PCGUIA 10/PC Guia 10.iso/database/body/cu10.txt

Text File | 1996-03-13 | 22KB | 496 lines

1.5
The man who performed the first heart transplant came from
a small town in the semi-desert scrubland of South Africa.
Christiaan Barnard  trained at Cape Town University in the
early Forties. He was a quiet, well-liked, hardworking
medical student - not a pacesetter, either academically or
socially. In the late Fifties he went to Minneapolis to train
under the eminent cardiac surgeon Walt Lilliehei. Once back
in South Africa, he worked on straightforward cardiac
surgery, and was in the forefront of all cardiac surgical
development. He made a further visit to the States in the
mid-Sixties to study their latest operative techniques. Before
he did a human heart transplant, Barnard did many
experimental operations on dogs. Dr Shumway, in the States,
had announced his intention to do a heart transplant back in
August 1967 and had established all the fundamental
surgical principles involved. Dr James Hardy had
transplanted a baboon's heart into a patient before that. But
Chris Barnard was the surgeon who, on December 3, 1967,
actually did the first one, and proved that a human heart
transplant is possible. Since then, many thousands of heart
transplants have been done. Barnard's second patient, Philip
Blaiberg, lived for 594 days after the operation. The
operation now ranks as a standard cardiac surgical procedure
with a great many survivors over five years. Barnard would
have been a first-class surgeon even if he hadn't performed
the world's first heart transplant. He was the right man in
the right place at the right time. It is a pity that rheumatoid
arthritis cut short his surgical career
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2.2
The heart of a 25-year-old woman, who had been killed in a
car crash on Saturday night, was beating yesterday morning
in the chest of a 56-year-old man in Groote Schuur hospital,
Cape Town.

The operation was the first transplant of a human heart.  It
lasted five hours.  The patient, Mr. Louis Washkansky, was
said later to be fully conscious and in very good condition.
His blood pressure was normal.

Professor Christian Barnard, who headed the surgical team, is
well known to British colleagues as a dynamic leader and
able surgeon.  The feeling last night was that if he had been
in charge the chances of success must be rated as high as in
any pioneer operation.

Mr. Washkansky had been admitted to hospital with cardiac
failure and the surgeons had been waiting four weeks for a
heart to transplant.  Miss Denise Darvall died in the hospital
after being injured in a car accident, and her father gave
permission for her heart to be removed.

It was not known in London whether compatibility tests had
been made.  This is standard procedure in kidney transplants
and success in these depends largely on it.  The tests used
are analogous to blood group tests except that white
corpuscles instead of red cells are used.

REASON FOR OPTIMISM

In kidney transplants between well-matched individuals the
success rate a year after operation has reached between 75
and 90 per cent.  A heart transplant is more formidable as an
operation, but the problem of compatibility may be less
great.  The reason for optimism in this respect is the greater
simplicity of the heart.

Professor Barnard said after the operation that the next few
days would be vital.  "The actual transplant was not really a
problem, but the question of tissue rejection is the important
one."

Even between well-matched individuals, tissue rejection as a
result of immunological reactions has to be controlled for
some time afterwards.  This is done by drugs borrowed from
cancer research.  There is a phase in the immunological
response to alien tissue which involves the multiplication and
division of cells.

The drugs used prevent or reduce this.  But in so doing they
limit also the production of white cells which are an
important defence against infection.  There is therefore an
added risk from infection and use of the drugs is tapered off
progressively.

A heart surgeon in London said to me: "I hope the operation
is a success, not only for the patient's sake, but because we
may then hope to get more support for what we are all of us
trying to do."

It would mean much to the relatives of the woman to know
that her heart had not been taken from her body in vain.
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2.4
Louis Washkansky, the most publicized hospital patient in
the world, died yesterday.

The cause of death was pneumonia, and not rejection by his
body of the girl's heart, transplanted into him 18 days
previously.

Professor Christiaan Barnard, the heart surgeon who carried
out a heart transplant operation in South Africa, said on BBC
Television last night that although his medical team were
very disappointed by the death of Mr. Washkansky, there
were some "very encouraging features".

"The organ that failed was not the heart, which continued to
function well.  We are disappointed but not discouraged and
we will go ahead with a second transplant" said Professor
Barnard.

ETHICAL ISSUES

The Washkansky transplant and the resulting publicity
raised several ethical questions, which trouble both doctors
and laymen.  Here Our Medical Correspondent discusses
them.

The tragic, though not unforeseeable, death of Mr.
Washkansky in the Groote Schuur Hospital, Cape Town,
brings to a close an episode which throughout has raised
more anxiety than enthusiasm.

In isolation, transplantation of a human heart raises no moral
or ethical problems, but no such operation can ever be
viewed in isolation.  If carried out, it inevitably raises a host
of direct and indirect problems, such as the dividing line
between life and death, euthanasia, and the cost of life; a
fascinating, if devastating triad which should give lifetime
employment to every moral philosopher and theologian in
Christendom.

That the medical profession is well aware of the problem is
shown by the current publication of a symposium on "The
cost of life" in the Proceedings of the Royal Society of
Medicine.  This is but one of a series of such discussions that
have been published in recent years, but it is of particular
interest because the participants are almost entirely
practising doctors discussing problems they have actually
encountered.

The title of the symposium is deliberately provocative.
Though no answer is given to it, even the most superficial
consideration of the various papers indicates how strongly
responsible members of the profession appreciate the
problems involved.  By and large, most of them accept that
there is a problem but find it difficult to face up to its full
implications.

Three random samples, to use technical jargon, may be taken
to exemplify the range of the problems reviewed.  The first is
from the introductory paper on the so-called artificial
kidney, or intermittent dialysis as it is technically known.  "If
all potential candidates up to age 54 were treated on
intermittent dialysis, about $30m. per annum of direct costs
and over 10,000 staff might be tied up in treating 23,000
patients.  The indirect cost of treating these patients,
particularly the unsuitable ones, defy computation."

The second is the episode reported by an Oxford doctor" of a
colleague of his who, in the first stage of cancer, extracted
from the friend who treated him, the promise to give him a
fatal injection when things became bad.  Things became bad,
and the patient, frightened and suspicious, refused to have
even the injections which would be ordinarily prescribed."

The third is the hale and hearty octogenarian woman doctor,
well known for her work for the elderly in the days of the
London County Council, who commented that "there was
nothing more discouraging, and causing more rapid
deterioration, than to give the patient the idea that his doctor
was no longer interested in him and that he might as well be
let go because nothing further could be done....  It was not
only medically wrong, but it was psychologically cruel to
inflict such an idea on any patient."

TRANSPLANTS

On the question of transplants,  Lord Kilbrandon, Lord of
Sessions in Edinburgh, said that at present the law seriously
handicapped surgeons.  Asking permission from next of kin
was a very unpleasant thing to have to do and as far as the
kidneys were concerned, there was a great hurry.  Half an
hour was all the time they had.  He thought the law should
be altered so that an organ could be taken if there was no
reason to believe that next of kin would mind or that the
person would have minded.

Dr. Adrian Kantrowitz of the Maimonides Hospital, Brooklyn,
said that he had concentrated his surgical effort on children
because they had felt that certain medical problems might be
easier to work out using the bodies of children who had died
from congenitally deformed brains whose hearts were good.

Professor J. Hamburger, Professor of Medicine, University of
Paris, who has carried out 86 kidney transplants thought the
South African operation was only the beginning of a very
important story.  He described the problems involved in
selecting donors and how the results of an operation
improved as the selection improved.

Dr. Barnard said he saw a very bright future for organ
transplantation.

The speakers seemed to agree on the moral question of
deciding when a person was dead.  It was necessary that one
team of doctors should pronounce a person dead and another
team should remove any organs.  There was nothing
unethical in taking a part from a dead person, provided they
were sure he really was dead.

In the United States the laws varied between states, but the
basic rule was that a person should give consent and he
should understand the consent he was giving before any
organs were removed.
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3.1
Surgeons led by Professor Christiaan Barnard successfully
transplanted the heart of a young coloured man into the
body of a white dentist in Cape Town yesterday.

Professor Barnard said later that the operation had gone
better than that on Mr. Louis Washkansky last month.  The
transplanted heart had begun beating by itself without
electric shock.  Last night the patient recovered
consciousness.

The man who received the transplanted heart was Dr. Philip
Blaiberg, and the donor was Mr. Clive Haupt, aged 24, who
died of cerebral haemorrhage.  Professor Barnard was
assisted by the same team which helped during the
Washkansky operation.

Today's operation started soon after 10.30 a.m. and ended
about 4.30 p.m. (South African time).  Again, the critical time
for rejection symptoms will be in about a fortnight.

Dr. Blaiberg had been forced to retire from dental practice
because of a progressively weakening heart.  During his
recent visit abroad, Professor Barnard repeatedly said that
he was anxious to return to Cape Town because Dr. Blaiberg's
condition was deteriorating.

Mr. Haupt, a Cape Town factory worker, was married three
months ago.  He collapsed on the beach during the New Year's
Day holiday.  The fact that Mr. Haupt is coloured answers
questions that had been asked about the possibility of
apartheid being a complicating factor here in such operations.

Mr. Haupt was transferred from the suburban hospital at
Wynberg to Groote Schuur hospital (where the operation took
place) when it was seen that the brain haemorhage made his
chances hopeless.  He underwent the required compatibility
tests and at one stage, it is understood, his heart stopped,
then revived.  He was kept alive for the last few hours by
"artificial ventilation".

Professor Barnard arrived home yesterday after what must
have been an exhausting visit to America, returning by way
of London.  The whole heart transplant team had been ready
for his return and for the arrival of a possible donor.

After the Washkansky operation the hospital had some
difficulty through the presence of a large number of
journalists.  The Blaiberg family, however, are guarding their
privacy far more carefully.  Mr. Washkansky's death through
infection must also induce the medical team to observe even
more strictly a virtual quarantine of the patient until the
danger of rejection is over.

Today's operation was the third of its kind.  A baby died in a
New York hospital last month soon after receiving a heart.
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3.2
Dr. Christiaan Barnard, who last December performed the
first transplantation of the human heart at the Groote Schuur
Hospital in Cape Town, takes issue with his critics in an
interview with the German newspaper Welt am Sonntag.

Dr. Barnard is concerned particularly with refuting the
arguments of Professor Werner Forssmann, a prominent
German surgeon and Nobel Prize winner, who has strongly
criticized the heart transplant operation on ethical, legal, and
medical grounds.

Dr. Barnard's main answer is that the transplantation of the
heart is no different from that of other organs, like the liver.
"Once one has removed a liver from the body of the donor
there is no artificial liver one can put in."

At least 11 or 12 liver transplantations must have been
performed, Dr. Barnard says, and, so far as he knows, only
four of the patients concerned are still alive.  Yet nobody has
criticized these operations.  The fact that the first heart
transplantation was carried out in South Africa may have
something to do with the hostile reaction of some sections of
the medical profession, Dr. Barnard feels.

Professor Forssmann argued that medical knowledge of the
immunology of transplanted organs was insufficient to justify
the kind of operation being undertaken at Groote Schuur.  Dr.
Barnard comments:  "Does he mean that no more
transplantations should be carried out anywhere in the
world?"

Professor Forssmann also drew a comparison between the
Groote Schuur operations and the activities of Professor Karl
Gebhardt, one of the most notorious of the Nazi surgeons who
used the bodies of concentration camp prisoners for "medical
experiments."

Dr. Barnard dismisses as "nonsense" the allegation that the
Groote Schuur operations had shown disregard for medical
ethics and humanity.  The doctor's task, he states, is to treat a
patient until there is nothing more that can be done for him.
This applies equally whether the patient is the receiver or
the donor of an organ.

Dr. Philip Blaiberg, the heart transplant patient, was allowed
out of bed for the first time today and sat in a specially
prepared and sterilized chair.

A medical bulletin from Groote Schuur Hospital, where he
received his new heart 12 days ago, said he was "bright and
cheerful and eating well."

The condition of his heart was satisfactory and his sore
throat had almost completely cleared up.
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3.3
Dr Christiaan Barnard, the South African cardiac surgeon, said
in Cape Town today that he would use chimpanzees' hearts in
future transplant operations after the failure last night of an
operation involving a baboon's heart.

An unnamed Italian woman, aged 25, died in the Groote
Schuur Hospital early today, two and a half hours after
professor Barnard attached the heart of a baboon to her
failing heart.

Dr Barnard told a press conference today that the baboon's
heart had proved to be too small to carry the woman's
circulation alone when her own heart began failing.  The
operation would have been successful if he could he could
have used a human heart, but none was available.

He explained that a chimpanzee's heart was larger than that
of a baboon and would therefore be able to carry a larger
load of the patient's life.  It was the first time he had carried
out an operation using a baboon's heart as a "booster"

Earlier his team had carried out open heart surgery to
replace a previously inserted aortic valve with a larger one,
but they found that the patient's heart failed each time they
switched off the heart-lung machine.  Dr Barnard pointed out
that the machine could not be used indefinitely as it was
destroying blood elements.

After all other means had failed, only one possible solution
remained - a heart transplant.  No human donor was
available, he added, "but I had a baboon with the same blood
group as the patient, and I transplanted the heart.  The
baboon was one of two kept at Groote Schuur.

As soon as its heart had been inserted the patient was taken
off the heart-lung machine.  For a while both hearts were
working well and the patient briefly regained consciousness.

"Then the patient's won heart deteriorated again and
eventually we couldn't get it to restart and the baboon heart
just couldn't cope with carrying the full circulation and the
patient died."

He had hoped, he said, that the baboon heart would have
been able to assist circulation for two to three days.  In the
meantime either the patient's own heart would have been
able to cope alone or else a human donor would have been
found.

He felt the operation might have succeeded if the baboon
transplant had been carried out sooner, "but it was a new
process and we tried to do everything we know first".

The first attempted animal-human heart transplant took
place in 1964, when Dr James Hardy, of the University of
Mississippi, stitched the heart of a chimpanzee into a 68-year
old man.  He survived for only two hours.
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3.4
Britain's first artificial heart transplant patient yesterday
squeezed the hands of his doctor and his nurse as he began
to recover from the long and complex operation at Papworth
Hospital near Cambridge.

Mr Francis Wells, one of two surgeons who carried out the
operation, lasting five hours, 20 minutes, over the weekend,
said at the hospital that the patient was in a very good,
stable condition and had signalled to his wife and medical
staff that he was comfortable.

The man, aged 40 and yet to be named, was receiving lots of
fluid and would shortly be able to eat.

Mr Terence English, the other surgeon, said the 13-member
medical team wanted to replace the plastic and metal heart
as soon as possible when a suitable natural one had been
found.  Ideally that would be within the next week or so
when the patient had recovered from the immediate effects
of the first operation.

Mr English said the patient had suffered three heart attacks
in the past three years, the most recent in September.  When
the decision to use a Jarvik-7 artificial heart was taken last
week, the patient knew he was very seriously ill and the
medical team thought he had no more than one or two days
to live.

Now that he had been fitted with an artificial heart he would
have priority among the 28 patients on the waiting list for
heart transplants at Papworth.

Mr English said that clotting and the possibility of a stroke
were the most likely immediate dangers to the patient's
health.  But he was being given drugs to thin his blood and
he had experienced no severe bleeding problems to date.
Rejection was not a problem with artificial hearts.

Mr English said the operation was a little more involved than
a normal transplant.  As a result, and because the team was
less familiar with the surgery involved, it had taken 20-30
per cent longer than usual.

Mr English said that the cost of the artificial heart-between
12,000 dollars (ú8,000) and 15,000 dollars (ú10,000)-was
being borne by the American company which had pioneered
the development of the artificial heart, as part of a 400,000
dollar programme for Papworth.

That included five artificial hearts as well as all the complex
compressed air system for circulating the blood and various
monitors for tracking the patient's health.

The Papworth team had decided not to have more than one
patient fitted with an artificial heart at any one time, Mr
English said.  That was because of the constant nursing and
technical supervision required.

Mr English said that Papworth regarded the implantation of
an artificial heart as a temporary device for patients who
might otherwise die if a suitable natural organ was not
available.

Experience in the US had shown that permanent implants of
artificial hearts were not successful in the long term.

The first patient to receive one-Dr Barney Clark, an
American-died 112 days after his operation in December
1982.  By August of this year, the first five men to be given
permanent artificial hearts had died-the last being Mr
William Schroeder of Louisville, who suffered several strokes
before dying 620 days after his operation.

The artificial heart is powered by a huge air compressor and
critics have questioned what kind of life a patient can enjoy
linked to such a device.
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3.5
Dr Christian Barnard, the pioneer of heart transplants, is
retiring at the age of 61 because of rheumatoid arthritis in
his hands. He will leave his position as chief specialist in the
department of cardiac surgery at Groote Schuur hospital,
Cape Town, towards the end of the year.

On December 7, 1967, Dr Barnard announced the world's first
heart transplant, that of an 18-year-old road accident victim,
into the chest of an ailing diabetic, Dr Louis Washkansky, a
dentist, who was 53 and lived with the new heart for 18
days.

Five years later he developed the so-called "piggy-back"
technique in which a donor heart is transplanted to beat next
to the patient's own ailing organ. In 1977, he carried out the
world's first baboon to human heart transplant but a year
later vowed not to perform such an operation again. Some of
his more than 50 patients lived for more than 12 years with
their new hearts.
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