16 Dec Heart Beat Heroes
Heart Beat Heroes
Celebrating three decades of heart transplantation, this piece focuses on the stories of real life heroes: the doctors that performed the first ever heart transplants in Poland, Portugal and Colombia.
STRAIGHT FROM THE HEART
At the beginning of the 17th century, the Italian physicist and professor Santorio Santorio adapted some of the inventions of Galileo Galilei (1564-1642) – of whom he was a friend – to medicine. He did it in a way that had never been done before. From the discovery of the law of the pendulum by Galileo after repeatedly observing an enormous chandelier swinging in the cathedral of Pisa, in Italy, the physician Santorio Santorio created a pulse monitor – pulsilogium -, the first device capable of measuring blood pressure. Measuring the pulse through the wrist had already been practiced for many centuries. Doctors were called to the homes of ladies who suffered from “lovesickness”, the so-called lover’s malady, and assessed their condition through the pulse beats of the wrist. Unrequited, absent or undeclared loves were the causes of lovesickness.
Santorio Santorio was the first physician to think of heartbeats in a scientific way. Consisting of a scale of inches and a cord with a movable weight made with a transverse line, this pulse monitor devised by Santorio worked in the following way: the Italian physician would move the pendulum and simultaneously measure the pulse with his fingers. Then, the physician would change the length of the cord until the speed of the pendulum coincided with the pulse rate, thus showing the pulse rate as a number of inches. The invention of the pulse monitor by Santorio Santorio paved the way for the discovery of other instruments to measure the pulse. A century after the Italian physician’s invention, John Floyer (1649-1734), born in the United Kingdom, began measuring his heart rate using a clock. He was the first scientist to do so. From Floyer’s discovery, other physicians, such as the Irish Bryan Robinson, Jean Senac and William Falconer, started recording their observations based on the number of heartbeats per minute. Already in the 19th century, the German physician Karl von Vierordt (1818-1884) invented the sphygmograph, the first instrument capable of graphically recording the pulse. Created in 1854, Vierordt’s sphygmograph gave rise to the modern sphygmomanometer, invented in 1881 by Samuel von Basch (1837-1905) and perfected in later years by other physicians such as Harvey Cushing, whose contribution to the field in 1901 helped popularise this device within the medical community.
Born in 1561 in Koper, a Slovenian city that belonged at that time to the ancient Republic of Venice, Santorio Santorio was a professor at the University of Padua between 1611 and 1624. In addition to the pulse monitor, he is credited with inventing the thermoscope, an instrument used to evaluate minute variations in temperature. His studies in the area of metabolism are also considered pioneering. In 1614, he published the book “De Statica” Medicina, which would influence several generations of physicians.
TO RESCUE AND GIVE HOPE
Cardiac surgeon and transplantologist. In 1985, he assisted Professor Zbigniew Religa in the first successful heart transplant in Poland. In 1997, Professor Zembala performed the first transplant of a single lung in Poland and, four years later, he was the first in Poland to use a heart-lung device in a transplant. Professor Zembala is the director of the Silesian Centre for Heart Diseases in Zabrze.
“A memorable event is and will always be the beginning – under the leadership of Professor Religa – in 1985 in Zabrze of the heart transplant programme. We knew we took part in an exceptional event”, says Professor Marian Zembala, a cardiac surgeon who assisted Zbigniew Religa in Poland’s first successful heart transplant back in 1985. “This was followed in 1988 by lungs and heart and lungs transplant programme under my leadership in 2001.”
The first attempt at heart transplant in Poland was made in 1969, in Łódź, by Professor Jan Moll. It failed. The first successful cardiac transplant was made by Professor Zbigniew Religa’s team in 1985. Why as many as 16 years passed by between the first and the second surgery?
The attempt at the heart transplant made by Professor Jan Moll in Łódź in 1969 was an important trial of an outstanding Polish pioneer of cardiac surgery. The team had little experience, just like many other cardiac surgeons all over the world at that time. After the success of Christian Barnard in 1967, heart transplants just started to develop. Besides steroids, no other methods to stop transplant rejection were known – and this is just too little. The effects of a high pulmonary artery pressure were not known. This explains the failure affecting the patient in Łódź. Such failures happened at that time and in many medical centres all over the world. Łódź was no exception but, for us, the noble person of Professor Moll and his workmates will always remain the symbol of pioneering achievements, particularly so because he supported us so much with his authority and rejoiced when we created in Zabrze the heart, and later also the lung transplant programme.
Why was it the Regional Cardiology Centre in Zabrze where the decision was made to proceed with the surgery?
The Regional Cardiology Centre in Zabrze – presently the Silesian Centre for Heart Diseases – was the hospital that brought together the best experts in Poland at that time with huge international experience. A cardiologist, Professor Stanisław Pasyk, in 1985 already had many years of internships under his belt in Boston (USA), Germany (Max Planck Institut in Bad Nauheim) and he was the pioneer in Poland of a modern method for treatment of heart attack with the use of Coronary Angioplasty, the second method in Europe after the French cardiology centre in Toulouse; Liliana Goldstein, M.D., was an outstanding children cardiologist with significant and already recognised achievements in the Netherlands. The third individuality was Professor Zbigniew Religa, a cardiac surgeon after internships in the USA, in the Professor Kantrowitz Centre and in the UK, in the centre managed by Sir Terence English. Those three pioneers of modern cardiology were the core of the very powerful cardiology and cardiac surgery centre in Zabrze, in the highly industrialised Silesian Region. Immediately after completion of over four years of on-the-job training in an academic centre in Dutch Utrecht, I had the pleasure – on invitation from Professor Zbigniew Religa – to join the ambitious people establishing this modern centre. My colleague Andrzej Bochenek, M.D. did the same and he became a member of our team after returning from the United Kingdom.
How long did the team prepare for this procedure?
The Zabrze Centre started its operations in the field of cardiac surgery on August 15, 1985 and just a few months later, on November 5, 1985, the first heart transplant was made. We prepared for it for more than two months. This was not long but these were very intense times. Our entire team spent the two days prior to the surgery in the hospital.
Professor Religa recalled that the procedure was followed against a majority of opinions in the Polish community of medical doctors.
Against opinions of some part of the medical community – the most conservative one. But the heart transplant was received very positively by a majority of patients and medical doctors. This was visible in the social support for the performance of this ambitious programme.
Chosen by the “National Geographic” as the best picture of 1987, this photograph depicts Dr. Zbigniew Religa keeping watch on the vital signs of a patient after a 23-hour heart transplant surgery
What was the atmosphere in the Zabrze team?
What helped us a lot to develop intensively was the very good cooperation between adults’ cardiologists and children’s cardiologists, anaesthetists and cardiac surgeons. This was the key to success enriched with experiences from the members of the team gained in good foreign centres. We knew we were participating in exceptional events because at that time treatment of myocardial infarction using the method of percutaneous transluminal coronary angioplasty was something extravagant in the widespread opinion of the medical community. We showed and documented that this was the most effective – and safest for the sick – treatment method. Myocardial infarction was and still is a major killer so a success in this area deserves in particular to be disseminated and supported over any political divisions.
The same concerned heart and later also lung transplant. The enthusiasm of Professor Religa, an assistant professor at that time, was contagious: after the first heart transplant, in which I participated also with Professor Andrzej Bochenek and other colleagues, he admitted he did not feel very secure. But we had enormous mutual trust in one another. We also knew that he assumed the burden of responsibility for this procedure. I’ll remember until the end of my life the first 24 hours when we saw how the transplanted heart was beating again. When the patient started moving his legs and hands and we ascertained he was in contact with us, we rejoiced and started singing: “Glory, glory, hallelujah” – this is an unwritten anthem of Zabrze pioneers. Still today we remind this with pride and emotions.
What criteria determined the decision to choose the 62-year-old Józef Krawczyk as the first candidate for the transplant? You suggested this patient as the candidate…
The patient was recommended for a transplant due to an irreversible heart damage and his condition was deteriorating dramatically. Secondly I knew this man personally. He trusted us, knowing there was no other rescue left for him. And thirdly, Mr. Krawczyk was a highly self-disciplined man: he would later make sure he would meet all the requirements set for patients after heart transplant. Those were the most important reasons why he became the first patient on our recipient list. Professor Religa accepted my proposal.
Józef Krawczyk survived one week…
He was extubated, he was in good contact with us for two-three days, he also communicated with his family. We experienced great joy and hope together. We were happy that the surgery itself went well and the first few days were practically without any complications. Later, complications emerged and disease – severe liver and kidney deficiency – won against health and us. Unfortunately, he died of multiple organ dysfunction syndrome and blood clotting a few days later. Our second patient lived for a month. His condition after a week was so good that he walked the corridors and we already prepared a place for him in the nursing home in Karpacz but in the third week complications happened due to heavy infection of cytomegaloviral disease type.
You were an assistant of Professor Religa and one of his closest colleagues. What kind of boss was he?
He was competent and brave. He had great determination and conviction that he would do what Professor Moll failed to do. A characteristic feature of pioneers – also in Polish medicine – is that they are visionaries. And Professor Zbigniew Religa certainly displayed this feature. He summoned us, his workmates, to the most difficult surgeries and he helped us to grow as a team. To be able to launch the difficult heart transplant programme, followed by lungs and heart and lungs transplants, which I performed as his closest workmate, one has to be both visionary and resilient to temporary inabilities and problems. Professor Zbigniew Religa was such a man and he will remain one in our memory.
“I’ll remember until the end of my life the first 24 hours when we saw how the transplanted heart was beating again”
Was Professor Religa constantly looking for new challenges?
In 1985, Professor Zbigniew Religa was the initiator and leader in the field of cardiac transplant programme but after the sixth or seventh heart transplant he entrusted the programme to me. While he returned to his favourite topic – to save a sick person when no donor is available – he started to build in Zabrze ventricular assisting devices. Owing to those devices we have saved the lives of several dozens of patients until today. Whenever I see a sick person owing his or her life to such ventricular assist devices – both the first pneumatic ones made in Zabrze, and those foreign, implantable ones – I feel an internal need to express gratitude for the initiative of Professor Religa in this respect.
Why do you use the words “to rescue, provide modern treatment and give hope” when talking about the mission of the Silesian Centre?
Those noble and important words are the best illustration of the Silesian Centre of Heart Diseases in Zabrze – one of the leading cardiac and cardiac surgery hospitals for adults and children in Poland. We are proud of 30 years of the history of our centre and its significance among the best academic hospitals in the country. But of the outmost importance is to provide to the sick our know-how, experience, professionalism, good organisation and also display empathy towards our patients.
More than 30 years have elapsed since the first successful transplant. What has changed within that time in Polish transplantology?
Heart transplants, lung transplants in adults and children, similarly to the programme of mechanical assistance for inefficient heart with the use of artificial heart ventricles, initially pneumatic, external ones and presently using implantable, axial-flow ventricular assisting devices, are all evidence of the progress that has taken place in the world, but also in Polish medicine and transplantology. We are proud that, in the last 30 years of activities, we have performed in Zabrze almost 40,000 heart surgeries in adults and children. As of today, there is not a single cardiac or cardiac surgery treatment used worldwide that is not done also in Zabrze centre. Transplantology will be always the strength of our centre and a certain speciality besides modern cardiology and cardiac surgery.
AN ALMOST SECRET SURGERY
João Queiroz e Melo
This specialist in cardiothoracic surgery coordinated the team that, in February 1986, performed the first heart transplant in Portugal.
Interviewed by Feed, the specialist in cardiothoracic surgery says that despite medical advances, 30 years later the surgical technique for heart transplantation “remains exactly the same”.
The operation was performed at the Santa Cruz Hospital in Lisbon, where he was a director, and also managed the Cardiothoracic Surgery Service. At a time when, as the specialist says, “cardiology and surgery were far less advanced than now”, and in which “collaboration between different specialisations was rare”, the transplant performed that year was an important achievement.
Queiroz e Melo recalls that it was Manuel Machado Macedo, a leading figure in Portuguese medicine, who brought together a group of young doctors from various specialisations and “encouraged us to do things, and gave us the authority to make decisions” – a freedom that was rare at the time. At that time, João Queiroz e Melo was working in the US. The other members of the team were also abroad and they were called to the Santa Cruz Hospital. The fact that they were working abroad explains how, moreover, “the transplant came to be carried out at that time in Portugal”. And it was also the reason the surgery was so successful. “We were completely autonomous and experienced, and everything happened very naturally. Five years earlier, we were doing surgeries that were not yet being performed in our country”.
Currently retired, the specialist vividly recalls the atmosphere on February 14, in 1986: “I usually compare a surgeon to a pilot who commands an airplane. It requires a lot of concentration. Feelings have to be put aside. There can not be any kind of self doubt”. “When a surgeon is operating he cannot have any emotions”, he says. The days before the surgery were also filled with “intense concentration”. “We knew that, from a certain moment, it was going to happen. We were ready a month earlier, but we had to wait for a donor. We were not at all anxious”.
“I usually compare a surgeon to a pilot who commands an airplane. It requires a lot of concentration. Feelings have to be put aside. When a surgeon is operating he cannot have any emotions”
The surgery, which lasted four hours, was performed under secrecy, and a code was used to identify it: “Teresa Costa”, whose initials corresponded to Transplantação Cardíaca (Heart Transplant in Portuguese). Eva Pinto, who was “about 50 years old” at the time, was the patient chosen to receive the heart. She suffered from dilated cardiomyopathy and the operation gave her over a decade more of life. It was considered a success.
Thirty years after this first transplant, some things have changed. “These surgeries have become routine in Portugal. Pre and post surgery have also changed completely. There are many more treatments to control heart rejection, that are less aggressive and allow for a much higher quality of life”. Furthermore, the specialist added, “over the years, this type of intervention has ceased to be a definitive solution, especially for younger people. There is now greater interest in delaying the transplant, while at the same time opting for other therapies.” However, there are other things that have not changed at all, such as the “surgical technique, which remains exactly the same.”
Born in Tomar in 1945, João Queiroz e Melo was a professor at the Faculty of Medical Sciences of the Universidade Nova de Lisboa and assistant director of the Health Sciences Institute of the Portuguese Catholic University, where he also taught. In 1988, João Queiroz e Melo was made a Grand Master of the Military Order of Santiago de Espada. He held management positions at the European Society of Cardiology, the Portuguese Society of Cardio-Thoracic and Vascular Surgery and the Portuguese Society of Cardiology. As a result of his research work, numerous articles have been published in international journals.
Eva Pinto, the first Portuguese patient to successfully receive a heart transplant, talks to the journalists outside the Santa Cruz Hospital, nearby Lisbon, in 1986.
Alberto Villegas Hernández
In Colombia, the first heart transplant occurred in December 1985, at the VID Cardio Clinic in Medellín, by cardiovascular surgeons Alberto Villegas Hernández, Mario Montoya Toro and Darío Fernández. In an interview last year with the Colombian radio station RCN, Mario Toro, current director emeritus of the clinic in the Colombian city, recalled how “beautiful” the moment was when the donor’s family authorized the transplant. On the other side was Antonio Yepes, a construction worker, who was then 40 and suffering from coronary disease. Thanks to the transplant, he survived for two more years, leading an active life. The operation, in addition to being pioneering in the country, has accelerated the development of other treatments and approaches, and has become “a good alternative for the treatment of patients with serious heart problems”, says Álvaro Quintero, coordinator of the transplant team at the VID Cardio Clinic. “After that, the team got stronger and their results improved.” In addition to being the first in Colombia, the 1985 transplant was the third in all of Latin America.