing for two reasons. It interfered quite significantly with my practice of surgery because there were always media around, and it also interfered with my family life."

After this famous transplant, however, Barnard was often on the leading edge of organ transplantation. Even before the heart transplant, he performed the first kidney transplantation in Africa and, later on, the third heart-lung transplantation in the world. He also performed the world's first heterotopic transplant (sometimes called the "piggy-back transplant"), an operation during which a donor heart is placed next to the patient's heart and the two work in parallel. This operation, which is still used today, was developed for circumstances when the donor heart was either questionable or too small.

Heterotopic Transplant:

A transplant of an organ or tissue, usually from one person to another, when the organ or tissue is not put in the location where it normally resides.

Dr. Bruce Reitz performed the world's first successful heart-lung transplant in 1981. His first patient, Mary Gohlke, was a long-term survivor.

Cyclosporins:

A drug used to help prevent organ rejection in patients who have transplants.

* The First Successful Heart-Lung Transplant

Dr. BRUCE REITZ GRADUATED ( from medical school in 1970 in an environment that had been electrified by the first heart transplant.

"After Dr. Christiaan Barnard did that procedure, that's the kind of thing I was reading about every day as a medical student, and it really stimulated me," Reitz said. By the mid-1970s, working with Dr. Norman Shumway, Reitz was involved in a heart-lung transplantation program at Stanford University.

"Shumway suggested that I look at transplanting heart and lungs together," Reitz said. "He had done some work years ago, with a little bit of success. So we added a few things that got some successful results in the laboratory."

Building on this early work, Reitz performed the world's first successful heart-lung transplant. He recalled:

"Well, it was really a unique highpoint of my career. First of all, it is a project that we had started in the lab about five years before. We had gone through some development phases and then through a phase when things started to click, and cyclosporine was an extremely ex

[Qj Heart and Lung Transplants

Almost fifteen years after the first heart transplant, a team of doctors headed by Dr. Bruce Reitz began a clinical trial to transplant both the heart and the lungs. Operating at Stanford University in 1981, the team's first patient was dis citing compound that was so promising. Then we had thought that it was ready for patients, and I had Shumway's complete support and encouragement. Then to actually do the operation — Shumway was assisting me — was a really terrific experience.

"When you take it all out like that (heart and lungs) and put it in, there are actually fewer connections. There's basically the blood coming into the heart and the blood going out that has to be hooked up, but the whole circulation to the lung and back to the heart remains attached, and you just connect the airway."

His first patient, and the world's first patient to have a successful heart-lung transplantation, was a woman named Mary Gohlke, who suffered from a lung disease that had damaged her heart. "We were fortunate because we had a good patient who needed it, and she got better and was a terrific spokesperson for transplantation," Reitz remembered.

Reitz' team also discovered that the risk of rejection remains the same for a complete heart-lung transplant as for a heart transplant.

charged from the hospital in good condition and was still healthy more than five years after the transplant.

This clinical success was partially due to the discovery of a potent antirejec-tion drug. Cyclosporine was discovered by workers at the Sandoz Laboratory in Basel, Switzerland, in

1970. Ten years later, it was Introduced at Stanford for cardiac transplantation. The incidence of rejection and infection was not reduced. However, these two major complications of heart and heart-lung transplantation were less severe with cyclosporine. The availability of cy-closporine stimulated the development of many transplant programs around the world in the mid-1980s.

Today, some patients who might have previously received a heart-lung transplant now undergo a single or double lung transplant, and the heart is repaired, if practical. Dr. Joel Cooper and his colleagues at the University of Toronto in the early 1980s led the way to human lung transplantation as we know it today.

Heart Transplants

Heart transplants are recommended for patients with advanced heart fail ure. Because donors are hard to locate, candidates for heart transplant have to meet certain standards. They should be psychologically stable. Their other organ systems, such as their kidneys, liver, and lungs, should be in good condition. It is possible, however, for some patients with severe lung disease and heart disease to undergo heart/lung transplantation. Candidates for heart transplantation cannot have long-standing insulin-dependent diabetes with organ damage. They are screened for most types of cancers because the drugs they will need to take after the transplant to help suppress rejection can actually cause certain cancers to grow rapidly. There are certain blood disorders that are also affected by these drugs. The drugs can suppress some blood elements and worsen these disorders. Patients generally are not considered qualified candidates if they have active infections because the immuno-

Heart Transplant Stitches

During heart transplantation, surgeons leave part of the native heart to sew onto the new, donor heart. The stitches show where the attachments are made during the operation.

Biopsy:

The process of removing tissue from a patient for examination.

suppression drugs make the body's immune system less effective in fighting infections and therefore can allow the infections to become worse.

Once it is determined that patients are candidates for a heart transplant, they are put on a waiting list for a donor heart that matches their blood and tissue type. When a match is found, the patient is admitted to the hospital.

The heart usually comes from a donor who has been in a traumatic accident and suffered fatal head injury and whose lung function was sustained by a ventilator. Frequently, the transplant team will have to go to another city or state, often traveling by private jet to retrieve the donor heart. The heart is removed from the donor. It is kept alive by using one of a number of techniques while it's brought back to the hospital where the transplant will take place. When the team bringing the donor heart is within a half hour of the hospital, the transplant patient is anesthetized and the chest is opened. When the team arrives with the heart, the patient is connected to the heart-lung machine. The diseased heart is then removed, and the new heart is sewn in (Fig. 11.1).

Portions of the transplant recipient's own left atrium with the four pulmonary veins and portions of the right atrium with the superior and inferior vena cava are not removed. The healthy donor heart is then sewn in. The left atrium and then the right atrium are connected to the remnants of the recipient's left and right atria. Next, the aorta and pulmonary arteries are connected. The clamp on the aorta is removed so the heart-lung machine, which had been supplying the body with oxygenated blood, can get blood to the recipient's new heart, and it will begin to beat.

After the chest is closed, the patient goes to the intensive care unit and usually spends at least a couple of days there followed by several more days in the hospital.

A number of powerful drugs are used to suppress organ rejection immediately after the surgery. When patients goes home, they will typically be taking cy-closporine, prednisone, and azathioprine or tacrolimus. These drugs have side effects that can be harmful, and they have to be monitored carefully. In a successful transplant, some of these can be eliminated after a few weeks.

In an attempt to diagnose rejection even before there is clinical evidence, the patient must undergo regular heart biopsy. This is done with a special catheter that is introduced through a vein in the neck to obtain a small biopsy specimen of the transplanted heart muscle.

Most rejection episodes can be treated successfully with medications, but sometimes when they are severe the patient's circulation needs to be supported with a mechanical heart assist pump or even a second heart transplant.

The chance of surviving heart transplant surgery and leaving the hospital is greater than 90 percent. The chance that the patient will be alive one year after the transplant is about 85 percent, and there is about a 4 percent mortality rate per year after that as the survival rates decrease owing to complications related to the rejection process. Nonetheless, some patients now are alive twenty years after a heart transplant. Some patients have had more than one heart transplant during that period. Many heart transplant patients return to work and live a relatively normal life after their surgery.

Research continues on using animals as donors for human hearts. At this point, the rejection process continues to be much more severe when an animal's tissues are transplanted into an animal of a different species, for example, a dog's organ transplanted into a cat. If the rejection problem can be solved through research, organ shortage would no longer be a problem because animals such as pigs could be bred for organ donation.

Heart Assist and Artificial Hearts

Beyond heart transplantation, physicians have a number of mechanical options to assist failing hearts. One particularly useful device is called the intra-aortic balloon pump, which is used temporarily to treat patients with failing hearts and more commonly to help wean some patients from the heart-lung machine.

Intra-Aortic Balloon Pump

The intra-aortic balloon pump consists of an external pump unit, a catheter slightly larger than a piece of spaghetti, and an inflatable balloon that's about the shape and size of a bratwurst (Fig. 11.2).

The catheter and the balloon pump are usually inserted into the femoral artery in the groin area and guided up into the aorta. The outside end of the catheter is attached to an external pump. The balloon is then synchronized to inflate and deflate with the cardiac cycle. This action pumps blood and helps the failing heart in a number of ways. For this machine to work appropriately, the heart has to do some of the work, but the device is capable of doing about 20 percent of the heart's work. In many cases, it can make the difference between life and death.

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