Part XVII Norman E. Shumway- The Dawn of a New Era- Standing on Tall Shoulders- The History of Cardiac Surgery Thomas N Muziani PA-C, CP

“A man is but the product of his thoughts. What he thinks, he becomes.” Mahatma Gandhi- All Men are Brothers

From Chrysalis Emerge –

In 1960, with the new buildings completed, Stanford University Medical Center blossomed in Palo Alto, CA. The first chairman of surgery at the new campus was Dr. Garrott Allen, from University of Chicago. With the immeasurable influence of Dr. Ann Purdy and her husband, Dr. Emile Holman, they contacted Dr. Allen and resolutely recommended Dr. Shumway for the position of Chief of Cardiac Surgery. Dr. Allen invited Shumway to visit him on the campus and, quoting from Dr. Lower: “fill the position as Chief of Cardiac Surgery until such time as a big name surgeon could be recruited.”

Shumway and his team established a routine of performing clinical cardiac procedures on Monday, Wednesday and Friday. Laboratory research would be conducted on Tuesday and Thursday. With the synthesis of their extensive laboratory experience in topical hypothermia applied to their clinical patients they began achieving superior results with both children and adults.

Also in 1960, Drs. Lower and Shumway were able to accomplish the first long-term survival of canine heart transplants, with the dog surviving for an extended time. Over the ensuing eight years, Dr. Shumway and his team perfected the myriad of challenging details with transplanting a human heart. From preservation, the effect of denervation, proper immunosuppression and the non-invasive ability to detect rejection…each detail needed to be addressed to a positive outcome. Then, in 1965, in the journal Surgery, they reported on their long-term survival of dogs with allografts.

On November 20, 1967, the Journal of the American Medical Association published the following quote from Dr. Shumway: “We think the way is clear for trial of human heart transplantation. We have achieved the degree of experience with heart transplantation in the laboratory with which we feel confident we can take appropriate care of the patient with a cardiac transplant…although animal work should and will continue, we are more or less at the threshold of clinical application.” It must also be remembered that, due to acute concerns regarding viability of the donor organ, the general dictum for all transplant programs at the time was for both patient and donor to be in the same hospital at the same time to limit the hypoxic exposure of the donor organ.

Approximately two weeks later, on December 3 1967, Dr. Christiaan Barnard performed the first human heart transplant in Capetown, South Africa. The story of Dr. Barnard performing the first heart transplant really began in the summer of 1967. Christiaan Barnard had been invited to Medical College of Virginia by Dr. David Hume primarily to study kidney rejection post-transplant. While assisting in Dr. Hume’s laboratory, Barnard reacquainted with his former perfusionist Carl Goosen, a very enterprising individual, who now worked at the Medical College of Virginia. It was Mr. Goosen who introduced Christiaan Barnard to Dr. Lower, who was now teaching at Virginia. Lower invited them both to observe heart transplantation procedures being conducted in Dr. Lower’s laboratory at the Medical College. Since Dr. Lower had worked so closely with Dr. Shumway in developing and refining their techniques for heart transplantation, he incorporated the same principals and application at the medical school.

After observing the laboratory procedures in Lower’s research facility, Dr. Barnard returned to Capetown…and the rest is well documented history. What is conveniently left out of the textbooks are all indications pointing to Mr. Goosen returning with Christiaan Barnard to South Africa. This would logically explain the “fast-tracking” for the myriad of details in assembling a transplant program so quickly. It is most definitely a procedure that, in the glorious words of Saint Paul; “does not suffer fools gladly.”

On 6 Dec 1967, three days after Dr. Barnard gave Louis Washkansky a new heart, Dr. Adrian Kantrowitz at Maimonides Medical Center in Brooklyn, NY transplanted a new heart in an infant. The infant died six and a half hours later and Dr. Kantrowitz declared the operation a failure. On 2 Jan. 1968, Dr. Barnard carried out his second transplant on Dr. Phillip Blaiberg, who lived 19 months. Mr. Washkansky survived 18 days.

Almost immediately, dozens of surgeons from around the world who had spent virtually no time investigating or practicing the techniques on animals transformed heart transplantation into a medical circus. Within a year, they had performed over 100 human heart transplants. However, the early transplants failed to achieve long-term success and, propelled by the carnival atmosphere and adverse publicity the medical community urged a moratorium on further heart transplants.

In 1967, Dr. Shumway and colleagues believed they were ready to commence clinical trials. However, completely independent of the voluminous empirical knowledge they had gained over the previous eight years…another impediment again stood in the way of proceeding with clinicals. This was a subject that, due to its extremely polarizing opinions, could not gain traction for universal acceptance. The lack of standardization regarding the definition of “brain death”. During the 1960’s, everyone felt they were entitled “experts” in defining when a person was brain dead. Clerics, Mystics, Psychologists’, Politicians…and the general public…all believed it was a relatively simple definition to answer.

Due to the fact that brain death became a societal issue, therefore leading to many acrimonious arguments, it initially appeared resolution would be impossible. As Dr. Shumway once said: “There was a terrible furor about the brain death issue.” In the late 1960’s, Dr. John Hauser, the coroner of Santa Clara County, which included Stanford, sought criminal charges against Dr. Shumway for transplanting organs without an autopsy on the donor…an action that would have rendered the transplantation impossible. The two men shouted at each other over the issue in Dr. Shumway’s office, recalled Dr. Eugene Dong, then a transplant surgeon at Stanford and now a lawyer.

As Dr. Shumway has mentioned: “For the first 5 years, we were technically in violation of state laws as far as donor utilization was concerned.” As a matter of record, the first donor was referred by a private neurosurgeon in Palo Alto, not from Stanford’s neurosurgery or neurology departments. Dr. Shumway performed his first clinical heart transplant procedure on 8 January 1968, with Dr. Edward Stinson assisting him. By this time, the operation was a culmination of more than a decade of research and launched the Stanford cardiac transplant program.

In 1971, many of the more than 100 patients who underwent heart transplants worldwide died, leaving a 1-year survival of approximately 20%. However, Dr. Shumway and associates extensive hands-on experience garnered over the many years of research…plus his ever positive philosophy matriculated from the early days at University of Minnesota they persisted. He was convinced that heart transplantation would become successful and therefore offer the only viable option for very ill patients with end-stage heart failure. The most revealing aspect of this positive philosophy lay in the fact that all other centers in the United States stopped performing heart transplantation due to the poor results that were deemed dismal.

Finally, in 1973, Louis P. Bergma, then the Santa Clara County district attorney petitioned the California Legislature to resolve the brain death issue and they adopted “cessation of brain activity” as the definition of death. Then, in recognition of the years of research and their very unique approach to the procedure, the National Institutes of Health awarded Stanford a National Institutes of Health program project grant that supported both clinical and laboratory investigations for the myriad unsolved problems associated with heart transplants. This grant spanned 23 years and directly lead to numerous advances and trained surgeons plus other specialists in the embryonic field of heart transplant medicine.

Clinical heart transplantation at Stanford and around the world benefited from the innovative developments in the experimental laboratory at Stanford University. Just a few of those innovations are topical hypothermia; demonstration the denervated heart functioned well; the use of electrocardiogram voltage to monitor the presence of rejection; the development of the transvenous endomyocardial biopsy; the production and use of rabbit antithymyocyte globulin; the use of totally implantable left ventricular assist device (Novacor, World Heart Corporation, Ottawa, Ontario, Canada) for a “bridge to transplant”; the use of cyclosporine A as an investigational drug for heart transplantation; the use of cyclosporine A for the first successful transplantation of the lung as a combined heart-lung transplant by Dr. Bruce Reitz, assisted by Dr. Norman E. Shumway.

Any of us that have participated in the brilliantly beautiful metamorphosis of human heart transplantation must be ever cognizant that we stand on some very tall shoulders. Dr. Shumway and his associates persevered through some very daunting trials of fortitude and faith. Past United States Senate Republican leader, Bill Frist, a surgeon who trained under Dr. Shumway called him “one of the greatest surgical thinkers.” Senator Frist continued: “Emphasizing the importance of keeping things simple forced people to develop systems to prevent errors and mistakes.”

Another small aspect of Dr. Shumway’s approach to teaching and mentoring prospective cardiac surgeons…was his willingness to be first assistant while the trainee performed the surgery. As Dr. William R. Brody, who trained under Dr. Shumway and was president of John’s Hopkins University stated: “We used to joke he was the world’s greatest first assistant.”

I do not believe with the present environment cardiac surgeons will be anointed the same autonomy as from those early formative days…therefore, we may never see his kind again.