Transplants: Why Blaiberg Died

Dr. Christiaan Barnard’s—and the world’s—first patient to receive a transplanted human heart, Louis Washkansky, lived for only 18 days after his historic operation. But Barnard’s second transplant recipient, Dentist Philip Blaiberg, recovered fully, wrote a book about his experiences and displayed such a zest for life that he went swimming on the first anniversary of his operation. Last week, after surviving for an incredible 594 days with another man’s heart in his chest—longer by far than any other heart transplant patient—Blaiberg died peacefully in the same Cape Town hospital at which he had received his new lease on life.

The challenge that confronted heart-transplant teams in Blaiberg’s case, as it has in all others, was more medical than surgical. The South African dentist was 58 when his own heart reached such an advanced stage of slow, progressive failure that it could no longer pump enough oxygenated blood to support any physical activity. After having been obliged to give up his dental practice, Blaiberg was bedfast. It was problematical whether he would hold out for another month or even a week. In these circumstances, Barnard felt fully justified in removing Blaiberg’s heart and replacing it with that of a young “Cape Colored” (half-caste) man, Clive Haupt, who had died of a stroke. The surgical technique, worked out by Stanford University’s Dr. Norman E. Shumway Jr., was clear-cut and immediately successful. It was only after the operation that the real struggle began.

Small White Cells. Blaiberg’s doctors were at once faced with the problem of controlling the immune mechanism by which the body seeks to reject any invading foreign substance, especially protein. Nature devised this complex reaction largely to protect the higher animals against parasitism and infection by such lowly microbes as bacteria and viruses. But the defense works equally well against tissues from higher animals, including those from any other man (except an identical twin).

The detailed workings of the immune mechanism are still imperfectly understood, but the main outlines are clear. The principal components of immunity are a type of white blood cell, the lymphoid cells. They have the genetically built-in ability to identify other cells as “self” (part of the same body) or “not self” (invaders to be destroyed). In the presence of “self” cells the lymphoid cells remain passive, but if they detect foreign material, they manufacture antibodies to contain or attack the invader. These antibodies are in the form of gamma globulin particles. Some remain on the surface of the lymphoid cells and circulate with them; others, free-floating, circulate in the blood stream. Both kinds adhere to cells in the foreign tissues of such organs as the transplanted heart. Which type is more important in graft rejection is still debated. What is certain is that, together, the two types can be devastatingly effective in destroying a graft.

Sensitized Animals. The billions of lymph cells in Blaiberg’s blood and other tissues began trying to destroy the alien heart as soon as it was implanted. To counter this intolerance, the physicians on Barnard’s team at Groote Schuur Hospital tried to suppress lymphocyte (and therefore antibody) production with drugs: azathioprine (Imuran) and a steroid of the cortisone family. Later, they resorted to a third weapon, antilymphocyte globulin (ALG), extracted from the blood of animals that have been sensitized to react against human lymph cells.

Blaiberg did well for six months, then had an episode of hepatitis. He also had a bout with pneumonia, because the immunosuppressive drugs that had weakened his defenses against the implanted heart had lowered the barriers against invading microbes. Using antibiotics and delicately juggling his doses of suppressive drugs, the doctors pulled Blaiberg through and kept him going for another year, which was marked by only occasional setbacks.

Nonetheless, the process of graft rejection was proceeding inexorably. Lymph cells with their attached antibodies were attacking cells in the transplanted heart muscle and in the heart’s own blood vessels, causing inflammation, swelling and formation of scar tissue. By this month, the heart muscle had been so damaged that it was in nro better shape than Blaiberg’s own heart had been 18 months earlier. It could no longer pump enough blood to his lungs to pick up oxygen for his body’s needs, or to his kidneys to sustain their vital filtering function. As a result, these organs had also deteriorated.

Surgeon Marius Barnard (Christiaan’s brother) signed a certificate listing the cause of Blaiberg’s death as “heart failure brought about by failure of the kidneys, and pneumonia.” Christiaan Barnard was quick to point out that there had been no sudden crisis of rejection like those observed in some other transplant patients; the process had been as slow as it had been relentless. Although there might have been time to find another heart donor, Barnard concluded that the condition of Blaiberg’s other organs had so declined that another transplant would be futile.

600% Improvement. In reviewing the causes of Blaiberg’s death, Barnard noted last week that medical science has not yet learned to prevent rejection —only to control it, with varying degrees of success. And, he might have added, suppression of the immune reaction is always accompanied by the risk of exposing the transplant recipient to a fatal infection. Thus, in light of the record* and the current state of the art, are heart transplants really justified? Yes, said Barnard, citing figures to support his contention. He has performed five such operations, and his patients have survived a total of 1,101 days—or an average of 220 days. Other heart patients who were accepted for transplants in Cape Town and at Stanford, but who died because no donor became available, survived an average of only 30 days. “So,” said Barnard, “we have an improvement of about 600%.” There had been no doubt in Blaiberg’s mind, as he had frequently testified in his newspaper column, that the added months of life had been deeply satisfying to him and had fully justified the rigors of surgery and hospitalization. The same has been true of virtually all, if not of all, long-term survivors.

Although Barnard declared that he would not slow down his transplant program, other surgical teams around the world were marking time last week, waiting for their medical colleagues to find improved ways to control the rejection phenomenon. They were watching other long-term survivors for clues. The new doyen, Pere Boulogne, 58, a Dominican priest who received his transplant in Paris on May 12, 1968, was carrying on most of his normal activities, working on a book and regularly celebrating Mass. He was being checked several times a week by his French doctors, who refused to divulge either the type or the dosage of immunosuppressive drugs being used to keep him alive.

*Of the 141 patients who have had 143 heart transplants (two have undergone two operations apiece), there were only 29 survivors last week.