My First Heart Transplant

It's 4:10 am and we just put in the new heart. Certainly surgeons are morning people and start work long before most people are even out of bed. But this is not case here; no, this case started at 7:30 pm last night with a trip to retrieve the donor heart - harvesting it is called.

One of the attending cardiac surgeons, a scrub tech, and myself loaded up a limousine with our special equipment for harvesting a heart, and of course, a big ice cooler you would find at a summer BBQ full of beer for bringing the organ back. Normally the retrieval team - us - flies to the hospital where the donor is. But in this case it was just close enough to drive. Too bad, I would have relished a trip in a small fixed wing airplane to Nevada or Colorado.

As we pulled on to the freeway we called the transplant coordinator to confirm we were going to the right spot. "Is that hospital name on the letter head in front of you?" the surgeon teased the coordinator. Yes, mistakes like that have been made in the past apparently, and in situations like this you will never be faulted for triple checking everything. Redundancy it the sine qua non of not screwing up. There was a second limousine too, one for the liver and kidney transplant team, and when we all left, the drivers thought they were going to different places. Yes, we got that figured out.

En route the surgeon turn to me and said he wanted me to do the sternotomy - opening up of the chest. He talked me through it, using the Bovie (an electrocauterie device used as a scalpel), and the sternal saw. "I can get the chest open in about two minutes, and have actually got someone on bypass in six." "Anyone can do this," he explained, as if to say it's not like it's heart surgery or anything, "I'm just good because I do this a lot. Ask me to diagnose a pin worm infection and I'm totally lost."

Arriving at the hospital we lugged our equipment in and quickly changed out of our scrubs into those of the hospital we were at and marched back to the OR where the patient and operating team were. There was a flurry of activity getting the patient transferred from the bed to the operating table; he was very large and difficult to move, even with 5 people. I did not know anything about the man but noticed a ventriculostomy drain in his head. He apparently had a lethal brain process - I later learned that he fell down the stairs on his way home from the bar, drunk, and caused a deadly brain hemorrhage. Sheesh. What a way to go.

Out in the hallway the transplant surgeon and the general surgeon at the hospital completed the formal paperwork to confirm the patient's identity, blood type, certification of brain death, and so on. We took a look at his echocardiogram. He heart was abnormally enlarged - probably a result of chronic hypertension - but usable.

Although the patient was brain dead, he was intubated (on the breathing machine) and sedated with general anesthesia. The body responds quite a bit to pain even when the patient is completely asleep; that said, this patient was on general anesthesia to control blood pressure and heart rate while the incisions and dissection proceeded. I took the Bovie in my hand, a simple little plastic thing resembling a pen with a thin piece of metal for a tip. I pressed the button on the handle that heated the tip and gently ran the tip across the patient's sternum to expose the breast bone. Once that was exposed the surgeon handed me a special saw for cutting the sternum, and within a minute we were looking at a beating heart.

The abdominal team was working at the same time, but their job was considerably more involved and time consuming because of the number of structures in the abdomen that they were trying to preserve - the liver, pancreas, and both kidneys. We waited until they had finished ligating all but the main arteries and veins to these organs and had freed the organs from their surrounding tissues. The organs need to be removed synchronously because once the blood flow between the liver and heart is cut, it is only a matter of minutes before the patient would completely exsanguinate.

With everyone ready, we packed the organs in shaved, sterile ice and then ligated the inferior vena cava, the main vein leading to the heart. This was the point of no return: blood poured out at 4 liters per minute, and within a few seconds I could see all the tissues and organs turn a cadaverous gray, having lost the vibrant color of life given to them by flowing blood. Then with the heart empty and struggling to beat, we filled its chambers with a chilled preservative solution that completely arrested its movement. This is key to preserving the heart outside the body - keeping it from beating that is. Yes, the heart will beat on its own independently of the body, and to some extent, independently of blood. Until it runs out of oxygen. So by arresting the heart, we can keep it from using that precious little oxygen that remains after we take it from the body. Six hours is the maximum window, but the less time the better, so time is off the essence.

It was midnight by the time we crawled back into the ambulance for the ride home. We slept most of the way, with the heart in the ice cooler on the gourney, carefully sealed in a bucket with preservative and ice.

Back at the main hospital another surgery team had been furiously working to prepare the transplant patient. He had been on a heart assist device for several months because of terminal heart failure. Although life-preserving for someone waiting on the transplant list, the machine is grusome and medieval: the patient is connected to it by several large vacuum cleaner type hoses that run air into and out of little penumatic pumps inserted into the patient's heart. It sounds like a washing machine is inside the person's chest when you listen up close.

By 2 am second surgery team was ready for the transplant. The patient was placed on total cardiopulmonary bypass, and his old heart, now barely able to do anything, was removed. The surgeon with whom I harvested the new heart gently lifted it in his hands and held it carefully to his bosom as he walked across the room to the operating table. Once the new heart was in and all the vessels connected, the heart began to quiver. It was sensing the life contained in the fresh blood, and the preservative that was keeping it from beating was now gone. The surgeons shocked the heart to kick start a normal rhythm and eventually it began to beat, just like it had been 4 hours ago in its original body.

Of course this patient and his new heart are not out of the woods. The body's immune system will see the heart as a foreign object and attempt to kill it just like it would a virus or bacteria. This happens despite donor and recipient being the same sex and blood type. The patient will be on life-long medication to suppress his immune system, basically a type of chemotherapy. We could test more deeply the characteristics of immune systems to better identify compatible organs and recipient bodies (as is the case for bone marrow transplant), but this would simply limit the already short, precious supply of organs.

Today the patient is doing as well as expected. He's recovering in the ICU off the breathing machine with a new vigorous heart, and hopefully, a new chance at life.