tag:theconversation.com,2011:/ca/topics/heart-transplant-26480/articlesHeart transplant – The Conversation2023-08-10T12:40:24Ztag:theconversation.com,2011:article/2036252023-08-10T12:40:24Z2023-08-10T12:40:24ZLab-grown ‘ghost hearts’ work to solve organ transplant shortage by combining a cleaned-out pig heart with a patient’s own stem cells<figure><img src="https://images.theconversation.com/files/537844/original/file-20230717-245914-zcsxaf.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A 'ghost heart' is a pig's heart prepared so that it can be transplanted into people.</span> <span class="attribution"><span class="source">Provided by Doris Taylor</span></span></figcaption></figure><p><em>Heart disease is the leading cause of death worldwide. The World Health Organization estimates that <a href="https://www.who.int/health-topics/cardiovascular-diseases#tab=tab_1">17.9 million people</a> lose their lives to it each year, <a href="https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)">accounting for</a> 32% of global deaths.</em> </p>
<p><em><a href="https://scholar.google.com/citations?user=-OixKmwAAAAJ&hl=en">Doris Taylor</a> is a scientist working in regenerative medicine and tissue engineering. Her work has focused on creating personalized functioning human hearts in a lab that could rule out the need for donors. Taylor has dubbed these hearts “ghost hearts.”</em> </p>
<p><em>In March, Taylor spoke at the 2023 <a href="https://www.imaginesolutionsconference.com/">Imagine Solutions Conference</a> in Naples, Florida, about the ghost heart and her journey to creating it. Below are edited answers to questions from The Conversation. Taylor is also featured on <a href="https://bit.ly/3KyiYe5">Guy Kawasaki’s Remarkable People podcast</a>.</em></p>
<h2>What are the biggest challenges facing organ donations today?</h2>
<p>Currently, patients in need of a heart transplant need to join a waitlist, and hearts become available when someone else has died. Because there are not enough hearts to go around, only the very sick are put on the waitlist. The U.S. transplants about <a href="https://unos.org/news/in-focus/2022-heart-transplants-steep-increases-in-transplants-from-dcd-donors/">11 hearts a day</a>, and on a given day there are <a href="https://www.organdonor.gov/learn/organ-donation-statistics/detailed-description#fig1">more than 3,000 people</a> waiting for a heart. </p>
<p>Even when organs are successfully transplanted, it isn’t a Hollywood fairy-tale ending. A person receiving an organ transplant essentially trades one disease for other medical complications and diseases. Toxic drugs necessary to prevent rejection can cause <a href="https://doi.org/10.5500/wjt.v12.i3.42">high blood pressure</a> <a href="https://doi.org/10.1210/er.2015-1084">diabetes</a>, <a href="https://doi.org/10.1016/j.bulcan.2016.12.008">cancer</a> and <a href="https://doi.org/10.1053/j.ackd.2021.10.010">kidney failure</a>. These are serious medical issues that also affect people emotionally, financially and physically. </p>
<p><a href="https://doi.org/10.1371/journal.pone.0263210">About 18%</a> of people die in the first year after a transplant. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/pDuk5nI3tBw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Doris Taylor speaks at the 2023 Imagine Solutions Conference.</span></figcaption>
</figure>
<h2>What is the so-called “ghost heart”? How does it work?</h2>
<p>The <a href="https://www.cnn.com/2022/06/01/health/ghost-heart-life-itself-wellness/index.html">ghost heart</a> is a heart whose cells have been removed. All that remains is the heart framework, or scaffolding. It’s called a ghost heart because removing the cells causes the heart to turn from red to white. A human heart wouldn’t work as a scaffold because so few are available to work with.</p>
<p>So my team and I went with the next best thing: a pig heart. Pig hearts are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4181683/">similar to human hearts</a> in terms of their size and structure. Both have four chambers – two atria and two ventricles – responsible for pumping blood. And structures from pig hearts such as <a href="https://www.health.harvard.edu/heart-health/valve-replacement-mechanical-or-tissue#">valves have been used in humans</a> safely.</p>
<p>To remove the cells, the pig heart is gently washed through its blood vessels with a mild detergent to remove the cells. This process is called <a href="https://doi.org/10.1038/nprot.2014.097">perfusion decellurization</a>. The cell-free heart can then be seeded with new cells – in this case, a patient’s cells – thus forming a personalized heart.</p>
<h2>What role do stem cells play in creating a heart?</h2>
<p>If you lined up the cells needed for an average-size <a href="https://journals.lww.com/amjforensicmedicine/Abstract/2012/12000/Normal_Organ_Weights_in_Men__Part_I_The_Heart.21.aspx">350-gram human heart</a>, they would stretch for 41,000 miles. Stacked on top of one another, they would amount to 2 billion lines of cells, or enough to fill seven movie screens. But heart cells don’t divide. If they did, hearts could likely repair themselves. </p>
<p>Stem cells, on the other hand, do divide. They can also form into specialized cells – in this case, heart cells. Nobel Prize laureate Dr. Shinya Yamanaka discovered a method to make <a href="https://www.nobelprize.org/prizes/medicine/2012/yamanaka/facts/">stem cells out of blood or skin cells</a> from an adult. My team and I employed this method to obtain stem cells, then grew those cells into billions. After that, the team used chemicals to “differentiate” them into heart cells. We employed this method to obtain billions and billions of heart cells.</p>
<p>The first time I saw heart cells beating in a dish it was life-changing. But while the cells are alive and beat, they are not a heart. To be a heart, these cells need to be placed into a form that lets them become a unified organ, to mature and to be able to pump blood. In a human body, this happens during development; we had to reproduce that capacity in the lab.</p>
<h2>In 2022, a pig heart that had been genetically engineered to reduce rejection and improve acceptance was transplanted into a human. Why is it better to build a heart from scratch using pig scaffolding instead?</h2>
<p>Let me be clear: Any heart is better than no heart. And <a href="https://theconversation.com/organs-from-genetically-engineered-pigs-may-help-shorten-the-transplant-wait-list-175893">xenotransplantation</a> – the process by which nonhuman animal organs are transplanted into humans – opened doors for all scientists in this field. </p>
<p><a href="https://www.weforum.org/agenda/2022/01/gene-edited-pig-heart-transplanted-into-human-patient/">The patient received</a> a pig heart that had been gene-edited. Human genes were added, and some pig genes were removed, but the heart still essentially comprised pig cells within a pig scaffold. As a result, the individual had to take anti-rejection drugs that suppressed the immune system. And, unbeknownst to doctors, the heart was <a href="https://www.newscientist.com/article/2319108-man-who-received-pig-heart-transplant-has-died-after-pig-virus-found/">carrying a pig virus</a> that ultimately killed the patient two months following the transplant.</p>
<p>I believe these sorts of problems are avoided with the ghost heart. My team removes the pig cellular material from the scaffold, leaving only the protein structure and blood vessel channels behind. The proteins are so similar to human scaffold proteins they that don’t appear to cause rejection.</p>
<h2>What are the biggest challenges facing the ghost heart effort?</h2>
<p>My team and I have encountered two major hurdles. The first is the time and cost it takes to <a href="https://doi.org/10.1159/000511382">grow the cells</a>.</p>
<p>The second is enabling the <a href="https://doi.org/10.1159/000511382">heart to mature</a> once the cells are delivered into it – all while maintaining sterility in the absence of any antibiotics. My lab and our partners have had to essentially recreate the heart outside of the body and build the equivalent of an artificial human body that provides food, temperature control, oxygen and other nutrients as well as a blood pressure and artificial blood flow – we call it a biocradle – in which to place the heart. We have to train the immature heart cells to work together even as we are coaxing them to grow strong enough to pump blood; figure out how to feed them and get oxygen to them without lungs; and keep them sterile without an immune system. It’s a huge endeavor. </p>
<p>I liken it to a symphony in which each section has to come in at just the right time to create a beautiful, complex song – but if one piece isn’t ready, the whole thing falls apart. My job is to be the conductor. </p>
<h2>Where do you see the future of organ donations in 30 years?</h2>
<p>Today, organ donation is lagging behind need. Scientists are aiming to change that by increasing the number of donors, making more organs available by rejuvenating those that can’t be used and by building new technology – as my team and I are doing with the ghost heart. But it’s more than supply and demand. Access is not equal. In fact, organ transplant is a huge health inequity issue. Today, the organ transplant system fails people of color. For example, African Americans have a <a href="https://www.aamc.org/news-insights/how-our-organ-transplant-system-fails-people-color">higher rate of heart failure</a> but are <a href="https://www.heart.org/en/news/2021/08/25/despite-progress-black-patients-still-less-likely-to-get-heart-transplants">less likely</a> to receive hearts. </p>
<p>As science evolves, scientists have the opportunity to make organs accessible and to deliver organs that don’t require expensive toxic drugs. I look forward to that day and work daily to help create it. </p>
<p>Most people know months to years in advance that they need a transplant. In general, the current <a href="https://www.heart.org/en/news/2018/11/12/wait-times-for-a-donor-heart-may-vary-by-race">wait for a heart</a> is about a year for white Americans but longer for African Americans, while the data for Latinos and Asians is less clear. For other organs, the wait can be three to five years. Not only is that a long time – it is an inequitable time that needs to change. </p>
<p>Building a heart is a 24/7, 365-day-a-year effort. A dedicated team and I, along with supporters, have the opportunity to build hearts earlier and change heart transplants from emergency procedures to planned hospital surgeries – and to do so equitably.</p><img src="https://counter.theconversation.com/content/203625/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Doris Taylor works for Organamet Bio, Inc and owns shares in Miromatrix Medical. She receives funding from ARMI BioFAB. She is affiliated with Organamet Bio, Inc; and owns shares in Miromatrix Medical, Inc. </span></em></p>Scientist Doris Taylor explains how she and her team are creating bioengineered human hearts in their lab with the goal of one day eliminating the need for heart transplants.Doris Taylor, Regenerative Medicine Lecturer, University of New HampshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1758932022-03-11T13:19:38Z2022-03-11T13:19:38ZOrgans from genetically engineered pigs may help shorten the transplant wait list<figure><img src="https://images.theconversation.com/files/451412/original/file-20220310-17-1rk65gg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C683&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Xenotransplantation has made significant strides over the past few decades.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/xenotransplant-drawing-news-photo/179793591">BSIP/Universal Images Group via Getty Images</a></span></figcaption></figure><p>Demand for life-saving organ transplantation is at an all-time high. In 2021, a record <a href="https://unos.org/news/2021-all-time-records-organ-transplants-deceased-donor-donation/">41,000-plus</a> organ transplants were performed in the U.S., with top numbers for kidney, liver and heart transplants. But a limited supply of donor organs remains an ongoing problem. Currently <a href="https://optn.transplant.hrsa.gov/data/">over 100,000</a> people are on the transplant wait list in the U.S., and many more are unable to get on the list because of <a href="https://optn.transplant.hrsa.gov/professionals/by-topic/ethical-considerations/general-considerations-in-assessment-for-transplant-candidacy/">strict eligibility requirements</a> and <a href="https://doi.org/10.1001/jama.2017.19152">racial</a> <a href="https://doi.org/10.1001/jamanetworkopen.2020.34630">disparities</a> in access.</p>
<p>As a <a href="http://www.ctsurgery.pitt.edu/person/david-j-kaczorowski-md">cardiac transplant surgeon</a>, I have personally witnessed the tragedy of this shortage of donor organs. But I have also seen the potential of one possible solution to this problem: <a href="https://www.fda.gov/vaccines-blood-biologics/xenotransplantation">xenotransplantation</a>, or transplanting animal organs into human beings.</p>
<p>In <a href="https://www.scientificamerican.com/article/pig-kidneys-transplanted-to-human-in-milestone-experiment/">September 2021</a>, researchers successfully transplanted two genetically engineered pig kidneys into a brain-dead patient. And in January 2022, I was <a href="https://mirm-pitt.net/tissue-engineering/dr-david-kaczorowski-member-of-surgical-team-on-historic-first-successful-transplant-of-porcine-heart-into-adult-human-with-end-stage-heart-disease/">part of the surgical team</a> that conducted the <a href="https://www.nytimes.com/2022/01/10/health/heart-transplant-pig-bennett.html">first pig-to-human heart transplant</a> in a living patient. Recent news about the <a href="https://www.nytimes.com/2022/03/09/health/heart-transplant-pig-bennett.html">patient’s death</a> two months after the procedure is sobering, but researchers like me remain optimistic. While much work still needs to be done, these successes point to how far science has come toward making animal-to-human transplants a viable treatment possibility.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Wqf3PXUngsE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The man who received the first pig heart transplant died on March 8, 2022, two months after the procedure.</span></figcaption>
</figure>
<h2>Early attempts</h2>
<p>While animal-to-human transplants have attracted considerable attention recently, many attempts have been made to transplant animal cells, tissues and organs into humans over the past 60 years, with varying degrees of success. </p>
<p>In the 1960s, kidney transplantation was not broadly practiced because of a <a href="https://doi.org/10.1093/bja/aer384">lack of donor organs</a>. <a href="https://doi.org/10.1093/ilar.37.1.9">Ethical and legal concerns</a> made it difficult to obtain live donors, and organs collected from deceased donors did not meet much success.</p>
<p>So a surgeon named Keith Reemtsma performed a <a href="https://doi.org/10.1111/j.1749-6632.1969.tb56392.x">series of 12 kidney transplants</a> using chimpanzees as donors. While most of the transplanted organs – and thus the human patients – survived for only a few weeks, one of the patients survived for nine months. Infection was the major issue in half of the patients, while irreversible organ rejection occurred in the other half. </p>
<p>Thomas Starzl is another surgeon who attempted animal-to-human organ transplants. He performed a similar <a href="https://doi.org/10.1097/00007890-196411000-00009">series of kidney</a> transplants around the same time as Reemtsma using baboons as donors, with the organs surviving up to two months. He’s most known for his <a href="https://doi.org/10.1111/xen.12306">liver transplants</a>, with three attempts using chimpanzee livers from 1966 to 1974 that lasted from 24 hours to less than 14 days. In the early 1990s, his two baboon liver transplants lasted for 26 and 70 days. While one of the baboon livers functioned well, the patient ultimately died from overwhelming infection. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/451410/original/file-20220310-19-1vyj5ez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An infant lies in incubator, with her head cradled in an adult's hand." src="https://images.theconversation.com/files/451410/original/file-20220310-19-1vyj5ez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451410/original/file-20220310-19-1vyj5ez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=614&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451410/original/file-20220310-19-1vyj5ez.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=614&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451410/original/file-20220310-19-1vyj5ez.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=614&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451410/original/file-20220310-19-1vyj5ez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=771&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451410/original/file-20220310-19-1vyj5ez.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=771&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451410/original/file-20220310-19-1vyj5ez.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=771&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Baby Fae was the first successful infant xenotransplant, surviving for 20 days with a baboon heart.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/BabyFae/a7e818231958441696f356ee12594a95">AP Photo/Duane R. Miller</a></span>
</figcaption>
</figure>
<p>Doctors have also made attempts to transplant animal hearts, the first of which predated the first human-to-human heart transplant. In 1964, a <a href="https://doi.org/10.1001/jama.1964.03060390034008">chimpanzee heart</a> transplanted by James Hardy survived for only a few hours. Len Bailey’s 1983 attempt at transplanting a <a href="https://doi.org/10.1001/jama.1985.03360230053022">baboon heart</a> into an infant known as <a href="https://time.com/4086900/baby-fae-history/">Baby Fae</a> prolonged her life for 20 days, a record at the time.</p>
<h2>Overcoming barriers</h2>
<p>While these early results may seem poor at first glance, a number of these transplants actually lasted longer than many <a href="https://doi.org/10.5772/940">early human-to-human kidney transplants</a>. The first patient to receive a donated kidney lasted for only four days in 1933, and later attempts in the 1940s and 1950s yielded similar results. Immunosuppressing drugs that prevent the immune system from attacking donor organs also weren’t available at the time of these early attempts at xenotransplantation, pointing to the promise of these procedures as science advanced. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/dCSiTpnNrMQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A pig heart under examination by researchers at the University of Pittsburgh.</span></figcaption>
</figure>
<p>But transplanting organs across species faces a number of obstacles, the most integral of which is evolution. As species grow apart, <a href="https://doi.org/10.1016/S1074-7613(01)00124-8">increasing differences</a> in their molecular makeup can result in incompatibilities that make cross-species transplant difficult or impossible. Among the most problematic are differences in immunity, inflammation and blood clotting that damage both the transplanted organs and the host’s body.</p>
<p>The similarity of <a href="https://doi.org/10.1080/08998280.2000.11927634">nonhuman primates</a> like chimpanzees and baboons to humans, both in anatomy and in their immune systems, made them appealing donors for early transplants. But their strong similarities to people also raised ethical concerns that dissuaded some physicians like Starzl from using them as donors.</p>
<p>On the other hand, <a href="https://doi.org/10.1080/08998280.2000.11927634">pigs offer a potentially better source</a> of donor organs. Compared with nonhuman primates, pigs mature much more quickly and produce more offspring. They are also a common source of food for people, and their tissues are already used for prosthetic heart valves and other medical treatments.</p>
<p>While <a href="https://doi.org/10.1016/j.ijsu.2015.06.060">pig-to-human transplants</a> have also been attempted in the past, 80 million years of evolution stood in the way. Pigs have <a href="https://doi.org/10.1080/08998280.2000.11927634">molecules</a> on the surfaces of their cells that humans do not. If these molecules are introduced into a person’s body, their human immune system will register them as foreign and mount an attack. This process, called <a href="https://medlineplus.gov/ency/article/000815.htm">hyperacute rejection</a>, is a central reason many transplanted animal organs fail.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/xgBnYr0_FRk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Genetically engineering pigs to be more compatible with humans could help reduce the risk of organ rejection.</span></figcaption>
</figure>
<p>A number of advances that reduce these incompatibilities have helped overcome the problem of hyperacute rejection. <a href="https://doi.org/10.1126/science.1078942">Genetically engineered pigs</a> without the genes that produce the foreign molecules triggering rejection and with additional <a href="https://doi.org/10.1002/mrd.21127">human genes</a> that help the recipient’s body accept the new organ are one key improvement. The <a href="https://www.nytimes.com/2022/01/10/health/heart-transplant-pig-bennett.html">pig heart</a> my team and I transplanted this year was genetically engineered, as were the <a href="https://www.nytimes.com/2021/10/19/health/kidney-transplant-pig-human.html">pig kidneys</a> from late 2021. There have also been improvements in medications that <a href="https://doi.org/10.1038/ncomms11138">suppress the immune system</a> of the recipient so it’s less likely to mount an attack against the organ.</p>
<h2>Looking forward</h2>
<p>Recent successes with genetically engineered pig transplants make clear that xenotransplantation is no longer a dream from a distant future but something becoming increasingly achievable by modern medicine.</p>
<p>But many questions still remain. What is the best way to suppress a recipient’s immune system so the transplanted organ survives but the risk of infection stays low? Can animal organs be tailored to individuals to minimize rejection? How can animal organs be better preserved and distributed? </p>
<p>Answering these and many other questions will be key to realizing the therapeutic potential of xenotransplantation, and helping the hundreds of thousands of people waiting for an organ.</p>
<p>[<em><a href="https://memberservices.theconversation.com/newsletters?nl=science&source=inline-science-corona-important">Get The Conversation’s most important coronavirus headlines, weekly in a science newsletter</a></em>]</p><img src="https://counter.theconversation.com/content/175893/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Kaczorowski has previously received research funding through a grant from United Therapeutics. </span></em></p>Recent successes putting genetically modified pig organs into people have brought xenotransplantation back into the spotlight.David Kaczorowski, Associate Professor of Cardiothoracic Surgery, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1450882020-09-09T21:23:40Z2020-09-09T21:23:40ZAn opt-out organ donor system could address Canada’s shortage of organs for transplant<figure><img src="https://images.theconversation.com/files/357316/original/file-20200909-24-1r85pz3.jpg?ixlib=rb-1.1.0&rect=498%2C188%2C4430%2C3175&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eighty-five per cent of Ontarians support organ donation, but only one-third have opted in under the current system.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>In 2018, there were <a href="https://www.cihi.ca/en/organ-replacement-in-canada-corr-annual-statistics-2019#:%7E:text=At%20the%20end%20of%202018,while%20waiting%20for%20a%20transplant">4,351 Canadians on waiting lists</a> for an organ transplant. In the same year, 223 Canadians died while awaiting organ transplants. </p>
<p>These numbers have been growing over the last decade. For example, between 2009 and 2019, the number of <a href="https://www.cihi.ca/sites/default/files/document/corr-snapshot-2019-en.pdf">Canadians in end-stage renal failure increased by 35 per cent</a>, significantly raising the number of individuals requiring kidney transplants. The situation is only expected to worsen, as it is anticipated that <a href="https://doi.org/10.1186/s12882-017-0699-y">more Canadians will require organ transplants over the coming years</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cross-sectional illustration of a human kidney" src="https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=911&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=911&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=911&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1144&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1144&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1144&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">End-stage kidney disease increased by more than 35 per cent in Canada between 2009 and 2019.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>In the backdrop of these sobering statistics, Nova Scotia is set to become the first jurisdiction in North America to enact legislation to tackle the shortage of organs for transplant. Passed on April 2, 2019, the <a href="https://nslegislature.ca/legc/bills/63rd_2nd/1st_read/b133.htm">Human Organ and Tissue Act</a> is scheduled to come into effect on Jan. 18, 2021. </p>
<p>The act institutes an “opt-out” system to organ donation, which functions on the idea of presumed consent. In its essence, this idea presumes that individuals have consented to having their organs harvested upon their death for transplantation into others in need of those organs. </p>
<p>Nova Scotia’s opt-out system goes against prevailing practice in Canada. Currently, organ donation is based on the “opt-in” system, in which individuals must sign up to be organ donors while they are alive in order for their organs to be harvested for transplantation upon their death.</p>
<h2>The case for presumed consent</h2>
<p>There is ample evidence to substantiate the effectiveness of presumed consent policy. Take the case of Spain, the country with the most robust opt-out system, which it established over 40 years ago. In 2019, <a href="https://www.healio.com/news/nephrology/20200605/presumed-consent-helpful-for-increasing-transplants-in-spain-but-challenges-remain">Spain had 49 deceased organ donors per million population</a> — by far the highest in the world. This compares to Canada’s paltry rate of 20.6 per million population on the same measure.</p>
<p>Despite Canada’s lagging donation indicators, most Canadians support organ donation. For example, <a href="https://www.giftoflife.on.ca/en/">85 per cent of Ontarians support donation</a>, although only one-third have opted-in to the current system. </p>
<p>This discrepancy has been attributed to apathy in registering as a donor rather than <a href="https://dx.doi.org/10.1177%2F1751143718777171">serious moral objections to donating posthumously</a>. If surveys of public opinion are correct, then an opt-out system would get it right more times than it gets it wrong when making assumptions about individuals’ wishes. </p>
<h2>Moral objections</h2>
<p>Those who object to organ donation for religious or other reasons are more likely to make their wishes known in an opt-out system as compared to those wishing to donate for altruistic reasons, who are <a href="https://doi.org/10.1076/jmep.29.1.37.30412">less likely to make their preferences clear in an opt-in system</a>. </p>
<p>In a system designed to save more lives, putting the onus on those who object to donation to opt-out is not only morally justified, but follows other initiatives in which public interest is placed at the forefront of policy. For instance, the introduction of mandatory seat-belt laws have often come under fire for infringing on individual autonomy, but the prevailing benefit to public interest has resulted in a now <a href="https://doi.org/10.1093/phe/phz014">widely accepted legal and social norm</a>. </p>
<figure class="align-center ">
<img alt="Illustration of kidneys, heart, lungs and liver with a green ribbon, symbol for organ donation support" src="https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=140&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=140&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=140&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=176&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=176&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=176&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Eighty-five per cent of Ontarians support organ donation, but only one-third have opted in to the current system.</span>
<span class="attribution"><span class="source">(Canva)</span></span>
</figcaption>
</figure>
<p>Policy debates over whether a jurisdiction ought to have an opt-out versus on opt-in system to organ transplantation are replete with thorny ethical questions. There are usually no simple, clear-cut answers and not all members of the public will be satisfied with any decision reached. </p>
<p>But given the number of Canadians detrimentally affected by types of organ failure that can be medically remedied through transplantation, the country has an ethical responsibility to consider how best to approach the ongoing shortage of donor organs.</p>
<h2>Lowering costs while saving lives</h2>
<p>Beyond the moral reasons for instituting an opt-out system, there are financial incentives too. For example, where it concerns end-stage renal failure, the British Columbia Renal Agency found that the <a href="http://www.bcrenalagency.ca/resource-gallery/Documents/Transplant%20and%20recipient%20eligibility.pdf">annual cost of dialysis treatment is $50,000 per person</a>. This is meaningfully higher than the cost of kidney transplantation, which has a <a href="http://www.bcrenalagency.ca/resource-gallery/Documents/Transplant%20and%20recipient%20eligibility.pdf">one-time associated price tag of $15,000 and $5,500 per year for anti-rejection drugs</a>. </p>
<p>To be sure, it would be wholly unreasonable to expect Nova Scotia’s new act to be implemented without any hiccups. There will likely be unforeseen, complex and difficult issues that emerge as the province begins to put the act into operation in the coming weeks. Moreover, as evidence from jurisdictions that have established presumed consent policy reveals, the effects of the opt-out policy are tenuous unless <a href="https://doi.org/10.3399/bjgp18X694445">sufficient financial and political support buttress it</a>. </p>
<p>While there may be challenges, instituting policy on organ harvesting based on presumed consent could be an important initial step in addressing the ever-growing shortage of organ donors in the country. Other provinces in Canada ought to pay close attention to the forthcoming experiment in Nova Scotia, and consider how their own jurisdictions might respond to the shortage of organ donors — a phenomenon that is causing many avoidable deaths and much unnecessary suffering to Canadians.</p>
<p><em>This is a corrected version of a story originally published Sept. 9, 2020. The earlier story incorrectly stated that the opt-out program would take effect on Oct. 1, 2020.</em></p><img src="https://counter.theconversation.com/content/145088/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ajnesh Prasad receives funding from the Social Sciences and Humanities Research Council and the Canada Research Chairs program. </span></em></p><p class="fine-print"><em><span>Karly Nygaard-Petersen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Thousands of Canadians are on waiting lists for life-saving organ transplants. An opt-out organ donor system, like the one Nova Scotia is implementing, could reduce avoidable deaths and suffering.Ajnesh Prasad, Professor & Canada Research Chair, School of Business, Royal Roads UniversityKarly Nygaard-Petersen, Doctoral student, School of Business, Royal Roads UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1160442019-07-23T13:02:19Z2019-07-23T13:02:19ZHeart transplant doctors could help more people by accepting donations from the obese<figure><img src="https://images.theconversation.com/files/276483/original/file-20190526-187176-gku2lr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The number of potential organ donors who are obese is on the rise.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-doctor-holding-red-heart-shape-291044921?src=ePsutfxdsAXDN6VNtdUmMQ-1-14">Csaba Deli/shutterstock.com</a></span></figcaption></figure><p><a href="https://www.cdc.gov/heartdisease/facts.htm">Heart disease</a> is the top cause of death in the U.S. For some people with end-stage heart disease, a heart transplant can save their life. </p>
<p>Unfortunately, there are currently more patients on the <a href="https://unos.org/data/">heart transplant list</a> than there are suitable donors. As a result, half of the patients on the heart transplant list wait for over a year. Some will die without ever getting a heart.</p>
<p><iframe id="CUlTs" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/CUlTs/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>As doctors who work with patients who desperately need heart transplants, we want to be sure that we are using all of the organs that we can.</p>
<p>One thing that is important in heart transplantation is finding the right size organ for the recipient. A heart that is too small may not support the patient. A heart that is too big may not fit in the patient’s chest. <a href="https://well.blogs.nytimes.com/2012/08/06/transplant-centers-struggle-with-donors-obesity/">Weight has been used by many transplant centers</a> as a way to ensure a good size match between the donor and recipient.</p>
<p>Today, 40% of Americans can be <a href="https://www.nbcnews.com/health/health-news/america-s-obesity-epidemic-reaches-record-high-new-report-says-n810231">classified as obese</a>. Almost 8% fall into the category of severe obesity, which is <a href="https://www.cdc.gov/obesity/adult/defining.html">a body mass index</a> greater than 40. These numbers have increased significantly since 2003 and are still going up.</p>
<p>Many heart transplant centers require that heart transplant recipients keep their BMI at 35 or less. As the donor pool becomes increasingly overweight, our concern is that severely obese donors may get overlooked, because of the mismatch between the donor and recipient weights.</p>
<h2>Oversized hearts</h2>
<p><a href="https://doi.org/10.1016/j.healun.2019.01.379">In our donor heart study</a>, published as an abstract in April, we looked at two questions. </p>
<p>First, what percentage of donor hearts come from super obese donors, with a BMI over 40? Second, what are the outcomes for patients who receive a heart from a donor who is super obese?</p>
<p>To answer our questions, we used the United Network for Organ Sharing database. We looked at all the heart transplants that were done in the U.S. between 2003 and 2017.</p>
<p>Of over 26,000 heart transplants, 3.5% were from donors who had a BMI over 40. Mirroring societal trends, the prevalence of super obese donors increased over time, from 2.2% in 2003 to 5.3% in 2017.</p>
<p>Obese donors were older and were more likely to have other medical problems, including diabetes and hypertension. In two-thirds of the transplants, the donors were considered oversized, at 130% the weight or more of the recipient.</p>
<p>Ordinarily, heart transplant doctors might think that more preexisting medical problems and older donor hearts, as seen in the super obese donor group, would result in more complications for the recipient. </p>
<p>However, in looking at over 10 years of data using these organs, our data suggests that this is not the case. Complications – such as postoperative dialysis, acute rejection or postoperative stroke – were the same for patients who had a super obese heart transplant donor as they were for patients who did not have a super obese heart donor.</p>
<p>People who received hearts from super obese donors also had similar long-term outcomes, including survival, as recipients of hearts from non-super obese donors.</p>
<h2>Accepting suitable hearts</h2>
<p><a href="https://uvahealth.com/findadoctor/profile/leora-t-yarboro">As doctors</a> <a href="https://surgery.virginia.edu/education/general-surgery-residency-program/current-surgery-residents/">who work</a> with patients that need transplants, we feel that it is important to improve awareness about how to become an organ donor.</p>
<p>It is also important to look critically at the organs that are being donated and make sure that they are being used to their fullest potential. Every year, patients die while waiting for a heart transplant.</p>
<p>This study shows that, for donors with a BMI over 40, it’s safe to use carefully selected hearts – screened for other important criteria examined in all donor hearts, like a history of coronary disease.</p>
<p>This data can potentially serve to expand the number of suitable donors for those patients in need.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/116044/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As the rate of obesity in the US rises, transplant centers are debating whether to accept organ donations from the obese. A new study suggests that oversized hearts are safe to use.Leora Yarboro, Associate Professor of Thoracic and Cardiovascular Surgery, University of Virginia Medical Center, University of VirginiaElizabeth D. Krebs, Resident Physician in General Surgery, University of Virginia Medical Center, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/848642017-11-30T10:08:55Z2017-11-30T10:08:55ZChimps, racism and the definition of death: the heart transplant story<figure><img src="https://images.theconversation.com/files/196741/original/file-20171128-28856-5zra8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Dmitry Kalinovsky/Shutterstock.com</span></span></figcaption></figure><p>In the summer of 1967, three of the four cardiac surgeons competing to perform the first human heart transplant were simultaneously <a href="https://books.google.co.uk/books/about/Every_Second_Counts.html?id=2Fv9dRT9TC4C&redir_esc=y">just hours from their place</a> in the history books. But each was thwarted – none of the planned operations went ahead. All four would come close again. But the race was finally only settled on December 3, 1967. Like that other iconic moment of the late 1960s, man’s small step onto the moon, the first human heart transplant was a giant leap that would be felt around the world.</p>
<p>The South African doctor <a href="https://theconversation.com/how-an-historic-heart-transplant-created-a-celebrity-scientist-50-years-ago-88277">Christiaan Barnard</a> was spoken of in the same breath as Neil Armstrong after he abruptly became a worldwide celebrity on December 3, 1967. His patient, 55-year-old Louis Washkansky, was also catapulted into the spotlight for the 18 tumultuous days he lived after receiving a new heart in Cape Town from 25-year-old traffic accident victim Denise Darvall. </p>
<p>A gifted surgeon and trailblazer from a resource poor country, Barnard was nevertheless a peripheral character in the field of cardiac transplantation research. Years of meticulous work and animal experimentation by Americans Norm Shumway, Richard Lower and Adrian Kantrowitz meant that by 1967 the quest to be first was no less exciting than the space race. None of them expected a man with no background in cardiac transplantation research to leapfrog them, but Barnard’s imperious self-confidence would surprise everyone.</p>
<h2>Primate hearts</h2>
<p>There had been a false start in 1964 when American surgeon James Hardy turned to desperate measures in an attempt to save a patient’s life. He was aware that a man had recently been kept alive with a circus chimp’s kidney. As a result, Hardy had purchased four chimps and decided to transplant one of their hearts into his patient. It was a disaster. The man died on the table and the public backlash was fierce. Hardy never attempted another heart transplant.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/196954/original/file-20171129-29098-1nchbg9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/196954/original/file-20171129-29098-1nchbg9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196954/original/file-20171129-29098-1nchbg9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196954/original/file-20171129-29098-1nchbg9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196954/original/file-20171129-29098-1nchbg9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1006&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196954/original/file-20171129-29098-1nchbg9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1006&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196954/original/file-20171129-29098-1nchbg9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1006&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Christiaan Barnard, 1968.</span>
<span class="attribution"><span class="source">Eric Koch / Anefo</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Over the next few years, the world eagerly waited for one of the three American doctors vying for success to write their name into history. But history had other ideas, as Barnard, who had learnt much while observing Shumway and Lower, beat Kantrowitz by a matter of days. </p>
<p>But as mentioned, his patient, Louis Washkansky, died of a chest infection 18 days later. Barnard, perhaps ill-advisedly, revealed his quintessentially surgical mindset when he announced that despite the patient’s death, his operation had been a success, as the postmortem revealed a “beautiful heart”.</p>
<p>This was a pattern that would repeat itself across the world as heart transplantation took off like wildfire. But suturing in a heart was the easy bit; it would be two decades until we understood and could effectively treat rejection.</p>
<p>After initial excitement, the realisation that most patients lived weeks or months meant practically everyone abandoned it. In 1968, there were 100 heart transplants performed worldwide; in 1970, <a href="https://books.google.co.uk/books/about/Every_Second_Counts.html?id=2Fv9dRT9TC4C&redir_esc=y">just 18</a>. Norm Shumway almost <a href="https://books.google.co.uk/books?id=QOXxDAAAQBAJ&printsec=frontcover&dq=matters+of+the+heart+thomas+morris&hl=en&sa=X&ved=0ahUKEwiRnJqw8c3XAhWMthoKHYUPABcQ6AEIKDAA#v=onepage&q=matters%20of%20the%20heart%20thomas%20morris&f=false">single-handedly</a> kept the idea alive and hence is remembered as the father of heart transplantation, even if it was Barnard lauded on the front cover of TIME Magazine, or partying with Sophia Loren on the inside pages.</p>
<h2>Ethical dilemmas</h2>
<p>The jubilant atmosphere surrounding Washkansky’s transplant happened against the backdrop of apartheid South Africa. A country shunned by much of the world rejoiced at their opportunity to show they were a modern nation. But the spectre of race had clouded the ethical issues surrounding transplant in both South Africa and 1960s America.</p>
<p>Barnard’s hospital had secretly decided to avoid a transplant operation involving a black recipient, lest they be accused of experimenting on a subjugated minority. One month prior to his transplant, Washkansky, a white immigrant from Lithuania, was moments from receiving the heart of a black man, but ultimately a medical reason gave the hospital a welcome excuse to cancel the procedure. Denise Darvall was also white and so while the gift of her heart was celebrated around the world, her kidneys were more controversial as they were donated to a mixed race 10-year-old boy.</p>
<p>The other major ethical and theological topic of discussion concerned how to appropriately retrieve organs from a donor. Patients with a fatal head injury may have irreparable brain damage but their heart will continue to beat, a concept known as <a href="https://www.livescience.com/42301-brain-death-body-alive.html">brain death</a>. This represents the best chance for successful transplantation as organs stay viable as long as the heart is beating. Once the heart stops beating and circulatory death occurs, organs begin to get damaged, especially the heart itself.</p>
<p>Brain death was not legally recognised in 1967 – death was then defined by American law as the lack of a heartbeat. Shumway was critical of this archaic “boy Scout definition” of death. It meant doctors would have to wait for the donor’s heart to spontaneously stop beating. South Africa’s looser legal definition of death benefited Barnard, who simply needed the approval of the state’s forensic pathologist, in contrast to staunch initial opposition to recognising brain death in the US. </p>
<p>The perils of operating in this new frontier were made all too apparent when Japanese surgeon <a href="http://content.time.com/time/world/article/0,8599,2054268,00.html">Juro Wada</a> performed his country’s first heart transplant. His donor was what today would be recognised as brain dead but Wada was charged with murder and waited several years to be exonerated. Japan didn’t perform another heart transplant until 1999. </p>
<h2>Heart legacies</h2>
<p>And what about the legacy of xenotransplantation – organ donation across species? This had kept a low profile since the catastrophic 1964 attempt to transplant a chimp’s heart. But in 1984, the American surgeon Leonard Bailey controversially selected a baboon’s heart in an attempt to save a two-week-old girl who became known as <a href="https://news.llu.edu/clinical/stephanie-s-heart-story-of-baby-fae">Baby Fae</a>. She lived for three weeks. Allegations later surfaced that Bailey <a href="https://en.wikipedia.org/wiki/Baby_Fae#Ethics">rejected</a> an available human donor and exaggerated chances of success on the consent form.</p>
<p>The heart transplant was the 20th century’s landmark medical event. In the UK, there are six heart transplant centres, the largest of which is Papworth Hospital in Cambridge, where I received my training. The first recipient of a successful heart transplant in the UK had their operation at Papworth. Another Papworth patient is approaching the 35th anniversary of their transplant, thought to be one of the longest surviving heart transplant patients in the world. Papworth has recently <a href="http://www.dcdheart.com/what-is-dcd/heart-transplantation/">pioneered</a> a new way to perform transplants, so that donors who have suffered circulatory death are now <a href="http://www.bbc.co.uk/news/health-32056350">also suitable</a>. This means the number of potential donors will soon <a href="http://www.independent.co.uk/news/health/heart-transplant-operation-new-waiting-list-halved-a7924896.html">increase considerably</a>. </p>
<p>Tens of thousands of lives have been saved since Denise Darvall’s posthumous act of generosity and heart transplantation has grown to comprise about <a href="http://www.who.int/transplantation/gkt/statistics/en/">5,000 operations</a> around the world each year. Yet in 2016, <a href="https://www.theguardian.com/society/2017/sep/04/silence-transplants-deadly-organs-shortage-nhs">457 people</a> died awaiting organ transplant in the UK. The operation itself has only been modified slightly since 1967 and despite our best attempts to build a replacement heart, the gift of organ donation remains many people’s best hope for life.</p><img src="https://counter.theconversation.com/content/84864/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rohin Francis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Human heart transplantation is 50 years old.Rohin Francis, Cardiologist and Clinical Research Fellow, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/882772017-11-29T09:08:31Z2017-11-29T09:08:31ZHow an historic heart transplant created a celebrity scientist 50 years ago<figure><img src="https://images.theconversation.com/files/196696/original/file-20171128-7434-1g3bvjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Dr Chris Barnard remains the only South African scientist who ever achieved global celebrity status.</span> <span class="attribution"><span class="source">Heart of Cape Town Museum </span></span></figcaption></figure><p>South Africa’s Chris Barnard stands out in <a href="http://www.sajs.co.za/chris-barnard-south-africa%E2%80%99s-fallible-king-hearts/marina-joubert">medical history</a> as the heart surgeon who became a global household name after transplanting the first human heart on 3 December 1967.</p>
<p>The historic surgery captured the world’s imagination and was hailed by 20th-century historians as socially and scientifically of <a href="https://www.palgrave.com/us/book/9781403987303">equal significance</a> compared to the moon-landing in 1969. </p>
<p>I examined aspects of this landmark surgery in two papers. The one looks at how Barnard <a href="http://www.sajs.co.za/footsteps-einstein-sagan-and-barnard-identifying-south-africa%E2%80%99s-most-visible-scientists/marina-joubert-lars-guenther?ct=t(3/4_SAJS_2017">fits into the mould</a> of celebrity scientists across the world. The other <a href="http://www.sajs.co.za/chris-barnard-south-africa%E2%80%99s-fallible-king-hearts/marina-joubert">zooms in</a> on Barnard himself and how the media shaped perceptions of his landmark surgery.</p>
<p>The dramatic events that unfolded 50 years ago in Cape Town on December 2 and 3, 1967 had all the makings of media gold. It was a daring world-first in medicine, performed by a largely unknown surgeon in a hospital far away from leading medical centres around the world where other surgeons were working towards the same goal. Embedded in the drama were real people set to become instantly famous and whose lives would change forever. </p>
<p>Underlying it all, were moral apprehensions about whether doctors were playing God which resulted in fierce criticism of Barnard. The criticism was tempered by public fascination with the idea that one person’s heart could beat in someone else’s chest, as well as by Barnard’s explanations that the heart was nothing more than a pump.</p>
<p>On top of all this, Barnard’s charisma and the increasing competition between news companies fuelled the unprecedented media interest. No other medical milestone has had such a defining effect on the relationship between <a href="http://journals.sagepub.com/doi/full/10.1177/0963662517738619">medicine, media and society</a>.</p>
<p>The historic human heart transplant demonstrates the power of mass media to transform a scientist into a global icon. It highlights how public visibility offers some scientists a path to influence and power, but also illustrates that scientific celebrity comes with considerable reputational and personal risk.</p>
<p>It reminds us that science, morals and politics have always been, and will always be, inextricably interlinked.</p>
<h2>Political undercurrents</h2>
<p>The apartheid politics in 1960s South Africa <a href="https://sagepus.blogspot.co.za/2017/11/how-politics-influenced-first-human.html">shaped the first human heart transplant</a> in a number of ways.</p>
<p>Once Barnard managed to convince his superiors at Groote Schuur hospital that he was ready to transplant a human heart, <a href="http://www.sahistory.org.za/people/louis-washkansky">Louis Washkansky</a>, already in the final stages of heart failure, was identified as a potential recipient. It was a race against time to find a heart donor. A suitable donor was identified, but the medical team made up of white doctors at Groote Schuur decided against using the heart of a man who under <a href="https://www.apartheidmuseum.org/race-classification">apartheid law fell into one of the categories of black people</a> called “coloured”. They were afraid of being accused of experimenting on black people. </p>
<p>Despite the risk that Washkansky could die before the heart transplant could proceed or that another surgeon could win this race, they decided to wait for a “white heart”. Ten days later, Chris Barnard transplanted the heart of 25-year old Denise Darvall, who was left brain-dead after being hit by a speeding car.</p>
<p>Following this medical triumph, the South African government called on Barnard to help promote South Africa’s image around the world. A patriot at heart, he mostly obliged. But, back in South Africa, he was fiercely opposed to apartheid and later refused to allow ongoing segregation of black and white patients in his intensive care wards at Groote Schuur hospital. His anti-apartheid views led to ongoing clashes with hospital authorities and politicians.</p>
<h2>A media frenzy like never before</h2>
<p>There were no journalists or photographers around when Chris Barnard walked out of Groote Schuur hospital on Sunday morning 3 December 1967, hours after making history. Before driving home, he called the medical superintendent of the hospital to inform him that they had performed a human-to-human heart transplant the night before. He told Dr Jacobus Burger:</p>
<blockquote>
<p>No, it wasn’t dogs. It was human beings… two human beings.</p>
</blockquote>
<p>Within an hour, South African Prime Minister John Vorster knew about the <a href="https://www.amazon.com/Celebrity-Surgeon-Christiaan-Barnard-Life/dp/1868421635">historic operation</a>. The news spread like wildfire and hordes of journalists and photographers descended on Cape Town over the next few days. Chris Barnard himself famously said:</p>
<blockquote>
<p>On Saturday, I was a surgeon in South Africa, very little known. On Monday, I was world-renowned.</p>
</blockquote>
<p>Barnard admitted that he found it flattering to be at the centre of so much attention and he went out of his way to accommodate the media. Given his limited exposure to the media before, he had a remarkable ability to control the media agenda and steer live television interviews in his <a href="https://www.palgrave.com/us/book/9781403987303">own favour</a>. In later years, he <a href="https://doi.org/10.1016/0002-9149(72)90055-0">reflected</a> more critically on the intense media attention and its effects on medicine and society.</p>
<h2>New rules</h2>
<p>The unprecedented media interest in the first human heart transplant, <a href="http://journals.sagepub.com/doi/full/10.1177/0963662517738619">transformed</a> many of the rules that governed the relationships between medicine and the media at the time.</p>
<p>With the names and faces of recipient Washkansky and donor Darvall on front pages around the world, it shattered rules about the anonymity of organ donors and recipients, how medical procedures were reported in the media and the extent of patients’ details that were disclosed. It also fundamentally changed the way leading surgeons would be identified in and pursued by the mass media in future.</p>
<p>One of the ways in which Barnard changed the way medicine was communicated was to appoint his own PR man and official photographer – something that was unheard of at the time. He allowed Don MacKenzie to take exclusive photographs of him which he could sell, after giving Barnard a fee.</p>
<h2>Celebrity surgeon</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/196887/original/file-20171129-28862-hzseva.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196887/original/file-20171129-28862-hzseva.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=649&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196887/original/file-20171129-28862-hzseva.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=649&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196887/original/file-20171129-28862-hzseva.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=649&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196887/original/file-20171129-28862-hzseva.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=815&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196887/original/file-20171129-28862-hzseva.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=815&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196887/original/file-20171129-28862-hzseva.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=815&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chris Barnard is mobbed for an autograph.</span>
<span class="attribution"><span class="source">Heart of Cape Town Museum</span></span>
</figcaption>
</figure>
<p>To this day, Dr Chris Barnard remains the only South African scientist who ever achieved global celebrity <a href="http://dx.doi.org/10.17159/sajs.2017/a0243">status</a>.</p>
<p>His celebrity status was boosted by his unique blend of charisma, media flair and boyish good looks. Barnard sustained it in years to come by his high-profile private life, public engagements with royalty and world leaders, as well as a series of flirtations with models and movie stars. </p>
<p>He remained an iconic public figure for the rest of his life, but also continued to do pioneering work as a cardiac surgeon, including many successful surgeries on children with congenital heart disease around the world.</p><img src="https://counter.theconversation.com/content/88277/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marina Joubert receives funding from the National Research Foundation.</span></em></p>The unprecedented media interest in the first human heart transplant 50 years ago transformed many of the rules that governed the relationships between medicine and the media.Marina Joubert, Science Communication Researcher, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/577012016-04-14T13:26:24Z2016-04-14T13:26:24ZHow long before we can transplant an animal’s heart in a human?<figure><img src="https://images.theconversation.com/files/118579/original/image-20160413-22081-20dy3i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A ready source of hearts...one day.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=mSbrvoIupQlaQly9s3K79Q&searchterm=pigs&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=272113169">www.shutterstock.com</a></span></figcaption></figure><p><a href="http://www.nature.com/ncomms/2016/160405/ncomms11138/full/ncomms11138.html">The announcement</a> that researchers in the US kept a genetically engineered pig’s heart beating in a baboon for nearly three years has, in some quarters, revived speculation about the prospect of pig organs being suitable for transplantation into humans. </p>
<p>Research into xenotransplantation (the transplant of live organs, tissues or cells from animals to humans) dates from at least the 1900s, when research on it and allotransplants (human-to-human transplants) <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1406409/">ran in parallel</a>. </p>
<p>Interest in animal-to-human transplants was renewed in the 1980s when the development of immunosuppressant drugs, such as cyclosporine, <a href="http://www.nejm.org/doi/full/10.1056/NEJM198310063091401">made transplants between humans more effective</a>. The hope was that such drugs –- which lower the body’s ability to reject a transplanted organ – could be used in cross-species transplants. Also, advances in genetic engineering and cloning in the 1990s and 2000s resulted in <a href="http://www.ncbi.nlm.nih.gov/pubmed/12493821">genetically engineered pigs</a> without the antibody that leads to their organs being immediately rejected by humans. These two advances led some to believe that cross-species transplants were an imminent possibility. </p>
<p>While some may see this latest research from the US as moving us a step closer to xenotransplants, a closer inspection of the study indicates that it is premature to view such a prospect as imminent. There are several reasons why this research is more of an inch than a significant step forward. </p>
<h2>Significant hurdles</h2>
<p>In this study, genetically engineered pigs’ hearts were transplanted into five baboons and while one of the hearts remained healthy for nearly three years, one baboon died from an antibiotic-resistant infection about five months after the transplant. The median (middle) survival rate was 298 days. While a survival time of nearly three years might seem reasonable given the shortage of human organs available for transplant, it is important to note that these were not life-supporting transplants – the baboons’ hearts remained in their chests with the pig hearts attached to the baboons’ abdomens. So the pig hearts were not functioning as the baboons’ hearts. And only one heart survived in a baboon’s abdomen for nearly three years.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/118575/original/image-20160413-22040-qpsyn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/118575/original/image-20160413-22040-qpsyn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=769&fit=crop&dpr=1 600w, https://images.theconversation.com/files/118575/original/image-20160413-22040-qpsyn3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=769&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/118575/original/image-20160413-22040-qpsyn3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=769&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/118575/original/image-20160413-22040-qpsyn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=967&fit=crop&dpr=1 754w, https://images.theconversation.com/files/118575/original/image-20160413-22040-qpsyn3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=967&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/118575/original/image-20160413-22040-qpsyn3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=967&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A pig’s heart.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=pig%27s%20heart&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=268838735">www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>The baboons were initially given large doses of immunosuppressant drugs so that their bodies would not reject the pig hearts. These drugs are needed because even though pigs can now be genetically engineered to minimise the risk of hyperacute rejection – where the organ is rejected within minutes of being transplanted – the baboons’ immune systems still need to be suppressed to prevent their bodies perceiving the hearts as foreign. </p>
<p>The large doses would not be tolerated by humans in the long term and so the researchers reduced the level of the immunosuppressants to see if the pigs’ hearts would still function. When they did this, two of the baboons almost immediately began to reject their hearts and the anti-pig antibody in them was reactivated. While the pig hearts connected to two of the baboons continued to function with the lower dose of drugs, once the immunosuppressants were discontinued altogether the hearts were rejected (at 616 and 945 days). </p>
<p>These are important findings because if such an immunosuppressant regime was replicated in a pig-to-human transplant, it seems that the recipient’s immune system would need to be suppressed on a long-term, if not lifelong, basis – otherwise the anti-pig antibody could well return. Whether people would tolerate taking these drugs for a lifetime is a different matter and research on this is still needed.</p>
<p>While the study may provide further evidence that there are ways of managing one of the types of rejection that is predicted to follow from a xenotransplant, there are other types which have yet to be addressed. These have not been studied in detail because they do not come into play until instant hyperacute rejection has been addressed. So, we do not know how these other forms of rejection will operate, if at all, nor have we really begun to consider appropriate strategies to counter them.</p>
<p>As these were not life-supporting transplants, we still do not know whether – and this study is clearly not evidence that – a pig’s heart could function and support the life of a baboon, let alone a human. The question whether the heart of a quadruped can appropriately function in a biped remains unanswered.</p>
<p>While strategies to meet the shortfall in organs available for use in transplantation shouldn’t be too readily dismissed, given the huge human cost involved, it would be rash to suggest that we are now significantly closer to using genetically engineered pigs as sources of organs for humans.</p><img src="https://counter.theconversation.com/content/57701/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sara Fovargue does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A baboon survived nearly three years with a pigs heart, so does that mean cross-species transplantation is imminent?Sara Fovargue, Reader in Law, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.