The Heart Healers (26 page)

In London reporters asked the South Africa House whether Dr. Blaiberg was classified as white or black now that he possessed Haupt’s heart. Blaiberg survived hospitalization to become an international celebrity. He lived for nineteen and a half months after the transplant.

Around the world, I witnessed the ethical barrier to human heart transplantation crumble in the face of the media reaction. Three days after Barnard’s announcement, Dr. Adrian Kantrowitz transplanted a human heart in a child at Brooklyn’s Maimonides Medical Center. Kantrowitz’s patient died within the first twenty-four hours.

Several days after Blaiberg’s surgery, Norman Shumway was allowed to perform his first cardiac transplant at Stanford. In proving the technical feasibility of heart transplantation, the Washkansky and Blaiberg surgeries had somehow also dismantled the ethical and administrative barriers surrounding the definition of death.

The intense publicity stimulated virtually every leading cardiac surgery program to perform cardiac transplantation. Drowned out in the clamor were the voices of nonsurgeons like renowned cardiologist Helen Taussig who hoped that “surgeons will proceed with extreme caution until such time as a cardiac transplant will not announce the imminence of death but offer the patient the probability of a return to a useful life for a number of years.” I shared Taussig’s deep skepticism. Over the next year ninety-nine heart transplants were performed around the world.

The stampede to perform cardiac transplantation devolved into a catastrophic embarrassment.

In the year that followed Washkansky, almost every patient died in the postoperative period because the surgeons had little knowledge and few tools to monitor or treat tissue rejection. In cardiology our past informs our present. I would like to say that from this experience we learned that even potentially great advances must be analyzed carefully before widespread implementation. As the deaths accumulated, most surgical programs abandoned heart transplantation. In 1971, just three years after the initial furor, only seventeen transplants were performed in the entire world, and only four cardiac transplant programs remained; all the rest had quit. Those four programs stood as testimony to the power of mentors: all four were directed by surgeons who had direct ties to Walton Lillehei.

Barnard, the Hare in the race to cardiac transplantation, performed only nine cardiac transplants in the next six years. The handsome, charming forty-five-year-old son of a poor Dutch Reformed minister was drawn like a moth to the incandescent flame of public adoration. He was more often seen in nightclubs than in operating theaters. He toured the world, his clean-cut features and dazzling smile adorning magazine covers in every language. Paparazzi pictured him with a different beautiful woman on his arm at each public event. Although married, he gloried in a much-publicized torrid love affair with 1960s iconic sex symbol Italian actress Gina Lollobrigida, and often dated actress Sophia Loren. The new rage became not the surgery, but the man himself. Photographed, interviewed, fawned over, and lionized like no other physician in modern times, he was received by the Pope in Rome and entertained by President Johnson in the United States. Barnard’s wife of twenty-one years, a nurse who had helped support him in his early years, divorced him within two years. After a few years of gallivanting, Barnard married a glamorous teenage daughter of a multimillionaire.

Cardiology reacted badly as Barnard donned the media-bestowed mantle of father of cardiac transplantation. Although part of our reaction, particularly in the United States, reflected loyalty to Shumway, much of the reaction was a direct response to Barnard’s own behavior. He traveled to the United States as an invited honored lecturer soon after the Blaiberg surgery. Richard Lower told historian David Cooper, about Barnard’s lack of political savvy: “I felt terribly sorry for Chris because he was smart in a lot of ways but he was really stupid when it came to this transplant thing. All the early pioneers of heart surgery and heart transplantation were in the audience. Chris could have shown a little humility, and said … ‘we built on what a lot of you had done.’ But he never once acknowledged anybody except himself. Every other word was ‘I’ … I don’t think anyone talked to him until he went out of the front door of the hotel and was mobbed by the press and the teeny-boppers. I thought ‘Gosh how stupid he was. He could have had the whole thing. Besides being so extraordinarily popular with ordinary people, young people and beautiful girls, he could have had the profession too if he had just turned that corner. But he couldn’t do that.” He left the nation’s cardiac surgeons with the impression that he was cardiology’s quintessential narcissist.

To me, the difference between Barnard and René Favaloro, which was profound, is captured in how they dealt with a surgical death. Here’s Barnard:

I have stood at patients’ beds when they died, and I’ve been upset with everybody around me … but I realize what I’m really upset about is that when I write up my series of operations, I have one more mortality. It wasn’t really the death of the patient … it is the ego that is hurt. I should not have a death … I’m too good for that.

Favaloro experienced a patient’s death quite differently:

I suffer with every single death of my patients … The day that I don’t feel the sensation that I am the guilty one, then I will drop the knife and I won’t operate anymore. I don’t mean “guilty” but “responsible” for the life of the patient. That is the feeling … The deaths associated with surgery are personal and the surgeon must endure their burden as long as he lives.

Narcissist vs. Humanist? Barnard showed me how ambition and acclaim could obliterate compassion; Favaloro held fast to benevolence and humility in spite of fame. Favaloro’s country doctor values transported me back to my reverence for a doctor’s humanity as a child in the cocoon beneath my father’s living room table, helping me find the balance between ambition and compassion.

Cardiology began to give Barnard the silent treatment that had engulfed Lillehei after his indiscretions. But Christiaan Barnard was not intimidated by his colleagues’ rebuff. He was a different breed. The more cardiology rejected Barnard, the more he stuck his finger in the profession’s eye. Here’s Barnard again:

I have heard the Americans say in front of me that I stole the idea from Shumway. As far as that is concerned, after all that these people had published, I ask, “Do they publish it so other people can learn from it or is it a secret after they have published it?”

In the spirit of science, Barnard was absolutely correct. All scientists stand on the shoulders of those who went before them. Ideas are free. But the Americans were right in a more subtle way. Barnard had taken the final relatively straightforward technical step in an incredibly difficult ten-year quest pioneered by another man. Any competent cardiac surgeon could take that last step (and, as soon as the ethical barrier was lifted, many did). Yet Barnard seemed unwilling to express the generous, magnanimous gesture of recognition for Shumway’s groundbreaking research that had made his own success possible. And so, neither side bent an inch.

Barnard found other ways to tarnish his persona. He endorsed Glycel, an “anti-aging” skin cream, which most physicians considered quackery. The cream made him wealthy, but terminally smeared his image. It was withdrawn from the U.S. market in 1987. By that time Barnard’s charisma had run dry. He was ostracized as a snake oil salesman. But Barnard had chosen his course, and was disinclined to apology. He countered by writing a sensational autobiography,
One Life
. The book was widely criticized as self-indulgent. With the help of a professional ghostwriter, Barnard also wrote several quite passable thrillers which involved skulduggery in organ transplants.

His second marriage failed after twelve years and two children. He married for a third time, this time to a model forty years his junior. When this marriage failed, also after twelve years and two children, Christiaan Barnard returned full circle, back to the Karoo region of his youth, to live on his 32,000-acre game preserve among the springbok and wildebeest. His implausible, complex, controversial, storybook life ended in a final touch of drama, with a sudden fatal asthma attack while on vacation at age seventy-nine.

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SHUMWAY PERSEVERED. IN
the 1970s his program stood virtually alone as the only center undertaking cardiac transplantation. The worldwide failure of cardiac transplantation had exposed an intimidating number of flaws in the system. Shumway and his team attacked each flaw. He worked out methods for selecting compatible donors and recipients. He stimulated a program to increase the donor pool. He worked out methods to improve organ preservation so that hearts could be transported between centers. He worked out a schedule of heart biopsies. He tested drugs to prevent rejection. Eventually Shumway found the path to more effective immunosuppression when Switzerland’s Sandoz Laboratory discovered the potent immunosuppressive agent cyclosporine. In December 1980, thirteen years after Barnard’s first heart transplant, Shumway introduced cyclosporine for the first time in cardiac transplantation. While it did not prevent either rejection or infection, the severity of these two deadly complications was sharply reduced.

In 1981, Shumway headed a team that performed the world’s first successful combined heart-lung transplant on a forty-five-year-old advertising executive, Joan Brand, who lived five more years and wrote a book about her experience. As his success rate with cardiac transplantation combined with immune suppression with cyclosporine became public, cardiac transplantation was reborn in the mid-1980s. Norm Shumway, the Tortoise, had indeed won the race to be the Father of Cardiac Transplantation. Cardiology, like all of science, awards the man who convinces the world, not the one who got there first. I first experienced that surprising insight when Dwight Harken repeated a surgery first performed by Ludwig Rehn a half century before him. And how did Norm Shumway feel about Barnard’s hopping past him on the stairway to immortality? His view was typical laid-back, generous Norm. He never bought into the resentment expressed by others; rather he found merit in Christiaan Barnard: “We were having a heck of a time trying to get our people to come around to accept brain death as diagnosis and confirmation of death. Had it not been for his December 1967 surgery, I don’t think our people would ever have submitted to acceptance of brain death … Within a year of Barnard’s case, the Harvard committee came out with the criteria of brain death. That’s the contribution I see from Chris that really helped all of us.” That remark, repeated to me personally as well, captures the essential beneficence of Norm’s character, and explains why he is my most admired surgeon.

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ALTHOUGH “EVERYONE KNOWS”
that Christiaan Barnard performed the first heart transplant in man, they are all wrong. In January 1964, three years before Barnard, University of Mississippi surgeon James Hardy, renowned for having performed the world’s first lung transplant, reached for further glory. He performed the world’s first human cardiac transplant by transplanting the heart of a chimpanzee into sixty-eight-year-old African American Boyd Rogers. A recent amputee, Rogers was semi-comatose, attached to a mechanical ventilator, and responsive only to painful stimuli. Compared to today’s documents, the consent form captures the ethics of a different era. It was a single paragraph, signed by the family since Rogers was unable to comprehend. The form does state that human heart transplantation had never been done, but does not mention the use of a chimpanzee heart. Hardy succeeded in the technical procedure of transplanting the heart, but the chimpanzee heart was too small for Rogers’s large body, and he died on the operating table. In an era of civil rights turmoil, the response of the nation was hardly positive. Hardy was invited to describe his experience at the meeting of the Transplantation Society in New York City a week later. Hardy described his reception to historian David K. C. Cooper: “When I got up to talk, the chairman William Kolff (inventor of the artificial kidney) said, ‘I want to ask Dr. Hardy a question before he begins. Dr. Hardy do they keep the blacks in one cage and the chimpanzees in another in the Southern states?’ … I gave my presentation, reporting exactly what we had done, and at the end of it, there was not one single hand raised in applause … It was a bad day.” Years later, Shumway would see the chance for another bon mot. “Hardy was an unbelievable enthusiast. But there was absolutely no evidence to suggest that the darn thing would succeed. If you’ll pardon the expression, we called it a fool-Hardy procedure.”

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MARCUS STUART SAILED
through the cardiac transplant procedure like he was a sixty-year-old. He started a battery of immunosuppressive drugs that are unpronounceable even to cardiologists. Each month for the first six months he had a cardiac biopsy for early detection of beginning rejection. As the months progressed and he did well, the biopsies became less frequent. A few months after surgery Marc remarked proudly to me, “I’ve had a heart replaced and a knee replaced, and believe me the knee was harder.”

A few months later, I got a worried phone call on the weekend. “Jim, I am having a lot of chest pain, on the left side.”

“How bad it, on the basis of one to ten?”

“It’s pretty severe, say seven on the basis of ten. It is not going away. I am worried that it’s my new heart.” It certainly sounded that way. Rejection is the feared disaster of transplantation. It is treatable, but it can be lethal. What terrible luck, I thought.

Except … otherwise he felt fine. Marc had no other symptom. No fatigue, no shortness of breath, no cough, no pain on exercise. Absolutely nothing. “Nothing at all? No tenderness? Nothing?” I repeated, looking for an alternative explanation.

“Well, actually, the skin itches in the same area where the pain is.”

“Marc, I could walk up the beach and put a stethoscope on your chest, but it’s not enough. You need to get to an emergency room and have an ECG. But don’t panic … there’s an excellent chance that this is nothing serious.”