Heart transplantation, 50 years on

Fifty years ago, on Sunday, December 3, the first adult human heart transplant was performed at the Groote Schuur Hospital, in Cape Town, South Africa by Dr Chris Barnard. It was an epoch-making advance in science, medicine and indeed in human culture. The heart, considered by many cultures as the seat of affection and courage, has changed ownership from a clinically dead person to a sick person.

The recipient was 53-year-old Lewis Washkansky, a South African grocer, who was dying from a chronic heart disease. The donor heart came from Denise Darvall, a 25-year-old woman who had suffered brain damage after being hit by a car.

Mr Washkansky lived for 18 days after the procedure but succumbed to a lung infection after his immune system was apparently weakened by drugs administered to prevent organ rejection.

Dr Barnard became a celebrity overnight. His fleeting success served as an inspiration to many surgeons around the world to perform heart transplantations. Worldwide, more than 100 transplants were performed by various doctors in 1968. Only a third of these patients lived longer than three months. Consequently, the number of heart transplants dropped from 100 in 1968 to just 18 in 1970.

The deaths were mostly due to the rejection of the transplanted organ by the recipient or infection. The situation was so bad that several countries, particularly the United Kingdom, placed a moratorium on heart transplantations.

The one person who continued performing the operation after the poor survival outcomes of the early transplants was Dr Norman Shumway of the Stanford University Hospital in California, United States of America (USA).

Shumway had every motivation to persist with heart transplantation. Shumway and Barnard had been surgical residents together at the University of Minnesota under the tutelage of Dr Clarence Walton Lillehei. According to a story told by Donald McRae in his 2006 book, Every Second Counts, and by many other accounts, Shumway and Barnard had a frosty relationship. “Dr Shumway scorned what he saw as Dr Barnard’s showmanship, aggressiveness and willingness to cut corners. Dr Barnard, for his part, was resentful that his colleague seemed to view him primarily as a foreigner from a pariah country.”

Dr Shumway and Richard Lower, one of his Stanford residents, had since 1959 performed many heart transplantations on dogs and had, thus, gained a lot of experience in transplantation. By 1967, about two-thirds of Dr Shumway’s research dogs were able to live for a year or more. At that point, he had transplanted hearts into nearly 300 dogs. Dr Barnard had done just about 50 in South Africa.

Issues with harvesting organs

In late 1967, Dr Shumway announced that he was going to start a clinical trial at Stanford that would lead to the first heart transplant in a human. American laws on organ donation were not in his favour. When it came to finding a human donor, American regulations at the time prohibited organ collection from brain-dead patients if their hearts were still beating. The heart had to stop completely before organs could be harvested. A surgeon who flouted the regulation could theoretically be charged with murder. Dr Barnard heard and took notice of this announcement by Dr Shumway.

Dr Barnard, on the other hand, did not have those difficulties. South African laws were liberal. In actual fact, Dr Barnard himself advocated that a neurosurgeon or neurologist could confirm brain death if a patient showed no response to light or pain. Another requirement was the consent of the family of the victim. When that was obtained, the transplant team could harvest the organs for transplant.

Dr Barnard went ahead and on December 3, 1967, he performed the first heart transplantation. The Americans changed their regulations almost immediately and about one month later, on January 6, 1968, Dr Shumway had to content himself with doing the first adult heart transplant in the USA at the Stanford University Hospital in California.
In the 1970s, when other surgeons, including Barnard, had suspended heart transplantation because of bad outcomes, Shumway and his team refined the operation, tackling the problems of rejection and the necessity for potentially dangerous drugs to suppress the immune system. In particular, he pioneered the use of cyclosporine, an immunosuppressant drug derived from soil fungus in the mid-1970s, instead of traditional drugs, which made the operation safer.

Shumway and his team of doctors and scientists developed techniques to determine whether a patient's body was rejecting an organ and the degree or extent of the rejection, allowing them to tailor their prescriptions of immune-suppressive drugs. They achieved very impressive results. From 1968 to 1980, Shumway’s team performed 200 heart transplants with 65 per cent of the patients surviving one year, while 50 per cent survived five years.

Over the next 20 years, important advances in tissue typing and immunosuppressant drugs allowed for more transplant operations to take place and increased patients' survival rates.
Shumway is widely regarded as the father of human heart transplantation, although the world's first adult heart transplant was performed by Barnard, who incidentally used techniques developed by Shumway.
The world still gives credit to Dr Barnard for his boldness in performing the first adult heart transplantation.

Worldwide, about 3,500 heart transplants are performed every year and the overwhelming majority, about 2,000 to 2,300, are performed in the United States.

Today, with the refinement of drugs that help prevent the body from rejecting a foreign organ and the effective treatment of infections, the long-term outcomes following heart transplantation are excellent. About 95 per cent of patients live for at least a year after the procedure. The median long-term survival in centres with vast experience, such as in Hannover, is greater than 15 years. Many have survived more than 25 years.

To complete the write-up, the writer was one of the pioneers when the heart transplant programme started at the Division of Heart, Thorax and Vascular Surgery at the Medical University in Hannover in 1983. I led the team to perform my first heart transplant operation in October 1985. In November 1988, I was fortunate again to perform the first heart-lung transplantation with my friend, Dr Axel Haverich.

I am still hopeful that transplantation of organs, including heart, will be made possible in the not-too-distant future in Ghana.