An amazing race (book excerpt: Every Second Counts)

During the 1960s, four surgeons competed to become the first to complete a human heart transplant. South African-born author Donald McRae details the race.

By Donald McRae, amednews correspondent — Posted Dec. 11, 2006

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The operation itself would be relatively uncomplicated, a replica of his hundreds of dog-heart transplants. Kantrowitz knew the primary battle would be the fight against rejection. How the human body would react to a transplanted heart remained uncertain. Yet he was convinced he had been cannier than Shumway and Lower in choosing an infant transplant. His research on puppies echoed earlier scientific findings that an undeveloped immune system was more likely to accept a transplanted organ. Even without any immunosuppressive drugs, one of his frisky dogs was still alive 119 days after receiving a new heart.

Looking down at Jamie Scudero, Kantrowitz forgot about Shumway and Lower. He confronted forces more powerful than any of them. A combination of deadly cardiac flaws -- pulmonary atresia with patent ductus arteriosus as well as atrial and ventricular septal defects -- lurked deep inside the baby.

Kantrowitz had been at this exact point 18 months earlier, when he had tried to save the small Gypsy boy by using the heart of an anencephalic baby born to Richard and Rhoda Senz. The raw drama of that night still haunted him, but he was determined to try again. A few weeks before he had attempted that transplant, in June 1966, Kantrowitz had made the front page of The New York Times with the news that, during a groundbreaking six-hour operation, he had implanted the world's first permanent left ventricular assist device, described wrongly by some journalists as "an artificial heart," into the chest of a terminally ill 63-year-old woman, Louise Ceraso.

Her breathing and circulation improved markedly after her operation and yet, 13 days later, with Kantrowitz at her bedside, she died on May 31, 1966. The success of the actual implantation, and his familiarity with death, did not lessen his distress. "When you lose a patient," Kantrowitz said, "you can only feel a sense of failure."

His fierce desire to save hearts remained. Brushing aside the likelihood of yet more international publicity for a modest community hospital in Brooklyn, he pressed ahead with his plan to transplant a human heart. The administrators recoiled in alarm. Cardiac transplantation still seemed a step too far -- even for Kantrowitz.

Yet he was driven on by the knowledge that, in 1966, he had been the nearest of all four to grabbing the grail. He had deliberately not revealed any details of his previous human transplant attempt at the surgical conferences where he often met Shumway and Lower. Kantrowitz respected his rivals but believed that daring, as much as methodical preparation, would be just as vital when the first human heart was finally transplanted. He was convinced the discrepancy in their characters was one of the reasons why Shumway seemed to have taken a subtle dislike to him. Shumway was more measured while Kantrowitz was decidedly brash. Shumway engaged in discourse with Nobel Prize winners in the California sunshine while Kantrowitz walked among the braided and black-clad Hasidic Jews in a New York ghetto. Shumway was cardiac transplantation's solid pioneer, Kantrowitz the risk-taking experimentalist who planned to salvage the heart on two fronts -- through mechanical assist devices and transplantation.

The race, for Kantrowitz, had been condensed into its own tight little triangle. Shumway at Stanford, Lower in Richmond, Kantrowitz in Brooklyn. While there existed a polite wariness between Kantrowitz and Shumway, Lower was warm and open. Still, Kantrowitz regarded it as natural that even he and Lower did not swap anecdotes about their respective plans. Some details of the race demanded discretion.

At least they agreed that they were all hampered by timid medical committees and ignorant legislators who refused to sanction brain death as a permissible concept in the United States. Kantrowitz would have liked to take a living heart from a brain-dead patient -- but the law suggested that he might be charged with murder.


This next excerpt describes Dr. Barnard's victory.

Chris Barnard lifted the small heart out of Denise Darvall's chest with his gloved hands. He placed the heart in the container.

"Okay," he said, taking the dish from Marius, "here goes..."

Slowly and carefully, his eyes never leaving the heart, he walked the 31 steps separating one operating room from the other.

In Theater A, at the head of the table, he gave the heart to Peggy Jordaan. He swung back to Washkansky's opened chest.

Barnard cut the aorta close to Washkansky's heart, but, using a technique he had seen Dick Lower apply in Virginia, he left behind more tissue than he needed. He cut the pulmonary artery in the same way and prepared for the six smaller vessels. After a few more minutes, the chambers were opened and he cut down through the septum -- allowing the heart to fall back into its cavity.

When Barnard lifted Washkansky's bloated heart up and out of him, he looked down into the blasted and empty hole of his chest. It was huge. Barnard felt the enormity of the moment, and wrote later of a chill ripping through him as he stared into the chasm. "I had never seen a chest without a heart or with such a hole -- as though the hole itself was fixed and permanent, while the man, with his chest split open, was merely a temporary object, existing briefly around the hole. And, in fact, it was just that -- something few men had ever seen: a human being without a heart, yet held in life by a machine eight feet away."

Barnard understood the profundity of what he was about to attempt, but he did not have time to linger. He nodded to Hewitson, who then delicately placed Denise Darvall's heart into the chest of Louis Washkansky.

"For a moment I stared at it, wondering how it would ever work. It seemed so small and insignificant -- too tiny to handle all the demands that would be put upon it. The heart of a woman is 20% smaller than a man's, and the heart of Washkansky had created a cavity twice the normal size. All alone, in so much space, the little heart looked much too small -- and very lonely."

The surgeons began to sew and stitch. They worked mostly in silence, as they attached the heart to its new home. When they reached the aorta, they decided to cut the machine so that they could work without perfusion and remove the catheters and clamps to give them more space. It took 19 minutes to cut and shape the aorta and then complete the anastomosis. The heart had turned blue.

At 5:43 a.m. that Sunday morning, Barnard released the venous snares and allowed the blood to flow once more. The heart tensed as warm, oxygenated blood flooded into the muscle. Slowly, it turned pink and began to fibrillate. Ozinsky injected 100 mg of suxamethonium into the heart-lung machine to prevent Washkansky's body from jerking violently when they shocked the heart.

Barnard called for the paddles. Peggy Jordaan passed him the two gray discs, wired up to the defibrillating machine, which he attached to each side of the heart. Hewitson inserted a sucker into the pericardial sac to drain excess blood.

"Go ahead," Barnard said quietly, "shock it."

Ozinsky sent a 20-joule charge into the heart. "For a moment," Barnard wrote, "the heart lay paralyzed, without any sign of life. We waited -- it seemed like hours -- until it slowly began to relax. Then it came, like a bolt of light. There was a sudden contraction of the atria, followed quickly by the ventricles in obedient response -- then the atria, and again the ventricles, Little by little it began to roll with the lovely rhythm of life."

As soon as they switched off the machine, the transplanted heart faltered. The blood pressure dropped to 70. Barnard ordered them to revert to the pump. They waited five nervous minutes before they tried again. The same pattern occurred. Barnard remembered grimly how many dogs he had lost when he could not wean them off the machine.

At 6:13 a.m. they made another fretful attempt. "Cut the pump," Barnard said.

There was another hesitation in the heart, as if it was deciding whether or not to live in its huge new body, and then it began to beat more strongly. The pressure soared back up to 90.

"Jesus, dit gaan werk!" Barnard said, reverting to Afrikaans. Jesus, it's going to work!

He looked around the room. "Eyes over masks blinked back," he remembered later, "moist with joy and wonder. In the theater the tension of silence broke with mixed sighs, mumbled words, and even a little laugh. All of us, like the heart itself, were suddenly sure of ourselves."

Barnard had won the race. He had become the first man to transplant a heart from one human being to another. The surgeon watched it beat for another minute more and then, smiling behind his mask, he removed the last catheter and tied the purse-string suture. The heart pulsed steadily and determinedly. A solid echo of its beat resounded from the EKG. The machine lit up with a perfect green pattern on the black screen.

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Author Q&A

How did this medical journey become a race, and how did the four physicians become aware of what the others were doing?

Shumway and Lower never actually for the first five or six years considered that they were in competition with anyone else because they were so far ahead. There was no question in the minds of Stanford [University leaders] that they were going to do the first human heart transplant. They would meet other teams, and I think they became aware that Kantrowitz was working well and his team was moving forward. Shumway and Lower always felt they wanted to downplay the fact that they were attempting to be the first. When Lower went to Virginia in '65, they would have this little joke between themselves, because they were best buddies, [about] who would be first. They never actually believed that anyone else would beat them to it. ... [Kantrowitz] said there was no doubt that we were vying against each other. They would meet at surgical conventions, each put their paper forward and they would be amiable with each other. But there was always this undertone of tension.

Was there much animosity among the doctors?

Shumway and Barnard go back a long way. In 1956, Barnard went to Minnesota. Norm Shumway was there as well. ...They never liked each other because they were total opposites. Barnard was a quite deeply ambitious South African who didn't have a lot of subtlety to his personality. He could be charming, but he was quite forceful in making himself heard. Shumway was much more the quiet and witty man. Most people in Minnesota saw Shumway as their coming star. Barnard was dismissed as this bit of a nut from South Africa. I think that made Barnard feel, "I'm going to show these guys what I can do."

How did the competition affect the final outcome?

It pushed them harder. Kantrowitz was being pushed by Shumway and Lower, and I think to a certain extent, Shumway was being pushed by Kantrowitz. And then Barnard knew he was so far behind, he had to move so quickly. The fact that he was the first, a large part of that was due to his urgency. And he knew how far ahead the U.S. surgeons were and he had to take shortcuts, which is what he did.

What should today's physicians take away from the story of these surgeons?

Although this book does focus on competition between surgeons, the underlying message I got, and I hope the books conveys, is that for all their competition, ultimately they were working to save lives. It came out again and again how dedicated these surgeons were. Even Barnard, for all his lust for fame, was enormously compassionate towards his patients and he cared intensely about them. They all had this feeling that although personally it would be a huge achievement for one of them to be the first, they also knew it would be a landmark step for medicine. ... These doctors had the dedication. They had the compassion. And they were in the business of saving lives first and foremost.

Interview by Damon Adams

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