Barnard: surgeon with heart

Chris Barnard won the praise of the world
for his astonishing medical achievement.
(Image: SA History)

Barnard and former South African
president Nelson Mandela.
(Image: Karoo Hartfees 2008)

The patient, Louis Washkansky, with his
physician, Chris Barnard.
(Image: Cape Gateway)

Barnard mobbed by admirers during a visit
to the University of Frankfurt-Hoechst.
(Image: Max Scheler)

Janine Erasmus

December marks the anniversary of the world’s first successful human-to-human heart transplant, performed in 1967 by the late South African Dr Christiaan Neethling Barnard – one of an eminent group of physicians renowned for their role in advancement of medicine.

Barnard put South Africa on the medical map with his pioneering work in the field of organ transplants. Today such operations are routine, but 41 years ago Barnard was venturing into unknown territory.

The Charles Saint theatre suite at Cape Town’s world-famous Groote Schuur Hospital was the scene of medical history when Barnard and his team successfully placed the still-beating heart of a fatally injured young accident victim into the body of 55-year-old Louis Washkansky.

At the time huge strides were being made internationally in the field of cardiac surgery, and it was also the collective work of a number of others around the world that contributed to Barnard’s extraordinary feat. There was increasing success in correcting congenital heart conditions and operating on the human heart, and new technologies such as the heart-lung machine were allowing surgeons to reach greater heights than ever before.

Extensive research had been carried out into the surgical techniques of heart transplantation, and much work on animals was being done by specialists in several countries. The time was right for the unthinkable – that of a human-to-human heart transplant.

Barnard had successfully performed South Africa’s first kidney transplant, his only such operation, earlier in 1967 and was convinced that the Cape Town team had the knowledge, expertise and facilities to do the same with the heart. However, he was not the only one.

A race for victory

In fact, there was something of a global race to see who would perform the daring operation, with teams at around the world standing by. While recipients were plentiful, it was the need for just the right donor that was delaying matters. For two teams, it all suddenly came together. Barnard performed his operation just days before Dr Adrian Kantrowitz in Brooklyn, New York, but sadly the infant American patient died mere hours after the transplant and the surgical team admitted defeat.

For months both Barnard and Kantrowicz had been on the point of achieving the breakthrough, but because of various factors, such as South Africa’s apartheid laws, which forbade the transplantation of a heart from a non-white into a white person, they were neck-and-neck until conditions gave Barnard the edge.

Before the historic moment Barnard was asked by friends if such a transplant would make headlines around the world. “There will probably be a ripple in the medical world,” the physician is reported to have replied, somewhat dryly.

Living on borrowed time

Washkansky had taken the brave step of agreeing to the operation, but he had little choice. His heart was badly diseased, he had suffered three heart attacks, and by that stage he was living one day at a time. Barnard had examined him the year before at the request of his own physician and had come to the conclusion that nothing could be done. A year later he was fighting for his life and when the surgeon offered him the unprecedented chance to improve his health he took it.

But while the world rejoiced, the family of donor Denise Darvall mourned. The 25-year-old was crossing a road in the suburb Observatory, with her mother, Myrtle, when they were hit by a car. Darvall’s mother died at the scene and the young woman was rushed to nearby Groote Schuur with extensive head injuries. Realising that she could not survive on her own, her father consented to the removal of her heart in the hope that it would save Washkansky’s life.

Barnard’s team sprang into action to remove the precious organ. Darvall’s body was taken into operating theatre A, next to theatre B in which Washkansky lay waiting. Shortly after midnight on 3 December 1967, her heart was removed and connected to a small heart-lung machine where it was simultaneously chilled. Her kidneys were also removed, to be transplanted into a 10-year-old coloured boy. This gave rise to some controversy at the time because of apartheid laws.

Although their blood types were not the same and the chances of rejection were unknown, Darvall was O-negative – the universal donor – and so the team decided to go ahead. Because of the urgency of the situation, hospital authorities were not alerted until the operation was over. Afterwards a number of ethical questions arose and it was said by some that the team had rushed into the operation without knowing enough about immune system repression.

The operation began at around 1am. The team of some 30 doctors, among them Barnard’s brother Marius, took five hours and five stages to complete their historic task. After stitching the donor heart into position, Barnard connected first the left auricle and then the right, followed by the aorta, the pulmonary artery, and the veins, and when the heart-lung machine was removed Darvall’s heart took over strongly.

Although Washkansky died almost three weeks later because his immune system had been compromised by anti-rejection drugs to such an extent that he succumbed to double pneumonia, his 18 days of improved quality of life offered new hope to others suffering from incurable heart disease.

The discovery in 1972 of the drug cyclosporine, which helps the body to withstand rejection of donor organs and protects against infection, has since opened up the field of organ transplantation.

Overnight sensation

The world’s reaction to the event was dramatic and unexpected. Barnard became a celebrity overnight and was soon rubbing shoulders with the likes of Princess Grace of Monaco, actress Sophia Loren, and Princess Diana. The constant jet-setting and playboy image took its toll on his first marriage, but Barnard married again in 1970 and then again in 1989, fathering five children over the years. All three marriages ended in divorce.

His second patient was Cape Town dentist Philip Blaiberg, who was operated on in January 1968 and died in August 1969, while Dorothy Fisher lived for 24 years and Dirk van Zyl lived for a further 23 years. Barnard was also the first to carry out the piggyback technique of transplantation, where the original heart is left in place and works alongside the transplanted heart for a time, and the first to do a heart-lung transplant.

The great healer carried out more than 420 heart transplants but was eventually forced to give up surgery because of rheumatoid arthritis. However, he continued to work in medicine in other ways, establishing the Christiaan Barnard Foundation for children with heart problems, acting as a consultant, and taking up a position as director of a hospital in Greece.

The distinguished career of this giant of medical science came to an end in September 2001 when he died while holidaying in Cyprus, reportedly of an asthma attack. In accordance with his wish, his ashes were laid to rest in the rose garden in front of the old Beaufort West rectory where he grew up, with the inscription “I came back home” on his tombstone.

Destined for greatness

Barnard was born in 1922 in Beaufort West on the Western Cape’s Great Karoo plateau. His father, a minister in the Dutch Reformed Church, and his mother, a school teacher, had five sons, of whom Barnard was the fourth. He always wanted to be a doctor and after a happy but poor upbringing, during which he excelled at school, his parents managed to get him into Cape Town University’s medical school. He was later awarded a three-year scholarship.

After qualifying as a physician in 1946, Barnard took up an internship at Cape Town’s Groote Schuur Hospital. Founded in 1938, the teaching hospital is the primary academic facility of the university medical school and is also internationally acclaimed as a research institution. As of November 2007 more than 516 heart transplants had taken place, with the longest-lived patient still doing well 28 years later, according to the hospital.

With its reputation for providing world class academic training, Groote Schuur receives many medical students, specialists and residents from all over the world, who come to gain experience in various fields. Groote Schuur (Dutch, meaning “big barn”) is named after the original Groote Schuur estate established by Dutch settlers in the 17th century.

Rising to the top of his profession

Barnard then did a stint as a general practitioner in Ceres, and married during this time, but found no challenge in being a country doctor and returned to Cape Town in 1951. He continued to study while working, completing his Masters degree in medicine in 1953.

During his tenure in Ceres one of his patients delivered a baby with an untreatable heart defect. The baby’s death made Barnard think about remedial surgery for damaged hearts, and gave him a direction for his future career.

In 1956 the physician received a scholarship to study in the US. He chose to study cardiothoracic surgery at the University of Minnesota under Prof Wagensteen, renowned as a teacher of experimental surgery. Barnard received his doctorate at the end of his course, which he finished in two years instead of the usual six. In 1958 he went back to Cape Town, bringing with him the country’s first heart-lung machine.

He continued to break the boundaries as he introduced open-heart surgery to his South African colleagues, designed an artificial heart valve, and began to carry out heart transplants on animals. Later he assisted with the development of the artificial heart. It was just a matter of time before he would accomplish something historic.

Barnard was named Professor of Surgical Science in the Department of Surgery at Cape Town University in 1972, and received the title of Professor Emeritus in 1984. He has been hailed as a brilliant and compassionate doctor, one who cared for his patients with unmatched dedication. He was creative and courageous, and was not afraid to try out new ideas – and many thousands of people today owe their lives to him.

Among the international honours bestowed on Barnard over the years are 71 fellowships, honorary degrees, decorations and awards from societies, academic and charitable institutions, and governments of several countries.

Barnard was put forward for the Nobel Prize in Medicine in 1968, but did not win. In a 1997 interview with Frontline, an Indian national magazine, he speculated that he was probably not chosen by the Nobel committee because he was a white South African and it would have been an unpopular choice.

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