Fifty years ago this week, heart surgeon Christiaan Barnard performed the world’s first successful heart transplant in Cape Town, South Africa, initiating a flurry of heart transplantation across the United States and throughout the world.
But within a few years, enthusiasm had waned. In 1968, 104 transplant procedures were carried out, but only 10 patients survived. Results for the next three years were similarly disappointing: 170 transplants with 24 survivors. In 1970, only 18 heart transplants were performed around the world.
By the late 1970s, only a handful of medical centers—including Columbia’s—were performing heart transplants. Columbia’s chair of surgery at the time, Keith Reemtsma, initiated a transplant program in 1971 and led its first cardiac transplant in 1977 at Presbyterian Hospital (now NewYork-Presbyterian Hospital). By the early 21st century, Columbia and NYP had built one of the largest heart transplant programs in the United States. It has now transplanted hearts into more than 2,500 patients.
The First Steps in Cardiac Transplantation
The road to the first heart transplant in 1967 was paved by researchers at Stanford. In 1958 Norman Shumway and his associate, Richard Lower, who later moved to the Medical College of Virginia, began experimenting in animals and had perfected their surgical techniques by the late 1960s. Adrian Kantrowitz, a cardiac surgeon at Maimonides Hospital in New York, also conducted hundreds of similar experiments, and the three were considered to be the most likely to perform the first human heart transplant.
But all three American surgeons faced the same obstacle: Possible donors were considered dead only after all heart activity had ceased. Waiting usually meant that the organ was unsuitable for transplantation.
Dr. Barnard, who had visited Dr. Lower in 1966 and observed transplants in animals, decided to perform a human heart transplant on his return to South Africa, which did not impose as many requirements on transplantation.
After performing some transplants in animals, Dr. Barnard transplanted the heart of a 25-year-old car accident victim into the chest of 53-year-old Louis Washkansky on Dec. 3, 1967. Mr. Washkansky died 18 days later of pneumonia, yet Dr. Barnard’s transplantation was considered successful.
Cardiac Transplantation Frenzy
Following Dr. Barnard’s bold move, organ transplantations started all over the world, long before doctors fully understood the working of the immunologic defense system.
Three days after the first heart transplant by Dr. Barnard, Dr. Kantrowitz performed the first transplant in America, transplanting a heart into a baby on the assumption that the baby’s immature immune system was less likely to trigger rejection. The baby lived for only a few hours. In January 1968, Dr. Shumway performed the first transplant at Stanford; his patient also lived for 18 days.
Transplantation at Columbia
At the same time that many centers were closing their heart transplant programs, Dr. Reemtsma started Columbia’s organ transplant program as part of an investigational surgery program.
“When we got started those of us who participated in the program spent some time with the Stanford group,” says Ronald Drusin, MD, a cardiologist who is now vice dean for education at P&S. “Drs. Reemtsma and Shumway were very close and Shumway was very helpful as a consultant and adviser. That helped us develop our program quickly.”
Columbia’s first cardiac transplant performed by Dr. Reemtsma in 1977 allowed the patient to survive for 14 months. Eight more heart transplants were performed by Dr. Reemtsma by July 1979, when the New York Times wrote about increasing interest in the procedure.
The program took off with the arrival in 1983 of cyclosporine, an immunosuppressant first used in kidney and liver transplants. “Our success rate went up significantly and we developed a large waiting list,” Dr. Drusin says. “We were more accommodating than other centers. We accepted patients who were perhaps sicker than those at other centers.”
“We developed a new way to approach transplantation, which also set us apart,” adds Craig Smith, MD, who completed his cardiothoracic surgery residency at Columbia in 1984 and is now chair of surgery at P&S. “We viewed the waiting list as a 24/7 365-day responsibility and we were prepared to do the transplants whenever they came up. At that time, there weren’t necessarily enough surgeons and cardiologists at other medical centers to do that.”
The Columbia program also pioneered children’s heart transplants, which resulted in the world’s first successful pediatric transplant in 1984. The cardiac transplantation program continues to lead innovative research, including the first use (in 2001) of the left ventricular assist device (LVAD) as a viable alternative for patients with heart failure who are not eligible for a transplant.
By the early part of this century, Columbia’s program transplanted an average of 100 to 120 hearts per year; in 2005, a record was set for the most transplants performed by a single center. In recent years, more hospitals have opened heart transplant programs. Columbia now performs about 50 adult transplantations and 15 pediatric transplantations each year.
While cardiac transplantation evolved impressively over the past 50 years, the field continues to face obstacles, including slow graft loss, known as chronic rejection, and a lifetime of immunosuppressant treatment. Two Columbia researchers, Megan Sykes, MD, and David H. Sachs, MD, are leaders in research seeking to identify ways to coax the immune system by using bone marrow to allow patients to better tolerate transplanted organs. Success could enable transplant patients to forgo lifelong drugs for immunosuppression.
“Like all fields of transplantation, cardiac transplantation continues to evolve,” says Dr. Smith. “Columbia’s historic contributions to the development of the field have kept us in the forefront of the quest for solutions to the challenges that remain. We are proud of what we have accomplished for thousands of recipients of hearts here and elsewhere but we also are focused on how future recipients can benefit from our research and ongoing surgical improvements.”