This article is as told by Sir Terrence English in a presentation to BHF staff in August 2019.
Picture the scene: 1979, an operating theatre in rural Cambridgeshire, a surgeon bends to his task and makes the first incision. Heart transplantation has not yet succeeded in Britain, and today may be his last chance. He doesn’t know it, but he is entering the history books of medical innovation.
The early years
While kidney transplants had been successfully performed since the 1950s, it was 1967 before the world’s first heart transplant was performed in South Africa. A month later in January 1968, the first US heart transplant took place and the following May, Mr Donald Ross performed the first transplant in the UK. Afterwards, he described the procedure as “quite a simple plumbing job”.
Sadly, Mr Ross’ patient survived only 45 days. Similarly, the results elsewhere were poor and by 1970, 167 heart transplants had taken place across the world. Despite the increase in the number of transplants, there was little improvement in long term prospects. Those who had received hearts suffered infections, haemorrhages, and organ rejections, leading surgeons across most of the world to stop attempting the operation. The expertise for transplantation existed, but the science necessary to improve survival did not. It appeared that the revolution had failed.
A new kid on the block
Terence English was still a junior doctor when he went on rotation with a team that included Donald Ross. The direction of his future took a turn during those months, and he switched his ambitions from cardiology to surgery. The young Dr English built up his experience in the UK and the US, honing skills that would one day prepare him for his attempt to break the deadlock in heart transplantation in the UK.
Research by both Sir Terence and Professor David Hearse (partly-funded by the BHF) was increasing the preservation of hearts once they had been removed from the donor. This meant transplanted hearts were in better condition when given to the recipient. The legal issues around heart transplantation were also moving forward. At the time of the first attempts, there were major legal and ethical issues: Was removing a beating heart murder? The US team who performed the second attempt in 1968 are reported to have said in the operating theatre: “Do you think this is really legal?”, “I guess we’ll see”. In 1976 however, the Medical Royal Colleges ruled that brainstem death could be considered the death of the patient. This made it clear that heart transplants were legal, and reduced the ethical concerns of the public and the cardiologists.
Despite the advances surrounding heart transplantation, the odds were against success and authorities still saw heart transplants as controversial. The Department of Health refused Sir Terence’s request to fund his work in heart transplantation, and the Chair of his local health authority agreed to fund English using the facilities at Royal Papworth hospital in Cambridgeshire for two of the operations. Thereafter, he would either find his own funding, or he would stop.
English’s first attempt was beset by bad luck. Whilst collecting the donor heart, the patient who was supposed to receive it suffered a cardiac arrest. He was resuscitated and placed on heart-lung machine. The anaesthetist could not be sure if the patient has suffered brain damage, but English continued with the transplant. Sadly, although the operation went well, the recipient never recovered proper consciousness, and died after 17 days. The failure was met with critical press attention, and the Department of Health were furious. As Sir Terence recalls “The roof fell in, and I was under it”. “But they did not know I had a second shot. And I was going to take it”.
Keith Castle, the patient who would undergo the next attempt, struck Sir Terence as a “great survivor”. When Sir Terence found a donor heart on 18th August 1979, he proceeded with the operation. Mr Castle was a heavy smoker with peripheral vascular disease (reduced blood flow to the legs and feet) and a stomach ulcer — not the healthiest candidate for a risky operation. Despite this, the surgery was a success and Mr Castle went on to live five more years, becoming the first successful heart transplant recipient in UK history.
The changing face of heart transplantation
Sir Terence’s success was a breakthrough but certainly wasn’t the end of the struggle, and the Department of Health still wouldn’t fund the transplant programme. Luckily, the National Heart Research Foundation was willing to fund the next six transplants. Hearse’s ongoing research in preserving donor hearts also meant surgeons could look further and further afield for the best heart to use.
In 1981, the Department of Health provided some funding, and the British Heart Foundation funded a research unit at Royal Papworth for five years to support a bigger team — including an immunologist to study the reasons behind transplant rejection. The discovery of cyclosporine, which helped to protect against transplant rejection, reduced rate of rejection and led to better post-op survival and a renewed interest in heart transplantation.
In 1985, the Department of Health formerly funded a controlled redevelopment of heart transplantation units in the UK.
Heart transplants today
In the forty years since Sir Terence operated on Mr Castle, heart transplantation has gone from strength to strength. Today, one of the biggest challenges is to avoid infection while someone’s immune system is suppressed by the anti-rejection medication. BHF-funded Professors Federica Marelli-Berg and Giovanna Lombardi are working towards fine-tuning immune suppression. The goal is to protect the new heart without leaving people vulnerable to infection.
According to the NHS organ donation and transplantation report, 182 heart transplants were performed in the UK in 2018, but as of mid-August 2019 there were still 320 people waiting for a heart or heart and lung transplant. The shortfall has been described as an “organ donation crisis” in the media[A1] . The new ‘Opt-out’ (presumed consent) organ donation system will be rolled out in England in Spring 2020 and will mean more people get the life saving heart transplant that they desperately need. Research suggests that within a year of being put on the non-urgent organ transplant list, 1 in 10 will have died whilst waiting for a heart.
It may be hard to talk about organ donation, but the long waiting lists and numbers of people dying while waiting for a new heart means we can’t afford to be squeamish. 2019 is the 40th anniversary of the first successful UK heart transplant: there’s no time like the present to talk to your family about your organ donation wishes. The BHF campaigned for the Opt-out system (presumed consent) in England — this already exists in Wales — and there is a bill currently going through Scottish Parliament too. In the meantime, you can find out how the BHF supports the Opt-out system, and register your organ donation decision.
Sir Terence entered the field at a time when heart transplants had halted due to poor survival rates. In the mid-1980s, 77 per cent of people who received a heart transplant in the UK survived at least a year after their operation. Now 85 per cent make it — and those who survive the first year post-op will live, on average, for another 13 years. According to Sir Terence, Sandra Law, a woman from Hertfordshire is still alive 37 years after her first heart transplant at Royal Papworth in 1982.
2019 might be the 40th anniversary of a landmark in British medicine, but it is also an opportunity to reflect on the fact that people are still dying while waiting for a heart. Such an incredible story should not simply act as a history lesson, but as an inspiring reason for us all to register as an organ donor and tell our family of our decision. A few moments of your life could add years to someone else’s.