Why was the First Heart Transplant a Failure

Christiaan Barnard

When Christiaan Barnard performed the first heart transplant in 1967, it was initially seen as remarkable scientific achievement, but overtime both the medical community and the general public were forced to re-evaluate heart transplants. The medical community quickly realized that the first transplants were little more than dangerous and unpredictable experiments. These operations were almost uniformly unsuccessful. They failed because the surgical procedure was extremely complex, the patients were prone to develop life threatening infections and organ rejection was incredibly common. Ultimately, heart transplants raised deep medical, ethical and even religious concerns that the medical community was forced to address.

Technological Innovation and the Oxygenator Pump

In the early 1950s, doctors in the United States and the Soviet Union began experimenting with heart transplants in animals. These surgeries were uniformly unsuccessful. Physicians were forced to induce hypothermia in their test subjects to prevent permanent brain damage, but many of these subjects died because it took too long to connect the heart to the cardiovascular system. The few subjects that survived typically only lived a few hours.

The creation of the oxygenator pump (the heart lung machine) in 1953 by John H. Gibson finally gave surgeons enough time to complete the transplant without killing their patient. The oxygenator pump temporarily bypasses the heart and lungs by both exposing the blood to oxygen and pumping it through the body. Instead of inducing hypothermia, the surgeon could use the oxygenator pump to keep the patient alive and safely work much more slowly. This device dramatically improved the chances that a heart transplant could succeed.

A Troubling First Attempt

In 1964, Dr. James Hardy from the University of Mississippi Medical School transplanted a chimpanzee heart into a patient who was dying, Boyd Russ. Hardy was an experienced transplant surgeon and the year before he had completed the first isolated lung transplantation. Russ was a semi-comatose, 68 year old man who was suffering from heart failure and "atheriomatous vascular disease throughout body." Under today's heart transplant standards, Russ would never have been approved for a transplant because the patient already had both legs amputated as a complication of vascular disease. Still, Hardy was determined to proceed and he witnessed a successful transplant of chimpanzee kidney's into a human. Despite Hardy's experience, Russ lived only an hour. The chimpanzee heart simply could not support a human body.

Since Boyd was semi-comatose, he never consented to Hardy's surgery. Additionally, Boyd's sister did not understand what a heart transplant entailed. Hardy also never informed Boyd's sister that he would be conducting heart xenotransplant, i.e. a cross-species transplantation. While Hardy's operation would not have met today's standards of informed consent because Boyd's sister did not understand the operation, it dd not violate the understanding of informed consent in the 1960s. Hardy's transplant was troubling because he essentially conducted a medical experiment on a human patient without that individual's knowledge or consent.

The First Human Heart Transplant

On December 3, 1967, Christiaan Barnard performed the first human heart transplant in South Africa on a 54 year old dentist named Louis Washkansky. Barnard was an experienced cardiac surgeon and had studied heart and kidney transplantation at the Medical College of Virginia in 1965. Barnard's own hospital, Groote Schuur, in Cape Town had a well-respected cardiac center. In addition to studying in Virginia, he spent time with Dr. Norman Shumway and Dr. Donald Longmore who were considered preeminent experts on heart transplantation surgical techniques. While he was an unlikely physician to perform the first heart transplant chiefly because he had not developed any of the necessary techniques, he was otherwise a qualified surgeon.

Barnad's operation was initially successful. Washkansky not only survived the surgery, but when he awoke from the surgery he stated, "I am the new Frankenstein." His statement was richly ironic because Mary Shelley's novel Frankenstein was banned in South Africa for immorality. He even had the opportunity to spend time with his wife during the next 17 days. Unfortunately, at that point he contracted pneumonia and died. While Groote Schuur had an excellent cardiac unit, it did not have sufficient expertise in immune suppression. To avoid organ rejection, Washkansky was administered immune suppression drugs, but they ended weakening his immune system too much and made him susceptible to infection. Board members of the United States Institute of Medicine argued that Barnard "lacked a proper team of immunologists" to assist in the transplant and that oversight doomed his patient.

Despite Washansky's death, Barnard's operation was a boon for both his reputation and South Africa. Barnard and Washkansky briefly became "pop stars with worldwide media coverage." South Africa was becoming increasingly toxic on the world stage because of its oppressive enforcement of apartheid. The South African government saw it as an opportunity to extoll the virtues of their regime.

The Heart Transplant Rush

Dr. Norman Shumway of Stanford University

Soon after Barnard's operation, doctors around the world began to perform heart transplants. It had been the case that physicians, such as Dr. Donald Longmore in London, had not performed any of these surgeries because their hospitals were justifiably skeptical of heart transplants. Barnard's operation overcame these reservations and a heart transplant rush ensued. Heart transplants were done in hospitals in India, Asia, Europe and North America. The results were abysmal. Aside from Barnard's second heart transplant patient who lived for 19 months, most patients succumbed quickly. Dr. Denton Cooley in Houston, Texas carried out 21 heart transplants in 1968 and briefly became a renowned public figure. Fairly quickly, it became clear that Cooley's attempts at heart transplants were also unsuccessful as all but 2 of his patients died.

The United States Institute of Medicine was deeply concerned that heart transplants essentially amounted to human experimentation. The Institute issued a statement arguing that heart transplants did not show any advantages over other forms of treatment and should only be conducted in hospitals that could be perform the surgery and handle all aspects of recovery, including immunology. The Institute's statement sought to quickly reduce both the number of transplants and institutions that could perform the operations. The Institute's statement helped shape public opinion about heart transplants in the United States and forced medical institutions to re-evaluate heart transplants.

Regardless of the Institute's statements, heart transplants began to run into other legal and medical issues. Heart transplants forced the medical community to make difficult decisions regarding when death was final. Determining when it was appropriate to harvest a heart from a donor was complicated and touched upon difficult ethical and religious issues. In several instances, there were disagreements about when and how hearts were harvested by doctors for transplants. Additionally, the medical community was simply not ready to perform heart transplants. The medical community at this time lacked effective immunological drugs, tissue typing was rudimentary and hospitals did not fully understand how much care was needed after surgery.

Therefor after 1968, the number of heart transplants declined dramatically and by 1973 there was only two units (one in both the United States and Europe) performing heart transplants. The only physician who continued to perform heart transplants in the United States was Dr. Norman Shummary, at Stanford University, but over the next 15 years who continued to improve and refine heart transplantation. It was not until the mid-1980s that heart transplants began to resume in earnest around the United States after the development of a new immunosuppressant, Ciclosporin (CsA).

Conclusion

While the first heart transplantation caught the attention of the world, the medical community lacked the tools to turn the procedure into an effective form of treatment. In essence, the first heart transplants were human experiments. The medical community was also forced to address when death was final and it was appropriate to harvest human organs. This was especially relevant for heart transplants, because unlike a kidney, you cannot live without a heart. It would take almost two decades before the medical community accepted heart transplantation as an essential tool for saving lives.

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References

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