Transplants: Summit for the Heart

It was a meeting of a rather special elite. Eleven of the 16 surgeons who have performed heart transplants gathered last week in Cape Town to consider what they had done, what they should do, and how they could do better. Why Cape Town? Explained Brooklyn's Dr. Adrian Kantrowitz: "Chris Barnard has been doing it better than all of us—that's why we are here." Barnard's aura was rivaled by the authority of Houston's Dr. Denton Cooley, who has three surviving patients, including one who is going back to work.

When Is Death? One question on which the surgeons spent little time was the most basic of all: Are heart transplants morally justified? Since all the principals at the symposium had performed transplants, they had answered this question long ago in their own minds. But there remained some sticking points in medical ethics. How to determine the death of the donor? On three criteria there was general agreement: The patient must no longer have any natural heartbeat, or respiration, or reflexes. Beyond that, he must have a "flat" electroencephalogram—no "brain wave" activity—but for how long? After the closed sessions in Cape Town, all that Spokesman Cooley could say was: "We have reached some agreement as to the nature of brain death."

The second ethical-medical question was: How to select the recipient for a transplant? Most operations so far have been performed on men with advanced and long-standing heart disease. In such cases, it seems that a new heart may be wasted on a patient with negligible chances of survival. But can a doctor, in good conscience, pass over the man who is most severely ill and doomed soon to die, in favor of a younger man with more vitality, whose need is less urgent but who has a better chance of survival? On this score, said Cooley, "We did not establish definite criteria."

There have been only 25 human-heart transplants, with seven patients surviving—too small a sample for many firm conclusions. But there was quick agreement at Cape Town that the best surgical technique is that devised by Stanford University's Dr. Norman E. Shumway Jr., in which part of the recipient's old heart is left in place to reduce the number of blood-vessel connections needed and to protect the heart's electrical system. There was also surprising unanimity on the desirability of getting transplant patients out of bed and walking within 48 hours after their operations.

New Star. The area of deepest ignorance and most hopeful new reports covered the problem of protecting the implanted heart against rejection. Here the star turned out to be not a surgeon but a drug, forbiddingly named antilymphocyte globulin, or ALG.

What is ALG? It is the nearest thing to a natural medication yet found to suppress the mechanism by which the body seeks to reject any foreign protein implanted in it. By that mechanism, the human system produces antibodies that attack the proteins in the transplants. The antibodies are made or transported by white blood cells, or lymphocytes, which multiply astronomically in the presence of foreign tissue.