6.12.1913  -  12.12.2002

Books of N.M.Amosov

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Digression. Heart transplantation

I have never performed a heart transplant.

I do not feel any inferiority because of this, since I never considered myself to be a first class surgeon, but still it pains me.

I wanted to do so quite badly, although soberly evaluated, our chances are miserly. I will briefly describe the situation for the curious. The problem has lost its actuality, although there was a time when not a single lecture or a talk with journalists would do without the question: "What do you think of heart transplants?" Interpret this as: "Why have you not performed a heart transplant?" I did not try to clear myself: "Because I could not."

Christian Bernard has accomplished this feat. I liked his novel about heart surgeons. I found we had much in common when he described his clinic and his work.

Although antibiotics, hormones, and artificial circulation have done far more for people, they were not so romantic. The heart is a special organ. People do not seem to perceive it as a pump, but as a receptacle for the soul. It is hardly the seat of the soul for a surgeon, but for a long time, it has been considered that the heart and life are inseparable. Nowadays we think differently: the heart can be replaced, at least temporarily. The same cannot be said for the brain. Therefore the seat of life is in the brain.

Mr. Bernard performed his first transplant in December of 1967. Everybody knew the name of the patient — Vashkansky. But only a few knew that the heart of the donor was still beating when it was removed from her chest. Formally the woman was still alive, although her brain had been destroyed by trauma. And the surgeon showed great courage in stepping over the obsolete dogma: "While the heart is beating, the patient is still alive."

Other surgeons, before Mr. Bernard, could not overcome this barrier. The operation, in all its details has been brilliantly elaborated upon by Shumway from Stanford University in California. His dogs with transplanted hearts lived for weeks, and the methodology has been published. Several days after Dr. Bernard, he performed a heart transplant and seldom operates till this day. He has the most statistics — hundreds of transplants and the most in-depth study.

In 1968, scores of surgeons in different countries performed success­ful heart transplants. The operation became standard for a top-class surgeon and for a clinic, the top-mark of pretensions and prestige. Those who had not performed a transplant who previously considered themselves "at the top" suddenly began to feel inferior.

The commotion about heart transplants was rather loud all over the world. Was it compatible with religion, various phylosophical ideas — and many other silly things.

Amazing developments took place under the impact of TV and the press. I myself read the following story in a newspaper. A patient of American surgeon Denton Coolie in Huston was dying. They urgently needed a donor. An announcement was made over the radio and local TV network: if an accident occurred nearby with a fatal cerebral trauma, the victim should be taken to the clinic immediately to save the life of this patient. There were numerous telephone calls and visitors began to come and offer their hearts. Coolie failed to find a donor and, in order to prolong life of his patient, he sewed in a mechanical heart with which he had experimented on dogs. With this heart, the patient lived for three days and died not having received a real heart. I heard about it in a scientific report at the Congress in Argentina in 1969. That was the first experience with a heart prosthesis.

After Buenos Aires, our delegation went on a tour of Chile. We were received by President Allende, who was a doctor. We were impressed by the natural beauty of the place but there was one surgical impression which I will share with you.

Port Valparaiso (I knew it from Jack London). A marine hospital. A surgical department with about 100 beds, maybe less than that. Equipment — nothing to write home about. They operate on everything: stomachs, lungs and hearts. Just then, they were marking the anniversary of a patient with a heart transplant. They showed him to us. The young man had suffered from three defective valves and had a weak heart muscle. A drunken sailor blew off the head of a woman. They took her heart and transplanted it. The whole year, the patient lived in a separate ward with stringent isolation from possible infection. Visitors came to him on that day, bringing flowers and food. We also examined him and listened to the beat of the transplanted heart, then looked through the case history. It did not sound convincing. I would have sewed in artificial valves on that particular patient. But we were surprised by another thing: that Kogan, the surgeon, having only three assistants — his wife, an anesthesiologist and a conventional department — ventured to operate. (This was his second transplant.) A brilliant surgeon — the patient was on artificial circulation for only forty minutes. For two weeks he and his wife lived in the hospital and nursed the patient. True, immunology was done by a doctor from Chicago; he brought all the instruments with him, I cannot remember on what conditions. Enthusiasm and an excellent performance, although I am not at all sure that it was irreproachable from a moral point of view.

Soon the boom abated, for at that time, heart transplantations did not meet expectations. Vashkansky lived for more than a year, but when he died, the autopsy showed that the new young heart had become old and worn out as a result of the impact on the part of the recipient's organism with sclerosis, and a bad liver, kidneys and metabolism. That was a problem nobody expected.

The effect of incomplete tissue compatibility and drugs to suppress the rejection of the heart myocardium turned out to take first, rather than the second place. Many patients became victims of infection resulting from the suppression of the immune system. I do not remember the precise statistics, but the majority of patients used to die before a year was up.

And then there were significant losses due to the operation itself. They could hardly be assessed, since the results of single abortive attempts were never made public. If we take into account that a heart transplant is a costly enterprise, then the number of volunteers for a heart transplant diminished, even among extravagant Americans. (They like to be operated on.)

What conclusions could be drawn from experience, the world over?

Several conditions are necessary for earnest work.

First. Rather difficult is the problem of a recipient. A transplantation should be performed only on those patients who may die within a few months. In practice, these are patients with persistent decompensation resulting from a primary injury of the myocardium after repeated infarctions, who have undergone comprehensive therapy and a thorough examination, including screening by the "Elema." However, the secondary damage to the liver, kidneys and other organs should not be irreparable. (Otherwise even a new heart will not help.) To examine all these conditions, a therapeutic department with highly qualified personnel and up-to-date equipment is required.

The heart must not be transplanted to a chronic patient in a state of agony. He will not survive the operation, and if he feels more or less satisfactory, how can you make up your mind to offer him a fatal operation? (Knowing the implications and the low long-term survival rate.) No doubt, in heart surgery, there are always patients whose hearts will not start beating after an operation, but they cannot be used in this case, since a donor cannot be found so urgently.

Next. The problem of a donor. A young, healthy heart is necessary for a transplant. This means that it should still be beating or it should have just stopped beating so that it can be triggered by artificial circulation, to restore its capacity. If the donor was in agony for long, then the myocardium is weakened as a result of oxygen deficiency. A "good" donor requires an excellent ambulance service and intensive care ward. Moral requirements narrow the range of potential donors: patients with a serious destruction of the brain. Large wounds are not sufficient; the skull must be fully destroyed; the donor must be unconscious, his brain must be half smashed, so the EEG gives a straight line. As a rule, this should be accompanied by hemorrhage, respiration arrest, and a fall in blood pressure. Under such conditions, the heart stops beating within an hour. Artificial respiration and blood transfusion should be provided at the place of the accident. The victim should be urgently taken to a clinic so that the death of the brain can be certified. And what is most difficult — convincing the donor's relatives. And they must be found, brought in, and showed... Flawless organization and several recipients waiting are necessary.

Third. Determination of compatibility by selecting. If we omit all the details, something similar is done during blood transfusion. Only it is incomparably difficult in the case of a heart transplant. Blood (four groups) and tissues (tissue antigens) make about a hundred and forty groups. Twenty-five, if we are not very accurate. If we want to be primitive, then selection can be done by blood-type alone. But this should be done only for a dying patient. In order properly to choose "pairs," an immunological service is a must. We have to create (or borrow) a set of standard antigens, to master the process of reactions, to provide a follow-up of rejection and dosage of drugs to suppress immunity. Without all this performing a heart transplant is a risky venture.

Fourth. Surgery per se. There should be an adequate artificial circulation system with half an hour standby. There should be two teams of surgeons, working in two operating rooms to start the transplant without a delay. The heart of the donor is cut off in such a way that the posterior walls of the left and right arteria with vena cava and pulmonary veins running into them are left intact. Then the aorta is dissected as well as the pulmonary artery. The heart of a donor is removed entirely and then is cut of the site so the atria and the arteries may be sewn together. Ideal sterility is compulsory, since protective immunity is being suppressed to prevent rejection.

Fifth. The post-op block. A separate aseptic, germ-free block — to bring to a minimum the risk of infection of a patient. Stringent supervision over all functions, particularly over the immune system, the way it responds to the transplanted organ. With this purpose in view, detailed blood tests and specific reactions must be made. The dosage of hormones and special drugs to suppress rejection and inhibit the immune system is determined by their results.

These are the complications. It is not sufficient to have an excellent surgical department; there must be an excellent therapeutic department so as to select a recipient, an ambulance service capable of performing intensive care before the donor reaches the clinic, and qualified immunology. All this is known as a high level of medical organization.

Besides that, another thing is needed — the public must be prepared so the relatives of potential donors, recipients and their families will understand the problem properly...

I will not pass judgement on others — on Moscow and Leningrad. These cities have specialized institutions for cardiology and organ transplant. They know whether they have all the conditions necessary for success.

We did not have them in 1968, and we don't have them now. Nowadays we don't need it, but then we also wanted to perform a heart transplant. My personal opinion was expressed in the following way: "We have to." Our clinic and the surgery we performed was ranked high in the country. This made us committed to the idea, to say nothing of our desire for prestige. But this was far from unusual. (To tell you the truth, I did not want it personally, since I doubted it would be a success.)

We began the preparations. Our possibilities were rather modest, so we had to request money for the organization of an immunological laboratory and additional personnel to service artificial circulation. We received the money, but did not transplant the heart. Are we ashamed? Not really. Immunology functions well at the institute; it is necessary for medicine in general. The number of operations has increased; we ranked first in the country (in number) and we had even less research personnel that specialized institutions did.

We made our preparations in earnest, but slowly. We were on the verge, and if we failed to try, then it was because... I do not know the reason for that. Judge for yourselves.

We were doing our best. We formed surgical teams, and I perfected the methodology with them on dogs. We made about a dozen experiments, and my recollections of them are not pleasant. It is so frightening to see a live dog (under artificial circulation) with an empty, open chest — the heart had been removed. (After I got a dog, Cherie by name, I was not able to take part in these experiments.) There were dogs who woke up with foreign hearts, but neither of them was taken off the table alive. We had to work harder.

We established contacts with an ambulance service; fortunately, they are pretty good in Kiev. We discussed every detail with shock teams, who should be brought to us, and how to perform intensive care and summon relatives. We addressed general practitioners and explained what types of patients we needed. It was extremely unpleasant to do all this, since we did not believe in the success, at least of the first attempt. Our doctors are and were conservative, and I can well understand them. The immunologists got ready to play their part and were on call at home. A team of intensive care physicians, the AIK machine operators, and a team of surgeons were at the clinic in wait.

Builders joined two small wards, painted them, and installed the ventillation — they made a sterile ward for the prospective patient.

That's how we approached the decisive moment.

That was back in autumn of 1969.

Our doctors offered us a patient. I talked with him only briefly; therefore, I didn't remember much. (I felt ashamed to talk with him.) The public had already learned about heart transplants from the press; therefore, some patients willing — those who had lost all hope. This man was one of them. He has sustained an infarction, recompensated, in very grave condition, and sufficiently intelligent to understand that it was hopeless... He was transferred to our clinic; here he saw patients after successful operations with valves, believed in us, and began his wait.

Maybe a month passed — and a donor was brought to us...

A young woman got into a traffic accident, and her skull was smashed, a gaping wound. She was kept under artificial respiration, blood pressure extremely low. She was placed right into the "donor's" operating room. Her relatives came. We told them that she was hopeless. Took an EEC A neuropathologist was not invited. Our two most senior intensive care physicians had been neurosurgeons in the past. They said the brain had died. Artificial circulation was prepared. We thought that as soon as the heart stopped, we'd switch on the AIK machine. Death would be a certified act, and we would revive the heart and take it to the recipient.

We were unable to overcome our reservations at the last moment. We did not have enough determination to ask the inconsolable relatives for the heart. It seemed to be an unthinkable blasphemy. I called off the operation. The heart kept on beating for several hours.

I do not remember whether we ever told the recipient about the donor. It seems to me we did not. He lived in the clinic for another month or so and quietly passed away.

For some time, we entertained hopes of an unthinkable coincidence: a donor without relatives and a recipient, who wished to be saved. But the tension had already subsided. About that time, the world cooled down about heart transplants.

But still we (to be more accurate, I myself) had experienced a failure.

Did I regret that I did not make an attempt while I considered the risk to be justified? No, since I did not believe in success.

I have to add a few words.

Heart transplant does not give any benefits, but remains the peak of skill and organization. And then: it contains a certain moral defect. The mind approves of it, if it is done honestly, but the soul does not accept it. I do not know; I am not sure that I am right, but when I recall the weeping mother of our donor, I do not feel quite myself.

I do not see any future for heart transplants; it is extremely difficult to select "pairs." We need revolutionary discoveries in reviving the dead heart and its conservation to have time for selection and to avoid moral problems — removal of a living heart. But then, there is tissue incompatibility, protection from infections, and the weakening of the transplanted heart... That is namely why the latest publication by Christian Bernard (1981) was dedicated to the implanting of a parallel heart during acute disease while the patient's real heart gains its strength.

The future lies with the heart prosthesis. Transplants gave a fresh impetus to research into this problem, although it was developed in the USA much earlier. (In Washington, in 1967, I had the opportunity to talk with the coordinator of this program. At that time, he promised me success in ten years, but failed.) Anyway, a calf with a mechanical heart can live for almost a year, and this is not limit. There is hope, but that's quite a different subject.

In spring of 1982, there were new reports on heart transplants in medical journals. It seemed that the operation had gained new popularity. A new immunodepressant (Cyclosporone A) had been discovered. This drug that suppresses the rejection reaction of the transplanted organ, but practically does not weaken protection against microbes.

The situation has changed radically. At the International Cardiological Congress in Moscow in June 1982, the same Dr. Shumway in a brilliant report, informed us not only of increasing number of heart transplants — up to a hundred a year — but also of the successful transplant of the heart jointly with the lungs, and of lowering of the requirements as to the selection of donors. He managed to do this after many hundreds of experiments on dogs and monkeys. (A heroic person he is, Shumway. But he looks small, wisened, and so very old...)

And now a new report. Barney Clark, operated upon by William de Vries, lived 112 days with a mechanical heart.