First Human Heart Transplant (1967): Christiaan Barnard

The first human heart transplant took place at Groote Schuur Hospital in Cape Town, South Africa, on 3 December 1967. A team led by the surgeon Christiaan Barnard replaced the failing heart of Louis Washkansky with the heart of Denise Darvall, a young woman who had been fatally injured in a road accident. Washkansky lived for only 18 days, but the operation made headlines around the world and opened the modern era of organ transplantation.

Background

By the mid-1960s surgeons could already operate inside the heart. The heart-lung machine, developed in the 1950s, allowed doctors to stop the heart while a pump kept blood circulating. Kidney transplantation had begun in 1954, when Joseph Murray’s team in Boston transplanted a kidney between identical twins, and kidney transplants between unrelated people were becoming more common.

The technique for heart transplantation was worked out mainly in the United States. At Stanford University, Norman Shumway and Richard Lower developed and published a method in dogs in 1960, joining the donor heart to the back walls of the recipient’s upper heart chambers. Lower continued the work at the Medical College of Virginia. In January 1964 James Hardy in Mississippi transplanted a chimpanzee heart into a dying man, who survived only about 90 minutes.

The central obstacles were rejection, the body’s immune attack on foreign tissue, and the question of when a donor could be considered dead. Surgeons needed a heart that was still healthy, yet the legal and ethical definition of death was still based on the heart stopping.

Christiaan Barnard

Christiaan Neethling Barnard was born in 1922 in Beaufort West, in South Africa’s Karoo region, the son of a minister. He trained in medicine at the University of Cape Town and then spent about two years at the University of Minnesota from 1956, where he studied heart surgery under Owen Wangensteen and alongside the pioneering cardiac surgeon C. Walton Lillehei.

Back in Cape Town he set up a cardiac surgery unit at Groote Schuur Hospital, the teaching hospital of the University of Cape Town. He performed open-heart operations, experimented with heart transplantation in dogs and carried out South Africa’s first kidney transplant in 1967. He was ready to attempt a heart transplant once a suitable patient and donor appeared.

The patient and the donor

Louis Washkansky was a grocer in his fifties who had been born in Lithuania and had moved to South Africa as a young man. He had diabetes and severe heart disease after several heart attacks, and by late 1967 he was dying of heart failure. He agreed to the experimental operation, knowing it had never been done.

On the afternoon of 2 December 1967, Denise Darvall, a 25-year-old bank clerk, was crossing a road in the Cape Town suburb of Observatory with her mother when they were hit by a car. Her mother was killed, and Denise suffered severe brain injuries. When doctors judged that she could not survive, her father, Edward Darvall, agreed to donate her heart and kidneys. One of her kidneys was transplanted into a ten-year-old boy.

The operation

The operation began in the early hours of 3 December 1967. Two teams worked in adjoining theatres, one preparing Darvall and one preparing Washkansky. The surgeons waited until Darvall’s heart had stopped before removing it, a cautious decision taken partly because there was then no accepted legal definition of brain death in South Africa.

Washkansky was connected to the heart-lung machine, and his diseased heart was removed. Barnard sewed the donor heart into place, a process that took several hours. When the new heart did not start beating by itself, the team gave it an electric shock, and it began to beat. By about six o’clock in the morning Washkansky’s circulation was being supported by his new heart. Barnard’s team numbered around 30 people, including his brother, the surgeon Marius Barnard.

Aftermath and the death of Washkansky

The news spread rapidly, and Barnard became an international celebrity almost overnight. Washkansky was conscious within a day and was soon talking to visitors and journalists. To prevent rejection, doctors gave him drugs including azathioprine and steroids, along with radiation treatment. These weakened his immune system.

Washkansky developed pneumonia and died on 21 December 1967, 18 days after the operation. A post-mortem showed that the transplanted heart had been working normally. The operation had shown that a human heart transplant was surgically possible, but also that controlling rejection and infection would be the real challenge.

The race that followed

Other surgeons quickly followed. On 6 December 1967, Adrian Kantrowitz in New York transplanted a heart into a baby, who died within hours. On 2 January 1968, Barnard performed his second transplant, on the Cape Town dentist Philip Blaiberg. The donor was Clive Haupt, a young man classified as “coloured” under apartheid, which drew attention to South Africa’s racial laws at a time when hospitals were segregated. Blaiberg left hospital, wrote a book about his experience and lived for about 19 months.

On 6 January 1968, Norman Shumway performed the first adult heart transplant in the United States, at Stanford. In 1968 more than 100 heart transplants were performed in many countries, but most patients died within weeks or months, mainly from rejection or infection. By the early 1970s many centres had stopped. Shumway’s team at Stanford and Barnard’s in Cape Town were among the few that carried on, refining patient selection and methods of detecting rejection.

The operations also forced a debate on the definition of death. In 1968 a committee at Harvard Medical School proposed criteria for irreversible coma, now usually called brain death, which became the basis for organ donation laws in many countries.

Key people

• Christiaan Barnard (1922–2001): led the transplant team and became one of the most famous doctors in the world. He later developed a “piggyback” technique in which a donor heart was added alongside the patient’s own.
• Louis Washkansky: the first recipient, who accepted the risk of a procedure never before attempted in a human.
• Denise Darvall: the 25-year-old donor, whose family’s decision made the operation possible.
• Norman Shumway (1923–2006): the Stanford surgeon whose research established the technique and who kept heart transplantation alive through the difficult 1970s.
• Philip Blaiberg: the second recipient and the first to live for many months with a transplanted heart.

Myths and facts

A widely repeated story claims that Hamilton Naki, a Black laboratory assistant at the University of Cape Town, took part in the 1967 operation and that apartheid hid his role. Naki was a remarkably skilled surgical technician who worked on animal experiments and trained many surgeons, but he was not a member of the team that performed the 1967 operation on a human patient. Several newspapers published corrections after repeating the claim in 2005.

Another misconception is that Barnard invented heart transplantation. The surgical method came largely from Shumway, Lower and other researchers. Barnard’s achievement was to be the first to put it into practice in a human patient.

Timeline

• 1954, December: The first successful kidney transplant between identical twins is performed in Boston.
• 1960: Norman Shumway and Richard Lower publish their technique for heart transplantation in dogs.
• 1964, January: James Hardy transplants a chimpanzee heart into a man in Mississippi.
• 1967, 2 December: Denise Darvall is fatally injured in a road accident in Cape Town.
• 1967, 3 December: Barnard’s team transplants her heart into Louis Washkansky at Groote Schuur Hospital.
• 1967, 21 December: Washkansky dies of pneumonia after 18 days.
• 1968, 2 January: Barnard transplants a heart into Philip Blaiberg, who lives about 19 months.
• 1968, 6 January: Norman Shumway performs the first adult heart transplant in the United States.
• 1983: Cyclosporine is approved for use in the United States, transforming transplant survival.

Legacy

Heart transplantation became a routine, if demanding, treatment only after the arrival of cyclosporine, an immunosuppressant drug developed in the 1970s and used in heart transplants from about 1980. With better drugs and care, survival improved dramatically. Today several thousand heart transplants are performed worldwide each year, and many recipients live for more than a decade. Cyclosporine had been discovered in a soil fungus by researchers at the Swiss company Sandoz, and its value in organ transplantation was first shown in kidney patients by the British surgeon Roy Calne in the late 1970s. Mechanical devices also joined the field: in 1969 Denton Cooley in Houston implanted the first total artificial heart in a human, as a temporary bridge until a donor heart could be found.

The operation also changed medical ethics and law, prompting new rules on brain death, consent and organ donation. In Cape Town, the theatres where the 1967 operation took place now house the Heart of Cape Town Museum. Barnard died in 2001 while on holiday in Cyprus.

The 1967 transplant belongs to a long line of surgical advances, from antiseptic surgery to antibiotics such as penicillin, that together made complex operations survivable.

Why it matters

The first human heart transplant proved that one of the body’s most vital organs could be replaced. Its immediate result was tragic, but it set off the research that turned transplantation into a life-saving treatment and forced society to rethink how death and donation are defined.