Fifty years ago yesterday, the first adult human heart transplant was performed in Cape Town, South Africa. It was an epoch-making advance in science - and also, perhaps, in human culture. The heart, heavy as it is with symbolism, has always occupied a special place in our collective imagination.
Despite our relatively sophisticated biomedical understanding of its function, many people still think of the heart as the seat of affection and courage. When Barney Clark, a retired dentist with end-stage heart failure, received the world's first permanent mechanical heart in 1982, his wife worried he might not still be able to love her.
A heart transplant is the definitive treatment for the most severe stages of heart failure, a disease that afflicts six million Americans (and a quarter of a million in its most advanced form). But as recently as the early 1960s, transplanting a human heart seemed like a pipe dream.
Organ rejection and life-threatening infections posed prohibitive risks. By the second half of the decade, however, animal research had pointed a path towards human transplantation.
In the end, the race to transplant a human heart - a story engagingly told in Donald McRae's 2006 book Every Second Counts - involved four surgeons, the most compelling of whom were Dr Christiaan Barnard at Groote Schuur Hospital in Cape Town and Dr Norman Shumway at Stanford. The two had been surgical residents together at the University of Minnesota, and by many accounts they 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 Barnard faced a considerable disadvantage in that Dr Shumway had a great deal more experience with animal transplants, which he had helped pioneer. In 1959, Dr Shumway and Dr Richard Lower, a Stanford resident, performed the first dog heart transplant. The recipient lived for eight days, demonstrating that an organ could be transplanted from one animal to another and continue to function.
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 about 50.
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. "Although animal work should and will continue," he said, "we are none the less at the threshold of clinical application."
But it was Dr Shumway who was at a disadvantage 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. Otherwise, a surgeon could theoretically be charged with murder. Dr Barnard, on the other hand, was governed by more liberal laws in South Africa - legislation he himself had presciently advocated - which allowed a neurosurgeon to confirm death if a patient showed no response to light or pain, a much lower bar. Once family consent was obtained, a transplant team could quickly harvest organs, including the heart, while they were still being perfused with blood.
It was a close race, but Dr Barnard broke the transplant tape first, on Dec 3, 1967. His first patient, Mr Louis Washkansky, a 55-year-old grocer, received the heart of a young woman who had suffered brain damage after being hit by a car.
Mr Washkansky lived for 18 days after the procedure, succumbing to a lung infection after his immune system was apparently weakened by drugs to prevent organ rejection. Dr Shumway had to content himself with doing the first adult heart transplant in the United States a month later, on Jan 6, 1968.
His patient, a 54-year-old steelworker, lived for 14 days before surrendering to what Dr Shumway described as "a fantastic galaxy of complications".
Today, with the refinement of drugs that help prevent the body from rejecting a foreign organ, the long-term outcomes following heart transplantation are excellent. About 85 per cent of patients live for at least a year after the procedure.
The median long-term survival is probably greater than 12 years, and it is about 14 years if the patient survives the first year.
Though heart transplants have saved many lives, many more continue to be lost while patients wait for a viable organ. Only about 3,000 Americans receive a heart transplant each year, though roughly 4,000 are on the transplant list and perhaps 10 times that number would benefit from a transplant.
Despite public campaigns to increase organ donation, the number of available organs has remained relatively constant over the years. (That is partly good news: Seatbelt and motorcycle helmet laws have resulted in fewer road fatalities.)
As a result, a heart transplant can seem as much like a crapshoot as a medical option. "A heart transplant is the answer to heart failure the way the lottery is the answer to poverty," Dr Lynne Warner Stevenson, a heart failure specialist at Vanderbilt, has said.
For this reason, replacing the human heart with an off-the-shelf mechanical device is a great ambition of cardiologists and surgeons.
Though permanent artificial hearts were introduced in the 1980s, they remain fraught with complications. The most reliable mechanical support today is the left-ventricular assist device, which attaches to the native heart, pumping blood directly into the aorta, thus essentially bypassing the failing heart.
However, these devices have drawbacks, too - they cause blood clots, strokes and bleeding, and they are ineffective for patients with severe failure of both sides of the heart.
For many patients, the best hope remains a transplant, a hope introduced to the world 50 years ago through the skill, determination and, yes, heart of a South African surgeon.
A version of this article appeared in the print edition of The Straits Times on December 04, 2017, with the headline 'Happy 50th anniversary, heart transplant'. Print Edition | Subscribe
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