New Life for Heart Transplants

But rising concern about high costs threatens the procedure

When South African Surgeon Christiaan Barnard performed the first heart transplant in 1967, medicine instantly had a new glamour field. In two years, more than 60 teams around the world replaced failing hearts in about 150 people. Barely 20% of the patients survived after twelve months. By the mid-'70s the operation was abandoned by nearly all its early advocates.

Now transplants are gaining new attention, largely because of a rising success rate at California's Stanford University Medical Center, where 199 heart exchanges have been performed since 1968. About 65% of the patients treated there by Transplant Pioneer Norman Shumway and his team now survive at least a year, and 50% live for five years.

The Stanford doctors, who do two dozen transplants a year, half the world total, credit several developments. New methods of handling organs have increased the availability of donor hearts; so has increasing acceptance of the concept of "brain death," which declares a person dead when the brain is not functioning even though the heart beats on. Also, recipients are chosen more carefully. The ideal candidate is under age 50, healthy aside from heart disease, optimistic, stable and has a supportive family.

Finally, a biopsy technique developed in 1972 is helping doctors tell when a patient's immunological defense system is attempting to reject the transplant. Drugs used to suppress rejection also limit the body's ability to ward off infection. The biopsy technique allows drugs to be used with more precision, thus tempering their undesired effect.

Inspired by Stanford's experience, surgeons in England last year resumed transplants after a five-year hiatus. But while the 24 operations done so far have won public applause, critics complain that the procedure is absorbing National Health Service funds better spent in educating citizens on the need for eating a sound diet and not smoking. The number of people who can be helped by transplants, says Dr. Peter Draper of London's Guy's Hospital, "is insignificant when compared with the 160,000 [Britons] who die every year from heart diseases."

U.S. health authorities are also grappling with this issue. The bill for a transplant, nearly always paid by private health plans or public funds, ranges from $30,000 to $190,000; postoperative ambulatory care costs $2,500 a year. The trustees of Boston's Massachusetts General Hospital this year voted against starting a transplant program partly because they reckoned that each patient would consume as much of the hospital's resources as eight routine open-heart operations.

A more serious blow to transplants has come from the Department of Health and Human Services, which has withdrawn Medicare coverage of such operations pending a two-year study of the procedure's medical, ethical, social and economic impact. If Medicare quits the field for good, private health plans are almost sure to follow.

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