Christiaan Barnard

Christiaan Neethling Barnard (8November 19222September 2001) was a South African cardiac surgeon who performed the world's first human-to-human heart transplant operation. On 3 December 1967, Barnard transplanted the heart of accident victim Denise Darvall into the chest of 54-year-old Louis Washkansky, who regained full consciousness and was able to talk easily with his wife, before dying 18 days later of pneumonia, largely brought on by the anti-rejection drugs that suppressed his immune system. Barnard had told Mr. and Mrs. Washkansky that the operation had an 80% chance of success, an assessment which has been criticised as misleading. Barnard's second transplant patient, Philip Blaiberg, whose operation was performed at the beginning of 1968, returned home from the hospital and lived for a year and a half.

Born in Beaufort West, Cape Province, Barnard studied medicine and practised for several years in his native South Africa. As a young doctor experimenting on dogs, Barnard developed a remedy for the infant defect of intestinal atresia. His technique saved the lives of ten babies in Cape Town and was adopted by surgeons in Britain and the United States. In 1955, he travelled to the United States and was initially assigned further gastrointestinal work by Owen Harding Wangensteen at the University of Minnesota. He was introduced to the heart-lung machine, and Barnard was allowed to transfer to the service run by open heart surgery pioneer Walt Lillehei. Upon returning to South Africa in 1958, Barnard was appointed head of the Department of Experimental Surgery at the Groote Schuur Hospital, Cape Town.

He retired as head of the Department of Cardiothoracic Surgery in Cape Town in 1983 after rheumatoid arthritis in his hands ended his surgical career. He became interested in anti-aging research, and in 1986 his reputation suffered when he promoted Glycel, an expensive "anti-aging" skin cream, whose approval was withdrawn by the United States Food and Drug Administration soon thereafter. During his remaining years, he established the Christiaan Barnard Foundation, dedicated to helping underprivileged children throughout the world. He died in 2001 at the age of 78 after an asthma attack.

Early life

Barnard was born on November 8, 1922 and grew up in Beaufort West, Cape Province, Union of South Africa. His father, Adam Barnard, was a minister in the Dutch Reformed Church. One of his four brothers, Abraham, was a "blue baby" who died of a heart problem at the age of three (Barnard would later guess that it was tetralogy of Fallot). The family also experienced the loss of a daughter who was stillborn and who had been the fraternal twin of Barnard's older brother Johannes, who was twelve years older than Christiaan. Barnard matriculated from the Beaufort West High School in 1940, and went to study medicine at the University of Cape Town Medical School, where he obtained his MB ChB in 1945.

His father served as a missionary to mixed-race people. His mother, the former Maria Elisabeth de Swart, instilled in the surviving brothers the belief that they could do anything they set their minds to.

Career

Barnard did his internship and residency at the Groote Schuur Hospital in Cape Town, after which he worked as a general practitioner in Ceres, a rural town in the Cape Province.''Every Second Counts: The Race to Transplant the First Human Heart'', Donald McRae, New York: Penguin (Berkley/Putnam), 2006. See esp. Ch. 10 "The Wait" and Ch. 11 "Fame and Heartbreak", pages 173–214. In 1951, he returned to Cape Town where he worked at the City Hospital as a Senior Resident Medical Officer, and in the Department of Medicine at Groote Schuur as a registrar. He completed his master's degree, receiving Master of Medicine in 1953 from the University of Cape Town. In the same year he obtained a doctorate in medicine (MD) from the same university for a dissertation titled "The treatment of tuberculous meningitis".

Soon after qualifying as a doctor, Barnard performed experiments on dogs while investigating intestinal atresia, congenital, life-threatening obstructions in the intestines. He followed a medical hunch that this was caused by inadequate blood flow to the fetus. After nine months and forty-three attempts, Barnard was able to reproduce this condition in a fetus puppy by tying off some of the blood supply to a puppy's intestines and then placing the animal back in the womb, after which it was born some two weeks later, with the condition of intestinal atresia. He was also able to cure the condition by removing the piece of intestine with inadequate blood supply. The mistake of previous surgeons had been attempting to reconnect ends of intestine which themselves still had inadequate blood supply. To be successful, it was typically necessary to remove between 15 and 20 centimeters of intestine (6 to 8 inches). Jannie Louw used this innovation in a clinical setting, and Barnard's method saved the lives of ten babies in Cape Town. This technique was also adapted by surgeons in Britain and the US. In addition, Barnard analyzed 259 cases of tubercular meningitis.''Every Second Counts'', McRae
pages 48–49

Owen Wangensteen at the University of Minnesota in the United States had been impressed by the work of Alan Thal, a young South African doctor working in Minnesota. Wangensteen asked the Groote Schuur Head of Medicine John Brock if he might recommend any similarly talented South Africans, and Brock recommended Barnard.''Every Second Counts'', McRae
page 49
In December 1955, Barnard travelled to Minneapolis, Minnesota to begin a two-year scholarship under Chief of Surgery Wangensteen, who assigned Barnard more work on the intestines, which Barnard accepted even though he wanted to move onto something new.''Every Second Counts'', McRae
page 51
Simply by luck, whenever Barnard needed a break from this work, he could wander across the hall and talk with Vince Gott who ran the lab for open-heart surgery pioneer Walt Lillehei. Gott had begun to develop a technique of running blood backwards through the veins of the heart so Lillehei could more easily operate on the aortic valve (McRae writes, "It was the type of inspired thinking that entranced Barnard"). In March 1956, Gott asked Barnard to help him run the heart-lung machine for an operation.''Every Second Counts'', McRae
page 53
Shortly thereafter, Wangensteen agreed to let Barnard switch to Lillehei's service. It was during this time that Barnard became acquainted with fellow future heart transplantation surgeon Norman Shumway. Barnard also became friendly with Gil Campbell, who had demonstrated that a dog's lung could be used to oxygenate blood during open-heart surgery. (The year before Barnard arrived, Lillehei and Campbell had used this procedure for twenty minutes during surgery on a 13-year-old boy with ventricular septal defect, and the boy had made a full recovery.) Barnard and Campbell met regularly for early breakfast. In 1958, Barnard received a Master of Science in Surgery for a thesis titled "The aortic valve – problems in the fabrication and testing of a prosthetic valve". The same year he was awarded a Ph.D. for his dissertation titled "The aetiology of congenital intestinal atresia". Barnard described the two years he spent in the United States as "the most fascinating time in my life."

Upon returning to South Africa in 1958, Barnard was appointed head of the Department of Experimental Surgery at Groote Schuur hospital, as well as holding a joint post at the University of Cape Town.''Dictionary of African Biography, Volume 6'', Emmanuel Kwaku Akyeampong, Henry Louis Gates, Jr., editors-in-chief
Barnard, Christiaan Neethling
Anne Digby, Oxford University Press, 2012. He was promoted to full-time lecturer and Director of Surgical Research at the University of Cape Town. In 1960, he flew to Moscow in order to meet Vladimir Demikhov, a top expert on organ transplants (later he credited Demikhov's accomplishment saying that "if there is a father of heart and lung transplantation then Demikhov certainly deserves this title.") In 1961 he was appointed Head of the Division of Cardiothoracic Surgery at the teaching hospitals of the University of Cape Town. He rose to associate professor in the Department of Surgery at the University of Cape Town in 1962. Barnard's younger brother Marius, who also studied medicine, eventually became Barnard's right-hand man at the department of Cardiac Surgery. Over time, Barnard became known as a brilliant surgeon with many contributions to the treatment of cardiac diseases, such as the Tetralogy of Fallot and Ebstein's anomaly. He was promoted to Professor of Surgical Science in the Department of Surgery at the University of Cape Town in 1972. In 1981, Barnard became a founding member of the World Cultural Council. Among the recognition he received over the years, he was named Professor Emeritus in 1984.

Historical context

Following the first-ever successful kidney transplant in 1953, in the United States, Barnard performed South Africa's second kidney transplant in October 1967, the first having been done in Johannesburg the previous year.

On 23 January 1964, James Hardy at the University of Mississippi Medical Center in Jackson, Mississippi, performed the world's first heart transplant and world's first cardiac xenotransplant by transplanting the heart of a chimpanzee into a desperately ill and dying man. This heart did beat in the patient's chest for approximately 60 to 90 minutes. The patient, Boyd Rush, died without regaining consciousness.

Barnard had experimentally transplanted forty-eight hearts into dogs, which was about a fifth the number that Adrian Kantrowitz had performed at Maimonides Medical Center in New York and about a sixth the number Norman Shumway had performed at Stanford University in California. Barnard had no dogs which had survived longer than ten days, unlike Kantrowitz and Shumway who had had dogs survive for more than a year.

With the availability of new breakthroughs introduced by several pioneers, also including Richard Lower at the Medical College of Virginia, several surgical teams were in a position to prepare for a human heart transplant. Barnard had a patient willing to undergo the procedure, but as with other surgeons, he needed a suitable donor.

During the Apartheid era in South Africa, non-white persons and citizens were not given equal opportunities in the medical professions. At Groote Schuur Hospital, Hamilton Naki was an informally taught surgeon. He started out as a gardener and cleaner. One day he was asked to help out with an experiment on a giraffe. From this modest beginning, Naki became principal lab technician and taught hundreds of surgeons, and assisted with Barnard's organ transplant program. Barnard said, "Hamilton Naki had better technical skills than I did. He was a better craftsman than me, especially when it came to stitching, and had very good hands in the theatre". A popular myth, propagated principally by a widely discredited documentary film called ''Hidden Heart'' and an erroneous newspaper article, maintains incorrectly that Naki was present during the Washkansky transplant. Refers to documentary film ''Hidden Heart'' about Hamilton Naki.

First human-to-human heart transplant

Barnard performed the world's first human-to-human heart transplant operation in the early morning hours of Sunday 3 December 1967.''S Afr Med J'',
A human cardiac transplant: an interim report of a successful operation performed at Groote Schuur Hospital, Cape Town
, Barnard CN, 30 December 1967; ''41''(48): 1271–74.
''Los Angeles Times'', Jill Gottesman, 20 March 1988. Louis Washkansky, a 54-year-old grocer who was suffering from diabetes and incurable heart disease, was the patient.Louis Washkansky (1913–1967)
, Science Museum. Louis was born in Lithuania in 1913 and moved to South Africa in 1922.1967: First Heart Transplant Patient Goes Under the Knife
''Haaretz'', This Day in Jewish History, David B. Green, 3 December 2013. ".. When he was 9, his mother took him ouis Washkanskyand his three siblings to Cape Town, to join their father, who had come ahead of the family .." Barnard was assisted by his brother Marius Barnard, as well as a team of thirty staff members. The operation lasted approximately five hours.Christiaan Neethling Barnard
South African History Online, updated 11 January 2017.

Barnard stated to Washkansky and his wife Ann Washkansky that the transplant had an 80% chance of success.Calculated Risks: How to Know When Numbers Deceive You
Gerd Gigerenzer, Simon & Schuster, 2002.''Every Second Counts'', McRae, pages 176, 190.Ethics of Scientific Research
Kristin Shrader-Frechette, Rowman & Littlefield, 1994, page 38. Along a similar line, this author states, "Barnard's failure to tell Washkansky's wife that her husband was dying," although it's not clear whether this was pre- or post-transplant. This has been criticised by the ethicists Peter Singer and Helga Kuhse as making claims for chances of success to the patient and family which were "unfounded" and "misleading".A Companion to Bioethics, Second Edition
Helga Kuhse, Peter Singer, Wiley-Blackwell, 2012.

Barnard later wrote, "For a dying man it is not a difficult decision because he knows he is at the end. If a lion chases you to the bank of a river filled with crocodiles, you will leap into the water, convinced you have a chance to swim to the other side." The donor heart came from a young woman, Denise Darvall, who had been rendered brain dead in an accident on 2 December 1967, while crossing a street in Cape Town. On examination at Groote Schuur hospital, Darvall had two serious fractures in her skull, with no electrical activity in her brain detected, and no sign of pain when ice water was poured into her ear. Coert Venter and Bertie Bosman requested permission from Darvall's father for Denise's heart to be used in the transplant attempt. The afternoon before his first transplant, Barnard dozed at his home while listening to music. When he awoke, he decided to modify Shumway and Lower's technique. Instead of cutting straight across the back of the atrial chambers of the donor heart, he would avoid damage to the septum and instead cut two small holes for the venae cavae and pulmonary veins. Prior to the transplant, rather than wait for Darvall's heart to stop beating, at his brother Marius Barnard's urging, Christiaan had injected potassium into her heart to paralyse it and render her technically dead by the whole-body standard. Twenty years later, Marius Barnard recounted, "Chris stood there for a few moments, watching, then stood back and said, 'It works.'"

Washkansky survived the operation and lived for 18 days; he died from pneumonia, possibly due to the immunosuppressive drugs he was taking.

Additional heart transplants

Barnard and his patient received worldwide publicity.Organ Donation
GlobalViewpoints, Margaret Haerens editor, Detroit, New York, San Francisco, New Haven, Conn., Waterville, Maine, U.S.; London, England, UK: Greenhaven Press, 2013.''Every Second Counts'', McRae, se
page 207
and, regarding publicity in the Soviet Union
pages 208–09
in which ''Pravda'' states, "in spite of South Africa's backward place in the community of nations, positive, creative forces seem to thrive there, as proven by the immense feat of Dr. Chris Barnard." A 2017 BBC retrospective article described the occasion as one where "Journalists and film crews flooded into Cape Town's Groote Schuur Hospital, soon making Barnard and Washkansky household names." Barnard himself was described as "charismatic" and "photogenic" while initial reports labeled the operation as "successful" despite the death of Washkansky 18 days later.The operation that took medicine into the media age
BBC, Ayesha Nathoo (Centre for Medical History, University of Exeter), 3 December 2017. The photo caption incorrectly states Louis Washkansky was the first heart transplant recipient, when in actuality he was second. Boyd Rush with physician James D. Hardy was the first person to receive a heart transplant in 1964.

Worldwide, approximately 100 transplants were performed by various doctors during 1968. However, only a third of these patients lived longer than three months. Many medical centers stopped performing transplants. In fact, a US National Institutes of Health publication states, "Within several years, only Shumway's team at Stanford was attempting transplants."

Barnard's second transplant operation was conducted on 2 January 1968, and the patient, Philip Blaiberg, survived for 19 months.Philip Blaiberg was dying—this time for certain
''Chicago Tribune'', Mrs. Philip Blaiberg, 12 October 1969, page 68. Blaiberg's heart was donated by Clive Haupt, a 24-year-old black man who suffered a stroke, inciting controversy (especially in the African-American press) during the time of South African apartheid. Dirk van Zyl, who received a new heart in 1971, was the longest-lived recipient, surviving over 23 years.

Between December 1967 and November 1974 at Groote Schuur Hospital in Cape Town, South Africa, ten heart transplants were performed, as well as a heart and lung transplant in 1971. Of these ten patients, four lived longer than 18 months, with two of these four becoming long-term survivors. One patient, Dorothy Fischer, lived for over thirteen years and another for over twenty-four years.Transplantation of the heart: An overview of 40 years' clinical and research experience at Groote Schuur Hospital and the University of Cape Town
''South African Medical Journal'', "Part I. Surgical experience and clinical studies." J Hassoulas, Vol. 102, No. 6 (2012).

Full recovery of donor heart function often takes place over hours or days, during which time considerable damage can occur. Other deaths to patients can occur from preexisting conditions. For example, in pulmonary hypertension the patient's right ventricle has often adapted to the higher pressure over time and, although diseased and hypertrophied, is often capable of maintaining circulation to the lungs. Barnard designed the idea of the heterotopic (or "piggy back" transplant) in which the patient's diseased heart is left in place while the donor heart is added, essentially forming a "double heart". Barnard performed the first such heterotopic heart transplant in 1974."A tale of two hearts"
''Postgrad Medical Journal'', 27 July 2016. "... HHT eterotopic Heart Transplantationinvolves transplanting the donor heart without removing the recipient heart, effectively forming a 'double heart'. It was widely used in the pre-cyclosporine era when the donor was not strong enough (eg, the recipient had a much larger body) or the recipient had pre-existing pulmonary hypertension. Christiaan Barnard performed the first HHT ('piggy back' transplant) in 1974 ..."

From November 1974 through December 1983, 49 consecutive heterotopic heart transplants on 43 patients were performed at Groote Schuur. The survival rate for patients at one year was over 60%, as compared to less than 40% with standard transplants, and the survival rate at five years was over 36% as compared to less than 20% with standard transplants.

Many surgeons gave up cardiac transplantation due to poor results, often due to rejection of the transplanted heart by the patient's immune system. Barnard persisted until the advent of cyclosporine, an effective immunosuppressive drug, which helped revive the operation throughout the world. He also attempted xenotransplantation

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