Heart: An American Medical Odyssey

by Cheney, Dick

  The solution soon turned out to be a combination of the drugs azathioprine (a less toxic derivative of 6-mercaptopurine) and prednisone (a steroid). The pair became part of the standard antirejection cocktail for the next twenty years.

  • • •

  At the end of 1963, Dr. James Hardy’s team at the University of Mississippi prepared to perform what they hoped would be the world’s first heart transplant. Hardy had already made news earlier in the year when he performed the world’s first lung transplant. The patient, fifty-eight-year-old John Richard Russell, an inmate sentenced to death for a 1957 killing in Attala County, Mississippi, had been diagnosed with cancer of his left lung. Hardy proposed to remove the diseased lung and transplant a new, cancer-free organ. On June 11, 1963, Russell became the first patient to undergo a lung transplant. Ten days later, the Associated Press reported that Governor Ross Barnett had pardoned Russell because his participation in the surgery would help to “alleviate human misery and suffering [for] years to come.” Russell died from renal failure about a week after his pardon.

  Six months later, as Hardy and his team readied themselves for what would be historic surgery to transplant a heart, they faced a difficult problem that every other team in the United States encountered: the very definition of death.

  Unlike the current era, in which brain death (the irreversible end of all brain activity) defines the end of life, in the 1960s, the cessation of a perceptible heartbeat was the typical criterion used to declare a person dead. This created a difficult technical issue in that a heart could not be harvested from a donor until the donor heart stopped beating. This required a surgical team to stand vigil, awaiting the moment the heart stopped, and then excise the organ immediately in an attempt to retain its viability.

  In a 1964 paper in the Journal of the American Medical Association describing his first operation, Hardy laid out the technical problem:

  But how soon after “death” of the donor could the heart be removed? If it were not done promptly, irreversible damage might have occurred. To minimize such damage it was planned to insert catheters into the femoral vessels and begin total body perfusion the instant death was announced by a physician not associated with the transplant team. . . . In this way, oxygenation of the body tissues could be affected while thoracotomy was performed to excise the donor heart and begin coronary sinus perfusion.

  At the outset, it was expected that months, or even years, might elapse before a suitable donor and recipient died simultaneously in the small University Hospital.

  Hardy had been concerned that while there should be no difficulty identifying a suitable recipient for a new heart, it might be hard to find suitable donors. To his surprise, in late December 1963, three patients with fatal brain injuries were admitted to his hospital: one with trauma from a fall, one with a brain tumor, and another with a self-inflicted gunshot wound to the head. All three of the patients died after a period of time on a respirator. Hardy rhetorically asked:

  When, if ever, would a physician be justified in switching off the ventilator in a patient whose voluntary respiratory effort had long ceased, to permit the hypoxia that would be followed by cardiac arrest? We were not able to conclude that we would be willing to do this, despite the fact that at some point fruitless resuscitation efforts must cease if a viable kidney, heart, or other organ were to be obtained for transplantation to a recipient.

  Lacking today’s organized network of hospitals perpetually on the lookout for possible organ donors and the contemporary definition of brain death, Hardy made a bold decision:

  Since we were not willing to stop the ventilator, we had concluded that a situation might arise in which the only heart available for transplant might be that of a lower primate.

  On January 21, 1964, Boyd Rush, a sixty-eight-year-old semicomatose, deaf-and-mute male with atrial fibrillation and gangrene of the left leg, was admitted to Dr. Hardy’s hospital in critical condition. Although the patient’s leg was amputated the next day, his condition continued to deteriorate. It was felt that his gangrene, as well as his declining mental status, was likely the result of embolized blood clots from his heart (probably a consequence of atrial fibrillation). On January 23, as the patient neared death, Dr. Hardy brought him to the operating room and placed him on the heart-lung machine. At the same time, a potential heart donor lay critically ill in the hospital, but his demise was not thought to be imminent. Hardy polled his teammates and by a vote of four to one, they voted to use the heart of a chimpanzee.

  In one operating room, the chimpanzee was anesthetized and his heart was removed, preserved with cold oxygenated blood, and brought into the adjacent operating room where Mr. Rush was supported by the heart-lung machine. Using the technique that Hardy had perfected in the animal laboratory, the heart of the patient was carefully excised and the chimpanzee’s sutured into its place. In Dr. Hardy’s words:

  A regular and forceful beat was promptly restored following defibrillation with a single weak shock of the pulse defibrillator.

  Unfortunately, the heart of the chimpanzee was too small to support the circulation of the much larger man. The patient died in the operating room. Hardy’s bold experiment had failed to save Mr. Rush’s life, but it was the first time the surgical techniques to transplant a heart had been tested in a human being, and the experience helped to set the stage for what would come next.

  • • •

  In the fall of 1965, Dr. Richard Lower moved from Stanford University to the Medical College of Virginia to assume the job of chief of cardiac surgery, where he continued his heart transplantation research. In May 1967, Lower was intent on proving that a human heart could be removed from a recently deceased donor, revived, and then used for transplant. Both Lower and Shumway had shown that this could be done with dogs, but it had yet to be proven that it could be accomplished with a human heart.

  In a reverse of the procedure performed three years earlier by James Hardy, Lower took the heart from a recently deceased patient, revived it with cold saline, and, using the technique that Shumway and Lower had developed at Stanford, transplanted it into the chest of a baboon. Perfused now with warm and oxygenated blood, the human heart began to beat inside the primate, the first time a human heart had been used as a donor organ. Lower had intended his experiment as proof of the concept that a “fresh” cadaver heart could be successfully resuscitated, and he had done just that. As Donald McRae states in his excellent book Every Second Counts: The Extraordinary Race to Transplant the First Human Heart, “It was another measured step toward the first full-scale clinical attempt between a human donor and a human recipient.”

  • • •

  In Brooklyn, Dr. Adrian Kantrowitz was also getting ready to perform a heart transplant. He understood the challenges posed by graft rejection and had focused his attention on cardiac transplantation in infants. Although the surgery “was harder technically and emotionally” than surgery on adults, because infant immune systems are immature, Kantrowitz knew infants were less likely to reject the donor organ. To prepare for his first case, Dr. Kantrowitz and his team worked in the lab for years performing hundreds of procedures on puppies, perfecting a technique to be used for the transplantation of a human heart about the size of a walnut.

  Kantrowitz was a remarkable innovator. During his long and distinguished career, first at Maimonides Medical Center in Brooklyn and later at Sinai Hospital in Detroit (now called Sinai-Grace Hospital), he developed more than twenty devices, including an electronic pacemaker, multiple LVADs, and the intra-aortic balloon pump (an easy-to-use temporary heart assist device that I have used hundreds of times to treat critically ill patients).

  In June 1966, Kantrowitz and his team had been poised to perform the world’s first heart transplant. A baby with anencephaly (a terrible and rapidly fatal congenital malformation marked by absence of the brain) had been born in Portland, Oregon, and in an act of heroic generosity, the parents offered their son’s heart to an infant in Brooklyn
who was dying from a congenital heart defect. The anencephalic child was flown to New York and prepared for surgery that would make history. As the definition of death in 1966 required the absence of circulation, Kantrowitz was required to wait until the child’s heart stopped beating. When that sad moment finally came, the little heart could not be revived, and Kantrowitz was forced to abandon the transplant.

  • • •

  On December 3, 1967, one month after the first test flight of the Saturn V moon rocket, the race to perform the first human heart transplant was won in Cape Town, South Africa.

  The surgeon was Dr. Christiaan Barnard, a dynamic forty-five-year-old who early in his career trained in Minnesota with surgical legends Dr. Owen Wangensteen and Dr. Walton Lillehei. After his training, Dr. Barnard returned to Cape Town and joined the staff at Groote Schuur Hospital. In the mid-1960s, Dr. Barnard became interested in heart transplantation and developed an animal lab, but unlike many of his American counterparts, Barnard’s team focused mostly on honing their operative technique, relying on the long-term animal results published by some of their counterparts in America. In an interview for David K. C. Cooper’s book Open Heart, Barnard said, “All we were interested in was perfecting the surgical technique.”

  Louis Washkansky was a fifty-eighty-year-old man, originally from Lithuania, who had suffered three heart attacks in 1965 and was dying of congestive heart failure at Groote Schuur Hospital. In life, he had never met Denise Darvall, a twenty-five-year-old woman who worked at a bank. On December 2, 1967, Denise’s young life ended when a car struck her and her mother, Myrtle, as they crossed a street after leaving a bakery. Myrtle died at the scene, and Denise was brought to Groote Schuur in critical condition with a crushed skull.

  When Denise’s neurological injury was determined to be nonsurvivable, her father, Edward Darvall, was approached about donating her heart to Mr. Washkansky. Despite having just lost his wife and daughter, Mr. Darvall somehow mustered the strength and selflessness to donate his child’s heart.

  In 1967, the law in the United States required that the heart stop beating before a patient could be declared dead and an organ harvested. In South Africa, a brain-dead patient with a still-beating heart could be declared dead by the consensus of two neurosurgeons, and theoretically the heart could be removed while it still beat, a far better option from the standpoint of graft and, likely, recipient survival.

  On December 3, Louis Washkansky and Denise Darvall were taken to separate operating rooms. Barnard told David Cooper that although South African law would have permitted him to remove the still-contracting heart, he decided to wait for the heartbeat to cease:

  I decided I would not take out Denise’s heart while it was beating, not even open the chest. I was scared that I would be criticized. Although we had discussed it with the forensic medicine people, and they said it would be no problem, I decided not to do that. When we had Washkansky’s chest open and we were ready to connect him to the heart-lung machine, I went to the donor and I disconnected the respirator myself. We waited. She didn’t breathe. After about five or six minutes, her heart went into ventricular fibrillation. I then said to my colleagues to open the chest and remove the heart.

  Marius Barnard, Christiaan’s brother and a crucial member of the surgical team, told Donald McRae for his book Every Second Counts that the process of waiting for the donor’s heart to stop beating was more complicated than that. According to Marius, disagreement arose among some team members who were opposed to removing Denise’s heart while it was still beating. To shorten the time it would take for the heartbeat to cease after Denise was taken off the ventilator, the donor was given an injection of potassium, which stopped the heart (an at-best ethically ambiguous action), and then harvesting began.

  Marius told Life magazine:

  Now we’ve got the heart in a donor, oxygenated and being cooled. We’ve got the recipient, on the bypass machine, also being cooled and ready. Now things are going. Now the whole thing is on. Now we remove the heart of the recipient and cut out the heart of the donor.

  Using the techniques pioneered by Richard Lower and Norman Shumway, Barnard sutured Denise Darvall’s twenty-five-year-old heart into Louis Washkansky’s chest. After all the suture lines were complete, the heart was defibrillated with an electrical shock. Marius’s description in Life captured the moment history was made:

  Right away after the shock, the beat started. It was a nice beat, you know. When the heart is beating right, you’ve got a kind of screwing action. And you can immediately see that it’s all right. . . .

  Then comes the moment when you stop the bypass. Now the heart is on for the first time, on its own. Now that heart’s got to do all the work for the body.

  The news of the transplant rocketed around the world, and Christiaan Barnard became a worldwide celebrity.

  • • •

  Three days later, on December 6, 1967, Dr. Adrian Kantrowitz became the first surgeon in the United States to perform a heart transplant and the first surgeon anywhere else in the world to perform the operation on a child when he transplanted the heart of an anencephalic baby into the body of two-and-a-half-week-old Jamie Scudero, an infant dying of a congenital heart defect called tricuspid atresia. The baby initially appeared to do well, with his heart rate and respiration near normal, but seven hours later, the heart suddenly stopped, and the child could not be resuscitated. Kantrowitz told the New York Times, “We were trying to make one whole individual out of two individuals who did not have a chance for survival.” At his press conference, Kantrowitz credited Dr. Norman Shumway with developing the techniques used for the transplant operation. Kantrowitz also made sure people understood that he considered his first procedure a failure.

  Two weeks later in Cape Town, on his eighteenth postoperative day, Louis Washkansky died from pneumonia, probably related to the strong immunosuppressive regimen of radiation, azathioprine, actinomycin C, and prednisone.

  Shumway’s first transplant would come on January 6, 1968, when he placed the heart of a forty-three-year-old woman, who had died from a cerebral hemorrhage, into the chest of a fifty-four-year-old retired steel worker suffering from congestive heart failure following a large myocardial infarction two years earlier. Shumway’s patient lived for fifteen days but died after a steady stream of complications.

  A few days before Dr. Shumway’s initial transplant, Christiaan Barnard operated again. This patient was Philip Blaiberg, whose surgery was a landmark in its own right. Not only did the fifty-eight-year-old dentist survive to be discharged from the hospital, he lived for another eighteen months, proof of the concept that a patient with a heart transplant could “return to life.” The operation pierced another barrier too: Blaiberg, who was white, had received the heart of Clive Haupt, a twenty-four-year-old man described as “colored” in the language of apartheid-era South Africa.

  Dr. Blaiberg’s longevity helped to fuel explosive enthusiasm for heart transplantation. During the months following Christiaan Barnard’s first operation, 102 transplants were performed around the world, unfortunately often with dismal results, some by surgical teams unsuited for the demanding operation. Soon many of the groups would abandon cardiac transplantation.

  Shumway persevered and continued to innovate, focusing on strategies to identify patients with rejection and new drugs to prevent it. In the first group of patients transplanted at Stanford University from 1968 to 1971, survival was 49 percent at six months and 30 percent at two years.

  In the early years, EKG and echocardiographic changes were used to detect graft rejection, but in 1973, Shumway’s program began using endomyocardial biopsy, a safe and easy-to-accomplish procedure whereby a slim biopsy catheter is inserted via a needle stick in the neck and guided to the heart, and a tiny piece of myocardium retrieved for analysis by a pathologist. This technique allowed not only the early identification of rejection, but also the identification of patients in whom the doses of the powerful antirejection drugs might
be decreased.

  In 1980, Dr. Shumway began using cyclosporin A, a new antirejection drug isolated a decade earlier from a soil fungus, which was very effective in preventing rejection. By 1985, the five-year survival rates for patients undergoing cardiac transplantation had soared to 70 percent.

  Norman Shumway died in 2006 at the age of eighty-three, leaving behind a remarkable legacy. According to the United Network for Organ Sharing, in 2011, 21,457 adult heart transplant recipients were alive in the United States.

  • • •

  Mrs. Cheney had a party for the vice president when he finally made it home after getting his VAD. Too weak to walk more than a step or two, Mr. Cheney was assisted to a reclining chair in the master bedroom, and that is where we feted his homecoming. Mrs. Cheney served cake, and she had presents for the doctors and nurses who had cared for her husband. The occasion had the feel of a birthday party.

  During the vice president’s long hospital stay, Mrs. Cheney had asked me if I was going to take my family on a summer vacation. I told her that I wouldn’t be going anywhere until the vice president was out of the hospital and that I would figure it out at that time. Now, in the second week of August, I still hadn’t given it much thought. As I stood in the bedroom munching on cake, Mrs. Cheney handed me an envelope, which contained a note and a key to their home in Jackson.

  August 9, 2010

  Dear Jonathan,

  This is a present you have to give back, but only after you & your family have enjoyed Wyoming.

  I can’t begin to express the enormous gratitude all Cheneys feel for the support & friendship you have been so generous with over the last month—and the last years. You have a special place in our heart and nothing will make us happier than thinking of you in Wyoming with your wonderful family.

  At the end of August, Charisse and I took our daughters, Molly and Jamie, to Wyoming, where we rode horses, rafted the Snake, went to the rodeo, and hiked to a lake where we watched a moose drink from the cold mountain water. Cheney loved this place, its crisp air and jagged Teton skyline. It was easy to understand why. Before the vice president got the VAD, I had promised him he would see Jackson again, and although the summer had been rocky, with a little luck I would keep my word.