The day of December 3 of the year 1967 is a memorable date for medicine. Indeed, for humanity. The 45-year-old South African Christian Barnard, in the Groote-Schure hospital in Cape Town, dared where no other surgeon had the courage to do: he explanted the heart of a twenty-five-year-old woman in an irreversible coma following a car accident, and transplanted him into a man of fifty-five. Louis Washkansky, this is the name of the transplanted man, survived only for eighteen days, but that intervention passed into history as a triumph also thanks to the media resonance that was given. Today, after fifty years, we can state that the aforementioned event and that date were straightforward for all that developed and defined itself in the years to follow. We must not forget that Barnard made a real gamble because he took the heart from a “technically” person alive in times when the concept of “brain death” had not yet been defined. Ethical and legal limits that had slowed down other surgeons who were also ready and equipped to take the step, like the team at Standford University in Palo Alto. Barnard, however, did so. Probably his undisputed operating technique associated with the ambition of wanting to be the first in the world, forced the international scientific community to codify a border situation. Mediterraneo e Dintorni on the occasion of this anniversary, hosts the prestigious contribution of some university specialists in the sector.
The ambition to change the human body
The idea of changing the human body, or replacing its sick part, has always existed in human religions and Christian hagiography itself celebrates the miracle of the saints Cosmas and Damian who transplant the entire lower limb that had been amputated because of a gangrene. In the night between 2 and 3 December of the year 1967 a young South African surgeon, Christian Barnard, was the first to perform an orthotopic heart transplant from a human donor. The media echo was enormous also because this type of treatment opened the way to an extraordinary lengthening of human life in the collective imagination. And yet, after a period of great enthusiasm all over the world, in 1971 it became clear that the problem of this type of treatment was linked to the immune reaction against a foreign organ. The results, 3 years later, were very disappointing, so the transplant was abandoned everywhere except at Stanford, Paris and South Africa. The discovery of ciclosporin brought back this type of treatment with results, in terms of survival and quality of life, extraordinary. The transplant today. In the third millennium, transplantation has become the final instrument in the treatment of refractory heart failure with very satisfactory results in terms of survival and quality of life. The discovery of new immunosuppressive drugs such as Tacrolimus, Sirolimus and Cell-cept has improved the control of rejection by determining a clear elongation of the survival of transplant patients. As regards the quality of life, the transplant guarantees a recovery in the working activity, the greater the younger the patient is; physical activity is allowed and there are patients who participate in cycling or marathon races; sexual activity in 80% of cases is recovered and procreation is possible both in transplanted women and in transplanted men. The indication for transplantation is placed in terminal forms of heart failure refractory to medical therapy. The unsolvable knot is the scarcity of donors compared to the large number of potential recipients. In the United States epidemiological studies indicate that in 2050 there will be more than 250,000 patients a year suffering from dilated cardiopathy. With these numbers it is well understood that the transplant represents a niche activity with an inverted pyramid for the treated patients, even if today it represents the golden standard. The future. Xenotransplantation and stem cells have not, at the moment, given the desired results. The only alternative is represented by mechanical pumps that promise lasting results in terms of survival and quality of life: the unresolved problem is represented by the energy consumption that requires an external source, thereby increasing the potential infectious risks, which together with emo-coagulative problems represent the Achilles’ heel of these machines.
The heartbeat, the meaning of our existence.
I have for many years been privileged to carry out my academic activity as a professor of cardiac surgery at the Vita-Salute San Raffaele University in Milan and at some foreign universities. In particular, I have a Visiting Professor position at the Cardiosurgery of the Groote Schuur University Hospital in Cape Town, South Africa, currently run by Professor Peter Zilla. It is there that fifty years ago, and more precisely the day of December 3, 1967, the first human heart transplant in history was made. The South African surgeon Christian Barnard, in fact, transplanted the heart of a young woman of 25 years, brain-dead after a serious car accident, in a 54-year-old patient, Louis Washkansky, suffering from terminal heart failure. Technically the surgery was successful but unfortunately the patient died after only 18 days due to bilateral pneumonia. Just a month later, on January 2, 1968, Philip Bleiberg was still undergoing cardiac transplantation by Barnard, surviving 19 months. It was in fact this success that gave the green light to heart transplants. In less than a year, more than sixty were carried out, not only in South Africa, but also in Europe, the United States, India and Venezuela. Many of these patients, however, did not survive long due to the numerous post-operative complications. The results improved noticeably after the introduction of ciclosporin, a new and powerful anti-rejection drug approved in 1983. Today, thanks to advances in immunosuppressive therapy and perioperative management, survival after heart transplantation is about 90% at one year and over 50% at twelve years. In Italy, the first cardiac transplant was performed in Padova, by dr. Vincenzo Gallucci who, in the night between 13 and 14 November 1985, implanted the heart of a young 18-year-old boy in a 38-year-old man suffering from terminal dilated cardiomyopathy. Around 6,000 heart transplants are performed worldwide each year, mainly in patients with severe heart failure. In Italy, in 2014, 265 heart transplants were performed, a still insufficient number compared to that of patients on the waiting list. The scarcity of donors has made the search for therapeutic alternatives inevitable to allow the survival of patients otherwise destined to death in a very short time. In particular, the development and the subsequent optimization of the so-called left ventricular assistance systems (L-VAD) has been very important in the last decades. Fifty years have passed since that extraordinary night in which for the first time it was shown that the human heart could be replaced. However, the time has not affected the intensity of the emotion that is felt every time we talk about a heart transplant. In fact, unlike the other organs, the heart immediately leads our mind to reflect on the very meaning of our existence. As I have said on other occasions, his heartbeat is the very sign of life, of its marvelous and unstoppable flow, of the time we are allowed to choose who to be and what to believe. Maybe that’s why I decided to take care of it for a lifetime. With the humility and respect that such an extraordinary mystery contains.