South African grocer Louis Washansky was the first, a self-described Frankenstein's monster who lived for 18 borrowed days in December, 1967, while the heart of another human beat in his chest. The second heart transplant patient of that year was an infant boy who lived only seven hours.
But neither of those late December failures deterred the world's cardiovascular surgeons, who performed 101 human heart transplants in 1968. Only one of those 101 patients is alive today and just one of the 47 patients who received "new" hearts in 1968 and three of the 17 transplant recipients in the 1970s.
Ten years after the first transplants the number of such operations performed annually is only about one-third of what it was. Twenty-one of last year's 31 heart formed in the U.S. at two centers, Dr. Richard Lower's at the Medical College of Virginia (MCV) in Richmond and Dr. Norman Shumway's at Stanford University in Palo Alto, Calif.
Much of the fanfare - the magazine cover stories, the near deification of surgeons Shumway, Christiaan Barnard, Adrian Kantrowitz, Denton Cooley, Michael DeBakey and Lower, the talk of transplantation as a cure for heart artificial heart in five years - was at least a decade, if not two de ades, permature, some surgeons now say.
These specialists believe that what was hailed as the drawn of the transplant age was really just the beginning of a long, slow, step-by-step period of experimentation with human subjects following experiments with dogs and primates.
Physicians say there are many reasons for the sharp decline in the number of heart transplants performed in the years following Barnard's first operation. Among the most significant reasons are:
The development of less drastic surgical procedures - such as the coronary artery by pass, a complicated procedure that involves repairing, rather than replacing the heart. These operations have a chance of alleviating several of the conditions that meant certain death 10 years ago:
The disappointingly slow improvement in the rate at which transplant patients survive, with only 20 per cent of the MCV patients survviing one year or more:
The slow progress made by researchers trying to understand, and suppress, the mechanism that causes the body to reject foreign tissue - in this case the donor heart:
The small supply of hearts available for transplantion.
MCV's Lower said recently that he thinks "there was a degree of optimism, even in the profession, that was not justified." Transplantation "was seen as an answer for all patients who were sick with heart disease, and it was not.
"It was hoped survival would be better," said Lower. "It was hoped matching donor and recipient tissue types would be the answer to the rejection problem and it wasn't. But for the few patients who make it through and live comfortably for a significant period of time," the procedure is worthwhile.
Adrian Lantrowitz, who performed the world's second heart transplant four days after Barnard's first, reflected recently on those heady early days when years of laboratory work came to fruition in the operating room, and on his reason for getting our of the transplant business after three operations.
"Shumway was thinking about doing it and Shumway knew damn well that I was thinking about doing it and. . .it was obvious that it was a reasonable thing to do because nobody knew whether the rejection problem would be more or less difficult in humans than in dogs," Kantrowitz said recently during a series of lengthy interviews at Mt. Sinai Hospital in Detroit.
"We knew how to do it," the surgeon said. "It was obvious it had to be tried. So it was.
"Then Shumway did it two or three weeks after we did and I'm sure he didn't do it because we did. It just worked out that way," said Kantrowitz. "That's the way it is in science. When something is ready to be done it's usually done simultaneously."
Krantrowitz did three heart transplants and then stopped for "several reasons. I'm a surgeon and surgery is what I know. The problems involved in making this work on a broad basis are not surgical problems," he said, "they're immunological problems I do not bring any special talent to solving those problems, nor does my team.
"We are very good at engineering devices," said Kantrowitz, the inventor of a heart pacemaker and a partial artificial heart. Transplants were "an engineering problem in those days - how do you engineer the whole thing so that you can smoothly take out one heart without having the whole system fall apart, put in another heart and make the heart take over, and that we worked out?
"I was interested in doing heart transplants and I still am and still think it should be done, but I think it should be done at a center where the research necessary to understand the immunological problems can be worked out, rather than at a place like my institution where we don't have that kind of (technical) support.
"When it became clear after a few months of doing heart transplants in humans that the problems were no different in humans than they were in dogs I was convinced that eventually the fad would die down. I just decided for myself and what Denton Cooley did or DeBakey or Shumway did was up to them," Kantrowitz said.
"I didn't tell them not to do it or to do it. I didn't tell them that I was convinced that they wouldn't do any better than we did in the dogs. It's not for me to tell them that.
"But I decided for myself, because I had to go and talk to the families and live with myself, that (heart transplants were) not warranted in my setup until the basic immunology had been worked out . . . I had decided that way to do this is to develop a mechanical device" that can make a heart transplant unnecessary.
Until such a device is perfected, and Kantrowitz has one in his laboratory that began pumping Oct. 30, 1972, and had pumped more than 219,513,000 times by mid-afternoon Aug. 18, a handful of surgeons around the world continues to implant human hearts into the chests of human patients.
This year and last Lower and his group at the Medical College of Virginia performed six such operations. Of those six patients, the two operated on within the past 45 days are still alive.
"Itis certainly not a highly successful form of treatment," said Lower, the man credited with working out the surgical procedure itself.
"It's quite properly reserved for patients in relatively terminal stages of their disease," he said. "You have a choice when you reach that stage of saying, let nature take its course," or trying an experimental procedure.
"We are still reasonabdly pessimistic about good long term results in the majority of patients," said Lower. "We're really only accepting patients who are completely hopeless cases . . . If you have a patient whose chances of survival (without a transplat) for only a brief period is close to zero, then the patient is worth taking the chance on. It's also possible that by small increments we can improve the survival."
Of the 18 patients who got new hearts at the facility in Richmond since May 25, 1968, four are alive. One, Arthur Gay of Washington, has survived four years and eight months. Two-thirds of the MCV patients survived 70 days or less.
"Without a question, rejection is the biggest problem; it always has been. The technical aspects of the operation itself have been well worked out for almost two decades now," said Dr. Frank Thomas, a surgeon and colleague of Lower at MCV.
"The basic problem is to design an anti-rejection drug which selectively and profoundly affects those portions of the immune system which are most germane to allograft (the transplantation of part of one human to another, unrelated, human) rejection and at the (transplant rejection) to continue . . . system which are as important in so that defenses can be maintained against infectious diseases," said Thomas, who has been working on the rejection problem.
Until recently the primary drugs used to battle rejection had the effect of knocking out the body's entire system of defense against infection. This meant that if the patient didn't die because of rejection of the new heart, he died of inflection,
The problem faced by transplant patients are similar to those faced by cancer patients taking chemotherapy. The chemotherapy, or, in the case of the transplant patient, the immunosuppressant drugs, attacks the antibody-producing while cells, leaving the systems of both groups of patients defenseless.
"It knocks down the defenses against bacteria, fungi, viruses, etc., and makes the recipient susceptible to a myriad of infectious complications," said Thomas. "The cause of death in 70 to 90 per cent of all transplant patients (who die in connection with the transplantion process) is infectious complications.
"We have an Achiles heel here, so to speak, and this is the thing that is going to have to be circumvented if we are going to improve our results in transplantion," explained Thomas, who noted that some of the same bodily defenses that ward off infection cause rejection.
While there have been some recent important developments in the field of immunosuppressants, including the development of drug tha appears to suppress the rejection mechanism without affecting the defenses against infection, the question still remains whether all the effort is worthwhile. Should society be expending enormous resources, in manpower and money, on such an apparently marginally productive effort?
"If I had a very bad heart today I would seriously consider getting a transplant," said Robert Veatch, an ethicist with the Institute for Society, Ethics and the Life Sciences, in Hastings-on-Hudson, N.Y. "My view, from a personal point of view, is why not give it a try?
"But that would conflict directly with my view when it is put in a resource allocation context," said Veatch. "I have reaI doubts whether we should permit the most skilled surgeons to devote their resources to techniques that have a very low degree of success.
"I'm not at all sure that the public policy should encourage, or even permit, the use of resources that way. There may well be more useful things that can be done with the skills," said Veatch.
"At the very least it seems reasonable to say that no transplants should be done with Medicaid-Medicare funds, and perhaps not with private insurance funds. Maybe we should have a policy that transplants can only be purchased on the open market" by those with the funds to pay the bill, which ranges between $10.000 and $50.000 - depending upon whose estimates one believes.
"You're not just treating patients," counters Thomas, "you're developing technologies. I mean, my God! If you could look at some of the things (the late) Dr. (David) Hume was doing when he first started his kidney transplants, such as putting baboon kidneys into humans. I mean things that really seem to make no sense at all.
That led to the development of technology that is responsible now for the transplantation of 30.000 kidneys into patients, with excellent results.
"You know," continued Thomas, "it's just a form of science, if you will, and I think it's just as wrong to say that it's not economical (to do heart transplants) as it is to say that it's not economical to have a scientist studying "anything else that does not appear to have a direct payoff.