Tag Archives: Transplant

50 Year Anniversary of the First Human Heart Transplant: Lessons for Today

On 3 December we commemorated the 50 year anniversary of the world’s first heart transplant. The operation took place in the early hours of a Saturday morning at the Groote Schuur hospital in Cape Town, South Africa. Christiaan Barnard sutured Denise Darvall’s donated heart into the chest of the recipient, Louis Washkansky. Barnard restarted the new heart with an electric shock and then tried to wean the recipient off the heart and lung machine. But the new heart could not take the strain and Washkansky had to go back on the machine. The second attempt also failed, but when the heart and lung machine was turned off for the third time the recipient’s blood pressure started to climb. It kept on climbing, and soon Denise Darvall’s small heart had taken over the perfusion of Louis Washkansky’s large frame. Later that morning the world woke to the news of the world’s first heart transplant. Looking back over fifty years what should we make of Barnard’s achievement?

The transplant in an historical perspective

The two decades preceding the heart transplant have sometimes been referred to as the golden age of medical discovery.[1] The transplant can be ‘fitted’ retrospectively as the culmination of this golden age just as Neil Armstrong’s moon walk, two years later, can be seen as the crowning achievement of the space race. They belong to a number of technical achievements, including the first “test tube” baby and the first man in space, which are emblematic of human progress. They generate great public interest and media attention, but differ from more fundamental intellectual discoveries, such as the double helix in DNA or Higgs boson, that are rewarded with Nobel prizes.

The heart transplant in the ‘heroic’ medical age

In his book ‘One Life’ Barnard provides an interesting cameo of the power and autonomy of the medical profession in his time.[2] He recalls writing up the routine operation note that must follow any surgical procedure. The anaesthetist, ‘Oz’, suggested that Dr Jacobus Burger, the hospital superintendent, should be informed. Barnard asked whether he should wake him so early in the morning, but Oz replied that the night’s events warranted such an intrusion. At first the befuddled Dr Burger, aware if work in the animal lab, thought that he was being informed about another heart transplant in dogs. However, even when he learned that the transplant involved a human heart, he cryptically thanked the surgeon and replaced the receiver. Nowadays, the idea of carrying out a procedure of such novelty, cost and risk without formal sanction would be unfathomable. The vignette from the doctor’s tearoom vividly illustrates how the relationship between the medical profession and the broader society has changed over one generation. Rene Amalberti argues [3] that many professions progressed through a heroic age in the twentieth century before gradually becoming more formalised and regulated – aviation followed a similar trajectory following Charles Lindbergh’s dramatic flight across the Atlantic in 1927.

Gradually changing ethical norms

The ethics of heart transplants relate mainly to organ donation. In ‘One Life’ Barnard describes the tense atmosphere in the operating room as the team waited for the donor heart to stop after turning off Darvall’s ventilator. In fact, they did not wait, and Barnard’s brother Marius has stated he persuaded Christiaan to stop the donor heart by injecting a concentrated dose of potassium in order to give Washkansky the best chance of survival. Today two different doctors need to independently carry out tests to confirm the donor is brain stem dead before the heart can be removed, as opposed to waiting for death by the whole-body standard, i.e. when there is brain death and the heart has stopped beating.

Public views of heart transplants, then and now

Following the operation the exhausted Barnard went home for a sleep. In the afternoon he returned to the hospital where he was surprised to find his route obstructed by a large crowd of reporters. He had unleashed a tide of publicity and acclaim that resonated for many decades, but dissenting voices were also heard. Some, notably Malcolm Muggeridge, the editor of Punch magazine, attacked the operation on the basis of a near mystical reverence for the human heart and to this Barnard had a succinct response: “it’s merely a pump.” Others worried about the allocation of scarce resources to such a high-tech solution when people were dying from malnutrition and malaria. Defence of the procedure came, albeit years later, from the economics profession when it was shown that the operation has a highly favourable cost-to-benefit ratio (at least in a high-income country).[4] The procedure not only extends life by many years on average, but greatly improves the quality of that life. In fact, patients feel much better from the moment they regain consciousness after the operation despite pain from the sternotomy. The operation is now uncontroversial and is performed routinely in high-income countries. It was long predicted that a mechanical pump would supplant the need for transplantation. Mechanical hearts have improved,[5] but they are largely seen as a bridge to transplantation, rather than a better alternative.

If Christiaan Barnard had not performed his operation, heart transplants would have developed anyway (the second transplant was carried out independently by Adrian Kantrowitz in the USA on 6 December). I was a school boy with hopes of getting into medical school when Washkansky received his new heart. I was among the many millions who were swept up in the wonder of the event and it still stirs my imagination half a century later. And my family knows that I wish to donate my own heart if the circumstances arise.

— Richard Lilford, CLAHRC WM Director

References:

  1. Lilford RJ. Future Trends in NHS. NIHR CLAHRC West Midlands. 25 November 2016.
  2. Barnard C & Pepper CB. One Life. Toronto, Canada: Macmillan; 1969.
  3. Amalberti R. The paradoxes of almost totally safe transportation systems. Saf Sci. 2001; 37(2-3): 109-26.
  4. O’Brien BJ, Buxton MJ, Ferguson BA. Measuring the effectiveness of heart transplant programmes: Quality of life data and their relationship to survival analysis. J Chron Dis. 1987; 40(s1): s137-53.
  5. Girling AJ, Freeman G, Gordon JP, Poole-Wilson P, Scott DA, Lilford RJ. Modeling payback from research into the efficacy of left-ventricular assist devices as destination therapyInt J Technol Assess Health Care. 2007; 23(2): 269-77.
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A Device for Failing Hearts

Back in 2005 I was approached by Sally Davies, then languishing as deputy director general of Research and Development, and asked to evaluate the utility of a trial of left ventricular assist devices (LVADs) for heart failure. We elicited a Bayesian prior from a chapter of surgeons from the American Society of Heart Surgeons. This prior was the basis for a value of information study,[1] which suggested that expensive LVAD technology might be a bridge too far for the hard-pressed NHS. Anyway, the world moves on and the New England Journal of Medicine has recently carried out a trial comparing two different LVADs, one more sophisticated (type 3) than the original version we studied (type 2).[2] The latest version had less problems with clotting up of the device, but survival free of a serious stroke at six months was similar, at over 80% in both groups – quite high considering how sick these patients were. The article has some extremely good diagrams explaining the devices. These devices are sometimes used to rest the heart, for example in a case of inflammation of the heart muscle. Most often they are used when the heart muscle packs up permanently, say as a result of heart attacks. In that case LVADs can be used to keep a person alive until a match can be found for a heart transplant, so called ‘bridge to transplant’, or as a permanent solution. However, I think the devices are themselves a bridge to a more subtle regenerative medicine approach based on stem cells.

— Richard Lilford, CLAHRC WM Director

References:

  1. Girling AJ, Freeman G, Gordon JP, Poole-Wilson P, Scott DA, Lilford RJ. Modeling payback from research into the efficacy of left-ventricular assist devices as destination therapy. Int J Technol Assess Health Care. 2007; 23(2): 269-77.
  2. Mehrea MR, Naka Y, Uriel N, et al. A Fully Magnetically Levitated Circulatory Pump for Advanced Heart Failure. New Engl J Med. 2017; 376: 440-50.