Transplants: An Anniversary Review

SURGERY'S most spectacular procedure, the transplant of a heart from one human being to another, marks its first anniversary this week. By the latest tally, 95 human hearts have been taken from newly dead donors and implanted in the chests of 93 patients (two of them got two apiece). Almost exactly half the recipients are still living, though some have received new hearts so recently that the likelihood of their survival cannot be judged, and another death is being reported almost daily. The world's record survivor has lived for just eleven months.

In the cold light of these figures, many questions arise. Were heart transplants begun prematurely? Have there been too many? Or too few? Did the mere existence of the procedure arouse false hope in patients for whom no donor heart could be found? Is it better to die after long hospitalization and distressing drug treatment, with a transplanted heart, than to die a little earlier with one's natural, inborn heart? What hope does the immediate future offer for longer and healthier survival?

The Me-Too Brigade. On the general answers to most of these questions, the heart surgeons are agreed, though they differ on details. No, say the surgeons emphatically, the beginning of transplants was not premature. The surgical technique had been worked out years earlier, in animals, by Stanford University's Dr. Norman E. Shumway Jr., with Dr. Richard R. Lower, who is now at the Medical College of Virginia. Both Shumway and Brooklyn's Dr. Adrian Kantrowitz had their scalpels poised when South Africa's Dr.

Christiaan N. Barnard performed the first operation. Though some criticized Barnard for haste, his Cape Town team was experienced in kidney transplants, and included specialists in most, if not all, of the ancillary medical fields.

Later, complains Cardiologist Irvine H. Page, a past president of the American Heart Association, the "circus trappings and glitter" surrounding the transplants set off a rush among surgeons to join "the me-too brigade." Many surgeons concede that by no means were all of the 36 medical centers in 16 countries that have tried transplants well-enough staffed or equipped to do so. Yet despite all the failures, Houston's Dr. Denton A. Cooley, who has transplanted more hearts than any other man, defends the operations. He points to what happened after early, unsuccessful attempts at heart-valve surgery in the 1920s: "Because of a few initial failures, no further surgery inside the heart was done for 20 years. Those years were lost, and the next efforts were relatively timid approaches. I believe it was a mistake to call a halt then."

Today heart-valve surgery is common, and is successful for nearly 90% of patients. Transplant of the heart may never approach that record, but Dr. Cooley is "glad that heart transplantation has not been abandoned."

Dr. Barnard's first heart-transplant patient, Louis Washkansky, lived only 18 days. He might have fared better if he had received fewer and smaller doses of drugs given to suppress his system's attempt to slough off the "foreign protein" of his new heart. But even of that there is no assurance. Many later recipients, whose doctors have had the advantage of almost a year's experience in efforts to suppress the reactions, have not lived as long.

Action and Reaction. For Barnard's second patient, the phenomenal dentist Philip Blaiberg, the surgeon and his medical colleagues were careful to give smaller and less frequent doses of drugs. Blaiberg pulled through the first weeks well and began a new life. In June he faced a crisis: Blaiberg developed hepatitis, presumably from transfusions, and had a severe rejection reaction. By this time the Cape Town doctors were better equipped to fight rejection. They had imported antilymphocyte globulin (ALG) from West Germany.

ALG, although prepared in animals, comes closer than any other synthetic chemical to being nature's countermeasure against rejection. Barnard gives ALG much credit for having brought Blaiberg back to a nearly normal existence, but the value of the substance remains controversial. Houston's Dr. Michael E.

DeBakey says: "We have no reason to believe that in our cases, at least, ALG has done much of anything to control rejection. The recipient's reaction against the ALG itself is a problem." Yet DeBakey uses the same ALG, prepared in Baylor University labs, as does Cooley in another hospital only a few blocks away. Cooley declares that ALG "shows great promise." And the immunologist who serves on both their teams says that he and his colleagues have given 1,700 injections of ALG to transplant patients without finding any significant adverse reaction.

Defining Death. Whether heart transplants can be given greater insurance against rejection by a better "tissue match" of cell types between donor and recipient is still being debated. Cooley told the American Heart Association a fortnight ago that among his transplants there had been no really close matches; eleven were considered pretty iffy and three were decidedly poor. But Cooley pointed out, as did Richmond's Lower, that some of the poorer matches had been followed by longer survivals. So, Cooley suggested, tissue matching cannot be very important. To Immunologist Gustav J.V. Nossal of Australia, this was heresy. He granted that present matching methods may be crude, but was confident that with foreseeable improvements, the technique would become crucial to transplant success.

On the strictly surgical side, there has been no significant argument or change. Cooley modified the original Shumway technique by cutting the recipient's heart at a different angle in order to leave intact two of the three major electrical connections between the heart's ignition centers. This modification is good enough for Shumway to have adopted it. Questions as to how the donor heart is best preserved before implantation and the speed of implantation have become almost academic. Ideally, the donor heart should be excised and trimmed at the precise time when the recipient's heart is removed, leaving the "distributor cap" top with the major blood vessels for attachment. Then any of the leading heart-transplant surgeons can stitch the two together in half an hour, give or take a few minutes.

Neither, surprisingly, is there any persistent medical conflict over the ethics of heart transplants. There is now almost unanimous agreement on a new definition of death. The donor's death is established when his heart will no longer beat and his lungs will no longer work unaided, when there are no reflex reactions to even painful stimuli, and when the electroencephalogram (brainwave tracing) has been flat for some time, usually two hours or more. In such cases, surgeons contend, "brain death," and with it legal death, has occurred. Physicians agree. They insist only that this death be certified by a team, including neurologists, that is independent of the surgical team. The surgeons willingly accept this condition.

Two Pumping Chambers. The broader problems remaining involve both the law of supply and demand and public policy. In one sense there have been too few transplants because many potential recipients, lying in hospitals awaiting an operation, have died for the simple reason that no donor heart became available. That is unavoidable with a procedure that depends on the gift of an organ without which the giver cannot live (unlike the kidney, of which every normal person has two, and can spare one).

The National Heart Institute's Dr. Theodore Cooper estimates that each year 80,000 Americans become, by virtue of their otherwise untreatable heart disease, suitable candidates for transplants. But by the most optimistic estimates, only 40,000 donor hearts are likely to be available each year. Even if there were more, there are not enough surgeons to perform the operation or enough hospital units to accommodate the patients. Beyond all that, the cost of a transplant is huge, ranging from $20,000 to $50,000. The patient may pay $10,000 to $15,000 of this, and the rest is absorbed through Government grants or charitable (largely foundation) gifts.

Ultimately, heart transplants may become unnecessary. By the time the immunologists have learned to induce tissue tolerance, an artificial heart should be perfected. To his pleased surprise, says DeBakey, the excitement over transplants has not hindered but has stimulated interest in efforts by his and other laboratories to produce an artificial heart. It will, he predicts, come in stages. First, a cumbersome external device that will keep the patient bedfast. Second, a portable but still external model. Eventually, he hopes for an implantable device with an internal power supply that will enable the patient to resume normal activities. Even then it may not be a substitute for the whole heart, but only for the two lower, more important pumping chambers.*

Is heart transplantation still an exploratory venture on surgery's frontier, or has it become an accepted mode of treatment? On that, the transplanters themselves are divided, Shumway and DeBakey holding that it is still only investigational, with Barnard and Cooley just as emphatically insisting that it is already much more.

Yet to the men and women who have received heart transplants and apparently beaten the prevailing fifty-fifty odds of survival, all the technical questions are of little concern. Blaiberg drives his car, drinks his beer, eats heartily and writes his autobiography. In Paris, Pere Boulogne uses his hospital room, after seven months, to celebrate his private Mass and work on his book on St. Thomas Aquinas. DeBakey's patient, William C. Carroll, plays pitch-and-putt golf in Arizona. A Shumway patient, Mrs. Virginia Asche, is at home and doing her own housework three months after the transplant.

Whatever their eventual fate, the decision of these patients in agreeing to the operation, knowing full well its great risks and only moderate hope of benefit, has helped surgery to make a momentous advance.

* Efforts to find an animal source of transplantable hearts are not likely to succeed before the artificial heart is perfected, according to DeBakey. The first heart transplanted into a human being was a chimpanzee's in 1964, and it failed. This year, a sheep's heart also failed. The great apes are too scarce, and too reluctant to breed in captivity to be a source of supply. Before animals' hearts can escape rejection, researchers will have to outwit the genetic code and raise special breeds--a matter of years.

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