History of Heart Transplantation

On December 3, 1967, a surgical team led by Christiaan Barnard performed the first successful human-to-human heart transplant at Groote Schuur Hospital in Cape Town, South Africa.[1] Using a technique based on the pioneering works of Alexis Carrel (vascular anastomosis, 1890s), C. Walton Lillehei (myocardial protection, development of open heart surgery, 1950s),[2],[3],[4],[5] John Gibbon (cardiopulmonary bypass, 1950s),[6] and Norman Shumway and Richard Lower (surgical technique and cold preservation),[7],[8],[9] Dr. Barnard and his team were able to successfully procure the heart of Denise Darvall, a 25-year-old neurologically devastated woman whose heart was donated after cardiac death had been declared, and sutured it into the chest of Louis Washkansky, a 54-year-old man with advanced heart failure. Despite dying of pneumonia just 18 days after his transplant, the technical success of the world’s first heart transplant led to an explosive era in the field of cardiothoracic surgery and was quickly followed in the United States by Dr. Norman Shumway’s first heart transplant procedure approximately 1 month later.[10],[11]

In the years following this surgical milestone, dozens of surgeons from around the world replicated the technical success of transplanting hearts, but enthusiasm rapidly waned as the realities of organ rejection and its associated complications quickly limited the applicability of the therapy. In the initial year following the first human-to-human heart transplant, 102 heart transplants were performed worldwide, but by 1971, this number had decreased to only 10. Despite its initial promise, it appeared that the field of cardiac transplantation would soon became a fleeting phenomenon if it were not for the sheer dedication of a single man leading a dedicated team at Stanford University, Norman Shumway.[12] (Figure 1)

Figure 1

Norman E. Shumway, Pioneer of Cardiac Transplantation

In 1971, Shumway’s group published their initial experience of 26 human heart transplant patients, citing survival rates of 42%, 37%, and 26% at 6, 18, and 24 months, respectively.[13] This success eventually led to the widespread use of specific clinical, electrocardiographic, and echocardiographic techniques for the diagnosis of acute rejection as well as the use of methylprednisolone, actinomycin D, and antilymphocyte globulin as potential immunosuppressive treatment options.[14] Two years later, Caves, Billingham and Shumway reported on the development of percutaneous transvenous endomyocardial biopsy as a means to more accurately document episodes of rejection based on histologic findings of the myocardium.[15],[16],[17]Despite advances in the development of accurate diagnostic strategies, it wasn’t until the early 1980s that the lymphocyte-modulating agent, cyclosporine A, demonstrated effective therapy to prevent organ rejectioin, catapulting heart transplantation (and all solid organ transplantation) into the modern era. (Figure 2).[18],[19],[20] In 1984, Denton Cooley performed the first successful heart transplant in an infant at the Texas Children’s Hospital in Houston, Texas, and by 1985, Shumway’s group began reporting 1-, 2-, and 3-year adult survival rates of 83%, 75%, and 73%, respectively.[21],[22]

Figure 2

A History of Cardiac Transplantation

With the newfound optimism for the use of cardiac transplantation as a means to treat end-stage heart failure, the rate of heart transplantation climbed exponentially worldwide (Figure 3). To date, more than 65,000 heart transplants have been performed, a number that is now primarily limited by the availability of suitable donor organs.[23] Even with the advent of ventricular assist devices and the developing applicability of total artificial hearts, the use of cardiac transplantation remains the surgical “gold standard” in the treatment of advanced heart failure.[24] In the sections to follow, a broad overview of adult heart transplantation from recipient selection to postoperative care and surgical outcomes will be discussed.

Figure 3

Trends in Heart Transplant Volume

Reproduced with permission from: Khush KK, Cherikh WS, Chambers DC, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-sixth adult heart transplantation report - 2019; focus theme: Donor and recipient sizematch. J Heart Lung Transplant 2019;38:1056-1066.