12 May

The emergence of cardiovascular disease as the major cause of death in the industrialized nations is a recent phenomenon, but deaths due to heart attack and stroke have long been of interest to physicians and scientists. Unfortunately, the approaches to the treatment of heart dis- ease that have seized the most media attention—heart transplant surgery and the artificial heart—are methods that are unlikely to have commen- surate effects on morbidity and mortality. The first human heart trans- plant operation was performed by South African surgeon Christiaan Barnard in December 1967. In the wake of Barnard’s emergence as a world-class celebrity, other heart surgeons were soon performing equally dramatic operations. Some of most daring and unsuccessful efforts in the 1960s and 1970s involved the transplantation of the hearts of chimpanzees, baboons, sheep, and artificial hearts into moribund patients. Ten years after Barnard triggered an era of boundless excitement and fierce com- petition among surgical centers, the heart transplant industry experi- enced a wave of disappointment and disillusionment.

When cyclosporin was introduced in 1980 to suppress rejection after heart transplantation, its success stimulated the development of new cardiac transplantation programs. By the mid-1980s, at least two thousand cardiac transplant operations were being performed in more than one hundred transplant centers in the United States each year. Organ transplantation has been called the greatest therapeutic advancement of the second half of the twentieth century and also the sub- ject of the most hyperbole. But post-transplantation issues, such as com- plications arising from immunosuppressive drugs and the recurrence of the initial disease, as well as ethical issues, including the problem of the utilization of scarce resources, persist.

The demand for organs has expanded to include people with a wide range of ailments, like hepatitis C. Although the number of people, living or dead, donating organs has increased each year, the number of people waiting for organs has more than quadrupled. Thus, thousands of people die each year while waiting for organs. In retrospect, it is clear that the great expectations generated by the first heart transplants were based solely on the boldness of the surgical feat, rather than any rational hopes of long-term success.

The same prob- lem that defeated Denis three centuries before—the body’s rejection of foreign materials—insured the failure of organ transplantation. Unlike Denis, however, doctors in the 1960s were well aware of the body’s immunological barriers. Even with drugs that suppressed the patient’s immune system, and attempts to provide some degree of tissue matching, the risk of organ rejection and postsurgical infections were virtually insurmountable obstacles. Optimistic surgeons pointed out that blood transfusion had once faced seemingly insurmountable obstacles, and they predicted that organ transplants would one day be as commonplace as blood trans- fusions.

Advocates of organ transplantation even managed to ignore the obvious objection that while blood is a renewable resource, hearts are not. Nevertheless, as surgeons proclaimed a new era in which organ transplants would be routine rather than experimental, healthcare pro- phets warned that in the not too distant future, the supply of money rather than hearts might become the rate-limiting factor. Given the tremendous toll taken by cardiovascular diseases, some analysts con- tend that prevention rather than treatment is our most pressing need. High-risk, high-cost therapy has been likened to fighting infantile paral- ysis by developing more sophisticated artificial-lung machines instead of preventive vaccines. Unfortunately, prevention lacks the glamour and excitement of surgical intervention.

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