Recollections of the Early Years of Heart Transplantation and the Total Artificial Heart (2011)

Finding a reliable substitute for the human heart remains a goal of modern-day surgical researchers. I am fortunate to have been involved in much of the early work in this area and would like to tell some of that story in this editorial (Fig. 1). Denton A. Cooley. In December 1967, Dr. Christiaan Barnard, of Cape Town, South Africa, announced that he had performed a heart transplant in 55-year-old Louis Washkansky. As the most exciting event in the modern era of cardiac surgery, Chris' feat captured the imagination of both the medical profession and the world at large. Although Mr. Washkansky died after 18 days, Chris was not discouraged. A month later, he performed another transplant, this time in a 55-year-old dentist named Philip Blaiberg, who had a successful outcome and survived for 19.5 months. Chris' success raised him to a pinnacle of fame and stimulated widespread interest in heart transplantation. Actually, Dr. Norman Shumway, of Palo Alto, CA, USA, and his colleague, Dr. Richard Lower, of Richmond, VA, USA, had been working experimentally with a similar technique and were on the verge of performing the same procedure themselves. Their stumbling block was defining the characteristics of a suitable donor. Chris Barnard was able to establish the concept of brain death, that is, the irreversible cessation of brainwave activity, as determining the moment of death. Once that concept was accepted, it paved the way for further organ transplants. Many cardiac surgeons were eager to participate in the new field. Just 3 days after Barnard's first transplant operation, Dr. Adrian Kantrowitz, in Brooklyn, NY, USA, attempted a transplant in a 19-day-old child, who did not recover from the operation. In January 1968, Dr. Shumway performed a heart transplant, but the patient survived for only about 2 weeks. At that time, I was at Baylor College of Medicine in the Department of Surgery, which was headed by Dr. Michael DeBakey. Like others, I had also been thinking about transplanting the human heart, and once the way was paved, I decided to get in the game. On May 2, 1968, I was in Shreveport, LA, USA, giving a talk to the medical society there. Before my talk, reporters had asked whether I was planning to do a transplant, and I said no. Ironically, a couple of hours later, I got a call from Dr. Bob Bloodwell, one of my associates in Houston. He told me, “Boss, I think we've got a donor. A 16-year-old girl, over at Ben Taub Hospital, shot herself in the head, and I have permission to take her heart.” That evening, I chartered a plane and returned to Houston. The next morning, we proceeded with the transplant. Those reporters picked up the newspaper and saw that I had done a heart transplant just 24 h after telling them I had no plans for one. They accused me of deceiving them. However, it just happened that, owing to the resourcefulness of Bob Bloodwell, a donor became available. The patient, 47-year-old Everett Thomas, was dying of calcific multivalvular disease. As I sutured the donor heart into his chest, I couldn't be completely sure that it would work. The transplant itself took only 35 min. The 5 or 10 min during which my team and I waited for the heart to begin beating strongly and regularly were some of the most anxious moments of my career. When the organ did begin to function properly, we felt as if we had witnessed a miracle. After recovering postoperatively, the patient was discharged from the hospital and even returned to work. That transplant was probably the first successful one performed in the United States. Dr. DeBakey learned about it when he read the headlines in the morning paper. Earlier, he had formed a committee to explore the possibility of transplantation, but I had not been included. Because I had my own busy surgical practice, I did not feel an obligation to let him know my plans. In any event, the experience increased the rift between us, which had begun when I decided to move my surgical practice from Methodist Hospital to St. Luke's Episcopal and Texas Children's Hospitals (which were joined at the time), so that I could have more autonomy. In those early days, the transplant procedure offered enormous promise. My team and I worked hard to establish our cardiovascular program as one of the most progressive in the world. After our first case, we performed eight transplants within a couple of months and had seven healthy survivors. I think that one day we even did two transplants. By November 1969, our series included 20 patients, one of whom had a combined cardiopulmonary transplant and another of whom underwent retransplantation. The heart and double lung transplant, the first such operation in the world, was performed on a desperately ill 2-month-old girl. Our successes were not just isolated events: all of our transplant patients reached the recovery room with a vigorously contracting heart. At news conferences, we took great pleasure in presenting the survivors, dressed in street clothes and appearing quite normal. Some of them were later able to leave the hospital, and a few even returned to work. Our longest survivor lived for just over 16 months. In view of their critical preoperative condition, these patients certainly benefited from their transplants, and the extra months of life granted by this procedure cannot be discounted as insignificant. The advent of cardiac transplantation, in the late 1960s, coincided with the first trip to the moon and other space explorations of that time. Indeed, the National Aeronautics and Space Administration (NASA) was located on the outskirts of Houston, and the astronauts were familiar members of our community. The Cold War was going strong, and the Union of Soviet Socialist Republics (USSR) had surpassed the United States by launching Sputnik and later sending the first human, Yuri Gagarin, into orbit around the earth. Both nations were engaged in an intense competition for international prestige. However, the USSR had not performed any cardiac transplants, and American heart surgeons intended to keep the lead in this field. The next breakthrough in cardiac surgery was sure to be the implantation of a total artificial heart (TAH), and I was determined that it would take place at the Texas Heart Institute, which I'd founded in 1962. Much of the initial work on TAHs was done in the 1950s in Dr. Willem Kolff's laboratories in Cleveland and later in Salt Lake City, but that group never implanted a TAH in a human being. One of Kolff's associates was Dr. Domingo Liotta, who was hired by Baylor in 1961 to work on a grant Dr. DeBakey had obtained for researching a TAH. Dr. Liotta became a colleague and friend of mine. He was discouraged because he would try to talk to Dr. DeBakey about his progress with the TAH and to find out when it might possibly be used clinically. Dr. DeBakey refused to consider such a thing. Dr. Liotta felt that his career was being kept on hold, so in 1968 he came to talk with me. He felt that I was the most experienced heart surgeon in the world at that time and asked whether I would be willing to get involved with developing a TAH and possibly using it alone or as a bridge to transplantation. Dr. Liotta's plan included using Dacron embedded in Silastic to construct the TAH's expandable membrane, using Wada-Cutter hingeless valves to decrease thrombus formation, and obtaining additional engineering support to produce a pneumatic drive console suitable for human implants. I agreed and used my own funds, as well as some money from a small grant I had obtained from one of the American Heart Association chapters. Though I was a fulltime member of the Baylor faculty and deserved access to the Baylor laboratory, I realized that if I sought Dr. DeBakey's permission to proceed, he would be very negative about the whole thing. In the spring of 1969, we completed the fabrication and testing for a double-chambered TAH, which was about the same size as a human heart. Blood flow was channeled through Dacron-lined inflow cuffs and outflow grafts and four Wada-Cutter hingeless valves. We not only performed extensive bench tests on the TAH but also implanted it in seven calves, the last of which survived for 44 h. Because the air-driven pump was connected to a power unit as large as a refrigerator, patient mobility would be severely restricted. We were convinced, however, that the TAH could be more effective than the cardiopulmonary bypass machine in sustaining the life of a human patient dying in the operating room after a failed cardiac repair and could also serve as a bridge to transplant. We believed that the time had come to try using the artificial heart clinically. Among several patients awaiting cardiac transplantation at our hospital was 47-year-old Haskell Karp, a printing estimator from Skokie, IL. Mr. Karp had extensive, irreversible cardiac failure, complete heart block, and angina caused by diffuse coronary artery disease. His greatly enlarged heart was generating very little output, so he was a good candidate for a transplant, although he wanted me to try to remodel his heart first via a ventricular resection procedure before proceeding with a transplant. I talked with him and received his agreement that if his heart could not be repaired, his life would be supported with the TAH as a bridge to cardiac transplantation, as there were no donors immediately available. He was in extremely desperate condition, and he readily agreed to this arrangement. On April 4, 1969, after undergoing an extensive repair, the patient's left ventricle was still too diseased to sustain life, and he could not be weaned from the heart–lung machine. Therefore, we made the decision to implant the TAH. Dr. Liotta assisted in the operation. Once emptied of blood, his old heart collapsed like a deflated basketball; its ventricular cavity and papillary muscles had been mostly replaced by scar tissue. Implantation of the TAH was completed without any problems. Mr. Karp soon regained consciousness and was able to move his fingers and toes. Once the breathing tube was removed from his throat, he was able to speak a few words. We were gratified, even exuberant. It took us several days to obtain a suitable donor heart. That was a saga in itself because Dr. DeBakey had called a moratorium on donations from Houston hospitals. We put out a request to the news media and a lot of other cardiac centers and finally found a donor in Massachusetts. We sent a team there in a Learjet to pick up the donor and transport her to Houston; a nurse and technician aboard the aircraft would keep the heart beating until we could harvest it. Unfortunately, however, the Learjet lost hydraulic control and had to make an emergency landing on a military airfield near Shreveport, LA, USA. There the donor was transferred to another Learjet and flown on to Houston, where the plane was met by an ambulance at Hobby Airport, about 13 miles from THI. On the way to our hospital, the donor's heart developed ventricular fibrillation. It continued fibrillating for 15 or 20 min. As soon as the donor arrived at our emergency room, we applied defibrillator paddles to the heart and were able to resuscitate it. Sixty-four hours after being implanted, the TAH was removed from Mr. Karp and replaced by the donor heart. So this case involved not only the first use of a TAH but also the first so-called bridge to transplantation. The transplanted heart worked well for 32 h, after which the patient died of overwhelming pneumonia. Unfortunately, his immune system had been compromised by the antirejection drugs (this was before the improved drug cyclosporine became available). We had accomplished our goal technically, but these other factors prevented a successful outcome. A number of scientific and clinical groups hailed this effort at cardiac replacement as a milestone in cardiac surgery. Others were sharply critical, claiming it to have been premature and unjustified. At first, the media were quite supportive. Later, they were just as negative as they had originally been positive. They seemed to feast on the whole situation. It was a very trying time for me, but I kept on with my busy practice and ignored my detractors as best I could. On the day of our TAH implant, Dr. DeBakey was out of town, at a meeting of the National Heart Institute in Washington DC. On hearing about our operation, he said that we had stolen the heart and acted while he was away, which simply was not the case. He embarked on a very active campaign to have me chastised by the medical profession. I was questioned by various authorities, but they were not prepared to punish me because in such a desperate situation, any physician should feel obligated to take whatever reasonable steps might save the patient's life. The fact that it had not been done before did not mean that it should not have been tried. Eight months later, in December 1969, I made an effort to remedy this situation. I called Dr. DeBakey's secretary. I told her that I wanted to talk to Mike and at least declare a truce, so that we could discuss the future of our respective institutions. Even in the Vietnamese conflict, the soldiers declared a Christmas truce. The controversy caused my resignation from Baylor. I had hoped that this experience would stimulate further use of the TAH. Overlooked by most critics was our demonstration that a human life could be supported for several days by a mechanical device. How much easier it would have been for us simply to stand by, awaiting the patient's certain death once the heart–lung machine was discontinued! However, that would have meant a profound personal defeat for me, as I had promised Mr. Karp that I would bring him out of the operating room alive. In this case, the TAH helped fulfill my promise to do everything possible to save his life. It was a desperate situation that warranted a desperate measure. I have been called the Chuck Yeager of heart surgeons because I enjoy pushing the envelope. I like that comparison. Indeed, when appropriate, I have been willing to take an extra personal risk when others were hesitant to take a chance. As Goethe said, “Daring ideas are like chessmen moved forward; they may be beaten, but they may start a winning game.” The Liotta-Cooley TAH used for that first artificial heart implant is now part of the “Treasures of American History” display at the Smithsonian Institution in Washington DC. News of the artificial heart implantation led to my final separation from Dr. DeBakey, who was irate that I had not requested his permission for the procedure. The controversy hinged over whether the heart that Dr. Liotta and I used was the product of National Institutes of Health (NIH) research, as Dr. DeBakey claimed, or whether that heart was created with private funds. Because the heart was indeed privately funded, the only governing criteria were medical ethics and the patient's willingness to receive the TAH. I knew Dr. DeBakey's stance about implanting an artificial heart, so I did not feel any need to ask permission. Despite our differences, I was always indebted to Dr. DeBakey for giving me a faculty position and the opportunity to continue my academic career. During the 8 years in which the two of us were very close, most of the time I enjoyed being his colleague. We traveled together to Europe, along with our wives and medical colleagues. He was very generous with his time on my behalf, and I learned much from him that was helpful to me as a young surgeon. For example, he had a very strong work ethic, and I was inspired by his dedication to his work. I enjoyed reading his medical publications and was impressed with his ability to manipulate opinion at the medical center. In turn, he encouraged me to publish medical articles. A brilliant man with a wonderful mind, he made an enormous contribution to the practice of surgery. He was always an outstanding figure, not only for his personal accomplishments but also for how he has benefited Baylor and the Texas Medical Center as a whole. Basically, we drifted apart because of differences in temperament and philosophy. Our break was painful to me, but the more I thought about our differences, the more I realized that our personalities were somewhat incompatible. I do not think that our rivalry interfered at all with Dr. DeBakey's career or reputation, and it seems to have enhanced my own. I am most pleased that, in 2007, we reconciled (Fig. 2). The reconciliation was very comforting to me. That year, I presented Dr. DeBakey with an honorary membership in the Denton A. Cooley Cardiovascular Surgical Society, and in 2008, he presented me with the same honor for the Michael E. DeBakey International Surgical Society. Last year, our two surgical societies met together in joint session for the first time. Drs. Cooley and DeBakey in 2007. From the TAH implantation, much was learned that impacted the continued of TAHs and left ventricular The TAH implant that a mechanical could be used for transplantation. Therefore, in the early was from of a TAH the of which could more At that time, I a at the Texas Heart Institute to developing and testing such Our team has now the most extensive experience with and has also been involved in the of most of the used A TAH, two DeBakey is being developed by Dr. in our with from his career in this as a medical in the Baylor with Dr. DeBakey, Dr. Liotta, and me. Therefore, years after the first human implant, a TAH for all of patients is to a than Mike DeBakey was involved with us in this work. The us together in the at the Texas Heart Institute during one of the implants. I only that he was with us to how much further along in the has A Denton A. has used in cardiovascular surgery. In 1968, he performed the first successful human heart transplant in the United States. In 1969, he became the first heart surgeon to implant an artificial heart in Dr. Cooley founded the Texas Heart Institute in Houston, and now as its and He and his associates have performed more than heart than any other group in the world. Among his more than and are the National of the National of the the by the National Association to a who has in his and the from the American Medical