(Originally published on Nov. 29, 1987)
Twenty years ago the world held its breath as South African surgeon Christiaan Barnard transplanted a dead woman's heart into the chest of Louis Washkansky. Today, transplants have become almost routine. Problems persist - too much competition over too few donor hearts and ethical dilemmas over the quality of life and the cost. Still, the operation fascinates: the heart of one human being beating in the chest of another.
Here's a look at some Carolinians intimately involved - the recipients, donors and doctors.
In the second-floor operating room at Charlotte Memorial Hospital, a heart transplant has been under way since 6:30 p.m.
It is now 7:55, and a dramatic moment has arrived:
The patient, a 48-year-old man, lies on the operating table, draped with blue-green cloths that expose only his gaping chest.
His sternum has been cut from neck to navel; his ribs are forced apart at least 6 inches by a metal retractor.
His old, diseased heart - just cut out by surgeon Philip Hess - lies on a green towel on a nearby table.
The 3-pound lump of flaccid muscle still beats intermittently.
Physician's assistant Bob Lawhorn reaches inside a red and white Igloo cooler. From the icy water, he grabs double plastic bags that hold a second heart - a healthy specimen taken from a 35-year-old man in Asheville more than two hours before.
Surgeon Mark Stiegel cradles the new heart in his gloved hands. "Ooh, big heart, " coos Hess.
"Nice heart, " agrees Stiegel.
Off to the side, a silent machine, connected by clear tubes to the patient, takes blood from his veins, cools it, fills it with oxygen, and pumps it back to his arteries to keep him alive until a heart beats in his chest again.
By 8:05, Hess begins sewing in the new heart.
Carly Simon ballads waft from the tape player in the corner. "As time goes by, " she sings.
An hour later, Hess unclamps the aorta, and the patient's blood flows through his new heart.
From one man's chest in Asheville to another's in Charlotte, three hours and 23 minutes have passed.
On tape, Stevie Winwood sings, "Back in the high life again."
Operation Now Routine
This Nov. 11 heart transplant was the third in a month at Charlotte Memorial Hospital - the second in less than a week.
It was the 24th operation performed at the hospital in 23 months.
Once front page news, heart transplants have become so routine in the Carolinas and the nation that each operation no longer rates a mention in local newspapers.
"It is just another heart operation, " says Dr. Francis Robicsek, who led the team of surgeons who performed the first heart transplant in Charlotte, in January 1986. Surgeons at the Sanger Clinic - Robicsek, Hess, Joseph Cook and Harry Daugherty - do all the heart transplants in the Charlotte area at Charlotte Memorial.
Robicsek says he still finds each transplant novel and exciting, but he agrees the procedure has become routine.
"We are doing, every week, heart operations which are higher risk and more complicated than transplants, " says Robicsek, referring to other open-heart operations.
"The technique of transplant is more logistics than surgical brilliance, " he says. "Get the (donor) heart. Fly there. Pick it up. Right now you have four hours to get it out, transport it and put it in."
Still, since Dec. 3, 1967, when 45-year-old Dr. Christiaan Barnard successfully performed a heart transplant on Louis Washkansky, the operation has held the world's fascination.
Washkansky lived only 18 days after that first transplant, but his death did little to dampen interest or enthusiasm.
However, it soon became apparent that the rest of medicine wasn't able to take over when the surgeons finished. One after another, patients died from infection or rejecting their new hearts.
By the third anniversary of Barnard's milestone operation, 166 transplants had been performed, but only 23 patients were alive - an 85 percent mortality rate.
By the early 1970s, scores of surgeons abandoned the technique - except for a few, such as Dr. Norman Shumway of Stanford University Medical Center.
In the '70s, Shumway pioneered the use of an anti-rejection drug called cyclosporine, a critical step in allowing heart transplant patients to survive.
In the early 1980s, the popularity - and success - of heart transplants began going up. The number has jumped twentyfold in seven years, from 49 in 1980 to 1,002 in 1986. One-year survival has increased from 20 percent to more than 80 percent.
Five-year survival is about 60 percent, although at a cost of $100,000 for the first year and $10,000 to $20,000 for each additional year.
Ten-year survival is projected to be between 25 percent and 50 percent.
One Stanford patient has lived 17 years with his transplanted heart - the world's longest survivor.
Still, with the vast progress, there are problems and worries that plague the operation. First is the shortage of donor hearts - many more operations could be done if there were hearts to be transplanted.
"We will never have enough hearts, " says Robicsek.
Each year, only 10 percent to 15 percent of an estimated 20,000 hearts that could be transplanted are donated.
Nationally, about 14,000 patients would benefit from heart transplants, according to Dr. Peter Van Trigt of Duke University Medical Center.
At any given time, about 300 people are waiting for new hearts, Van Trigt said, but about 30 percent to 40 percent die waiting.
At least 29 states, including North Carolina, have passed laws requiring hospitals to discuss organ donation with families of brain-dead patients.
The N.C. law, which became effective Oct. 1, could increase the supply of donor organs by four to five times, Robicsek says.
But approaching a family about organ donation at what is always an emotional time requires sensitive, trained professionals, people other than the doctors on the case, he says.
"It's not so easy to go to some people and ask, especially if you're involved, " says Robicsek. "You always have guilty feeling if you lose a patient.... You want to get the hell out. You don't want to see any more crying. You cry yourself. Your heart is breaking."
Until artificial hearts make it past the experimental stage, the number of transplants will depend on the availability of donors, Robicsek says.
"We don't have a very excessive waiting list (at Charlotte Memorial), but we always have three or four people waiting at one time.... And some of them die."
Another issue surrounding heart transplants is the rapid growth in the number of medical centers performing the operation. That increases competition for hearts and raises the question of whether all can provide the best-quality care.
In the Carolinas, six medical centers have performed 58 heart transplants since the first operation at Duke University Medical Center in April 1985.
More heart transplants have been done at Charlotte Memorial than any of the other medical centers in the Carolinas. The others, besides Duke, performing the operation in North Carolina are N.C. Memorial Hospital at Chapel Hill, Bowman Gray School of Medicine at Winston-Salem and East Carolina University School of Medicine in Greenville, N.C. The Medical University of South Carolina in Charleston began performing transplants this year.
There has been some resistance to the growing number of transplant centers.
Medicare, for example, pays for the surgery only at centers that have proved they can do the operation safely. The federal standard requires that a center perform 24 operations in two years with a 65 percent survival rate.
Only 10 of the nation's medical centers - none in the Carolinas - have qualified. Shumway, in an interview with Newsday, argues that smaller hospitals won't be prepared for complications that come later on.
He suggests that hospitals with empty beds will use transplants as loss leaders, hoping the publicity will bring them other types of cardiac surgery.
Doctors at the Sanger Clinic reject the suggestion that only the largest medical centers should perform heart transplants. Cardiologist Alan Thomley says regional centers can provide better care for patients.
"We're able to follow up our patients very carefully and closely, " Thomley said at an American Heart Association conference last spring. "If they have problems, they can come back. I am certain that our first lady (Sandra Collier, Charlotte's first heart transplant patient) would not have lived if she'd had to travel farther than she had to go.
"I don't know how a center like Stanford does it. We've got so much more control. We can see patients more frequently."
The heart transplant procedure also is troubled by several ethical debates.
Because the operation is so expensive, many hospitals require patients to have insurance coverage - most plans cover the cost of heart transplants - or make hefty down payments. At least for now, Robicsek says, he and his colleagues don't choose transplant recipients on their ability to pay.
"I am in practice in Charlotte now 31 years, and we have never refused to give service to anybody, " he says. "Honestly, I don't know who is covered (by insurance) and who is not covered. Until the number of operations increases substantially, that's the way it will remain."
There is also debate over whether the patient's quality of life after the transplant justifies the procedure.
Some experts point to the extensive drug regimen - sometimes 20 or more pills a day - that over time can weaken the patients' bones and cause cancer and kidney dysfunction. Coronary artery disease also plagues half the patients after five years.
"I was a big skeptic to start with, " acknowledges surgeon Hess. "But I've become more and more convinced that it's worthwhile. "If somebody gets 15 or 16 years, and is mostly out of the hospital and working, that's certainly worthwhile."
Transplants for infants are a different matter, says Robicsek. He questions the value of transplanting the hearts of infants, only to have them die perhaps five years later.
"You have to consider what you're doing. You are not playing with hearts. You're playing with lives."
On the other hand, he believes a 60-year-old who could live 10 more years is as justified in receiving a transplant as a 40-year-old who can live until 50.
"We are not curing things (with transplants), we are delaying things, " Robicsek says. "The same number of people die from lung cancer as died before, only later. The same number of people die from breast cancer, only later. If I do heart surgery on a person, he's going to die from heart disease at one point, but I hope I can delay it by 10 or 15 or 20 years."
In the Charlotte Memorial operating room, the patient's new heart jerks regularly inside the bloody chest cavity.
It has been pumping for about 45 minutes.
Surgeons and the half-dozen others in the operating room - the anesthesiologist, the anesthetist, nurses and other doctors - closely watch the television monitor in an upper corner of the room.
Jagged red and yellow lines show the patient's pulse and blood pressure getting stronger. "How we doing?" Hess asks.
"Looking real good, " replies Jay Veale, who runs the heart-lung machine.
At 9:48 p.m. Veale turns off the machine.
Hess pulls the tubes from his patient's chest and sews up an incision in the groin where an artery was attached to one of the machine's many tubes.
At 10:30, Hess takes a break to tell the patient's family the operation is a success.
In the hallway outside the operating room, he leans against the wall.
He has been working since 7:30 a.m.
He has another hour's work to close the patient's chest.
And he's scheduled to be back in the operating room at 7:30 a.m. the next day.
But he's not complaining. And he doesn't appear tired.
"The thing that's been so gratifying to me, " Hess says, "is that the patients come in so sick. They're almost given up for dead, and a month later, they walk out of the hospital.
"I saw Sandra Collier the other day, walking out of the hospital. She looks like a million dollars.... That makes it all worth it."