A Different Boston
It is strange. Even though I remember all the details of the Hellenikon Airport before boarding the aircraft for New York, I remember nothing about the transatlantic flight, nor about the flight from New York to St. Louis, Missouri. But I do remember, as if it were yesterday, being in the vast terminal with my two unwieldy suitcases at 10:00 at night. Complete emptiness again. Around me the last passengers were leaving in the cars that were waiting for them. I was in a completely unknown city, with little money in my pocket and the address of only one hotel where the FLEX examination was to be held.
With difficulty I dragged myself to the first taxi and gave the address of the Ramada Inn. I arrived in St. Louis midweek, and for the next 3 days in my motel room I revised the material I had studied. Jet lag was a problem. I fell asleep early in the evening and got up during the night to start studying again. I was woken by anxiety and fell asleep from exhaustion. These were the most uncertain days of my life.
Boston City Hospital was like a jungle. The underworld of drunkards, the homeless, psychopaths, and drug addicts all came to the emergency room as if it were the pool of Siloam. Many came in simply for the comfort of human presence, to feel that someone was concerned about them. So many times they left before we could examine them. I had never before seen human beings so neglected, with chronic ulcers and unbelievable stench, that made you hesitate to touch them.
One afternoon the order was given by the central office for an ambulance and doctor to be sent to South Boston where fire had broken out and the deputy chief of the fire department had fallen in an attic. They had not moved him in case he had broken his neck and was in danger of being paralyzed. Along with the emergency medical technicians and all the first aid equipment, we rushed out to the ambulance. The driver was a real cowboy. He made the heavy vehicle roar like a tank, lights flashing like a Christmas tree and the two sirens deafening the passersby. When we reached a traffic jam he did not hesitate to turn into the oncoming traffic by mounting the central divide. I was in seventh heaven as I discovered unexpectedly that I was an “adrenaline junkie,” as someone very rightly called me much later at Baylor. As soon as we arrived, we ran up to the sixth floor, where we found the deputy chief lying on his back but still conscious. We put him on the special stretcher with two metal blades snapping together, lifted him carefully, and I had the time to put an intravenous infusion into his arm. All’s well that ends well. The whole adventure was immortalized by an unknown bystander and appeared in the newspapers the following day.
For the next 3-month period, I was transferred to vascular surgery under the chief of the Department of Surgery Anthony Mannick. A pioneer of kidney transplants, he had worked with the famous David Hume at the Medical College of Virginia. He was a cold man, completely disciplined and precise, with the military haircut of a colonel in the Marines, penetrating blue eyes, a slim frame, and movements that were flexible and assured. At 7:25 each morning, he was tying his sports shoes in the locker room, and at 7:30 he was at the wash basin scrubbing. There for the first time I came into contact with the American surgical training system in which the chief simply helps the trainee and intervenes only when there is a problem. So Mike did the carotids, aortic aneurysms, and aortofemoral bypasses and I, as senior resident, assisted. There were always four of us at the table, until the day that Mike fell ill and the case was a major one, an aortofemoral bypass. Without thinking twice, Dr. Mannick asked me to take the place of the surgeon. It was my first operation in a year. I managed it, though, by applying all I had learned in Dallas and having done two or three such cases in Athens. I finished the surgery without a hitch, whereupon Dr. Mannick, turning to Weizel, said: “Dick, we must be pretty good surgeons since Peter, just by watching us, could do the operation so well.” Academic humor!
The wedding (February 1976), with a glowing bride.
First taste of “adrenaline”. The Rescue of the Deputy Fire Chief, Boston (1975).
End of the 3-year ordeal. Chief resident at Boston City Hospital (1978).
The wedding took place on February 26, after Margaret had been baptized into the Orthodox Church because, as I said, “I’m not going to marry a Turk,” meaning that anyone who is not Orthodox belongs to another religion! We soon left for the little house in the woods and my friend Markos. I had taken special leave from the hospital for that weekend, even though we were on duty. We ate, drank champagne, and slept together in a sleeping bag with a zipper because, in spite of the wood-burning stove, it was cold. And so, holding each other, we spent our wedding night, in someone else’s house, wrapped in a bag, forgotten by friends and relatives. I was overwhelmed by a feeling of intense bitterness that my country had cheated me and my colleagues had betrayed me. On Sunday afternoon, we returned to our little apartment.
Margaret found work fairly easily because of her qualifications and, indeed, at the Mecca of American institutions, Massachusetts General Hospital, and I returned to Boston City for the last 3 months of the first year, this time in general surgery.
The second year passed with work, study, staff conferences every Saturday morning, and preparation for the boards at the end of my 3 years. During this period, I continued to be plagued by the strong desire to do heart surgery, and in the summer of 1977 I started to apply for a resident’s post. All the replies were negative because the good programs were much sought after and the places always taken 5 years in advance. October 1977 found me without an affirmative answer from anywhere, and July 1, 1978, was approaching dangerously fast. Unexpectedly I received a phone call from Mark Constantian, a prior trainee at Boston City, who at that time was doing plastic surgery at the Medical College of Virginia. Hearing of my fruitless search for a place in cardiac surgery, he asked if I had applied to his hospital. He explained that he knew the chief of cardiac surgery, Dr. Richard Lower, who was also doing heart transplants, and would ask him.
I wrote to Lower right away and he requested references. I therefore enlisted the help not only of those I worked with at Boston University, but also of Dwight Harken. Thus, 2 weeks later I was on my way to Richmond for an interview with Lower. I met him in his office and he immediately impressed me with his simplicity, his friendly manner, and the intelligence I could clearly see in his eyes.
There on the floors came the revelation. Sitting in an armchair with an IV in his arm was a middle-aged man who had had a heart transplant 10 days earlier. My mouth fell open! I couldn’t believe that a human being was living with someone else’s heart. I realized that this was my vocation. So I returned to Boston full of enthusiasm and soon received Lower’s confirmation.
However, it was one thing to be offered a slot in an important program and another to have the necessary strength for it. Over the years, fatigue had built up dangerously, and dealing with routine was becoming more and more difficult. One morning at Malden, I got out of bed after only an hour’s sleep and realized with horror that I could hardly stand. Outside it was snowing. I turned on the shower and went under the icy water to get rid of sleep and tiredness. And so, full of life, I went out into the corridor. At 6:30 every morning we would all meet in the hospital center.
Meanwhile, Margaret had been promoted to head nurse of the neonatal unit at Massachusetts General Hospital, something quite unusual for someone who had not graduated in the American system. It was in her interest to stay, but she was ready to sacrifice her position so that I could do cardiac surgery with Lower. The problem, however, was that I was completely exhausted and for that reason ambivalent. I had the contract in the drawer but couldn’t make up my mind to send it. And for the second time Margaret helped me decide by making an agreement with me. If I tore up the contract, heart surgery would be at an end for me. But if she found it on my desk when she came back in the afternoon, she would mail it. Of course, I didn’t tear it up and she sent it off.
Richmond, Virginia – Richard Roland Lower
After Uncle Gerasimos, Yannis Boudouris, and Dwight Harken, it was the turn of my next teacher, Richard Lower. In the 3 years that followed I would really get to know the father of heart transplantation. Lower came from Michigan, that is to say, he was a Midwesterner, and as is usual with people from these middle American states, he was different: serious, a man of few words, with a very strong accent and simple manners.
In 1958, Lower was taken on as Shumway’s first trainee, and together they began to experiment on dogs, looking for a way to operate with the heart stopped and dry but also without damaging the function of the myocardium. Shumway created a bath in the pericardium, the sac surrounding the heart, in which a cold saline infusion continuously circulated as a preservative. They stopped the heart, therefore, closing the aorta, and, after waiting an hour, opened it to let the blood again circulate in the myocardium. While they were waiting, they would sit idly around the table until Shumway had the idea that perhaps they could cut into the heart at the level of the ventricles (the organ’s reservoirs) and suture it together again before opening the aorta. Then Lower had a brilliant idea: “Why don’t we use the heart of another dog so that there will be enough tissue for stitching?” After the first failures, they started to have survivals.
The results of the method were announced in October 1960 at a meeting of the American College of Surgeons and were published in a concise article, as short as that historic one about the discovery of the double helix of DNA. As Shumway described it, the only ones present at the presentation were himself, Lower, who gave the paper, and the technician who was projecting the slides. The medical world ignored them completely, as if it was something out of science fiction. Undeterred, the two researchers continued their work and, during the following decade, whatever was written about heart transplants had their signature.
In 1965, Lower was appointed professor at the Medical College of Virginia (MCV), He came very close to doing the first human transplant in 1966, but he refused to carry on, because of some incompatibility of secondary importance in the blood groups. He did not want to endanger the success of the operation after the conscientious work of almost a decade.
This decision was fatal. A few months later, the South African surgeon Christiaan Barnard came to watch Hume perform kidney transplants. Up to that point he had had no contact with heart transplants. A coincidence led him to the experimental cardiac surgery laboratory. He had popped in there simply because he was looking for Carl Gosen, who had formerly been his pump technician. Through Lower’s pump technician, Lanier Allen, he asked if he could watch the procedure. When it was over he said to Gosen: “Was that all? It’s extremely simple. As soon as I get back to South Africa, I shall try a human transplant. You here have many prohibitions to negotiate before you can find a donor. We have no such obstacles”.
Richard R. Lower (1989), professor of the Medical College of Virginia,
father of heart transplantation and my teacher.
Thus, while Lower in Virginia and Shumway at Stanford waited for a suitable opportunity for the first human heart transplant, on December 3, 1967, Christiaan Barnard transplanted the heart of a young woman road accident victim into the chest of a middle-aged former boxer. Although the patient lived for only 18 days, Christiaan Barnard had made history.
Shumway and Lower were wounded to the core. The former never forgave Barnard for what he considered to be the theft of his work. One Saturday morning in the MCV auditorium, I heard Lower blame himself because he had hesitated to go on, adding sadly: “God never forgave me for that hesitation of mine and so fame and fortune went to Cape Town, South Africa, and not to Richmond, Virginia,” expressing that we only regret those things we didn’t do and not those we did, even if they were mistakes.
As if this was not enough, when he performed his first heart transplant in May 1968, he was accused of manslaughter for removing a beating heart. His acquittal—and that of 10 other MCV doctors in May 1972—established the acceptance of “brain death,” which allows the removal of a heart before it has stopped beating.
This is the story of one of the most definitive and at the same time unjust developments in the history of medicine. Heart transplantation was the most famous operation of the 20th century and it is generally considered that the glory went to the doer and not to the thinker. People respect thought but adore action.
He died as he had lived, quietly and with dignity, describing himself in his own obituary as “a physician working in a clinic for the poor.” He had tasted bitterness, though, because he was denied the world recognition for which he had worked harder than anyone else.
Premature Triumph(1967)…
The ingenious simplicity of Lower’s surgical technique avoids the time consuming vascular anastomoses.
…and Tragic Ending.
Medical College of Virginia (1978)
When I went to work with Lower, he was already in his 50s. Always in his surgical garb and sports shoes, fit and flexible, he came and went silently. What he said, little and well thought out, confirmed his real genius, also betrayed by his eyes that flashed behind his spectacles for short sight. Watching the sparks fly, I was reminded of a flight board where the numbers change so fast that it is impossible to follow them. It was no accident that Shumway called Lower “the most important experimental surgeon after Alexis Carrel,” who had been honored with the Nobel Prize for Medicine in 1912.
The other facet of Lower was the teacher. In spite of being recognized as a leader in transplants, his pride in his students was even greater. For him it was almost a religious rite to sit on the left of the table and from there to help the resident, with the simplest to the most complex procedures, only intervening when it was necessary. In the years that I operated in his presence, only once did he operate himself, on the sister of a doctor with blood vessels as fine as hairs. This happened at the beginning of my training when I had not yet obtained the necessary magnifying lenses.
On July 1st, I started with Lower and continued for the next 4 months. We would operate on at least two cases a day, morning and afternoon, and if there was an emergency then we could go on well into the night. I used to leave the OR at about 5:00 or 6:00 in the evening and then I would have to visit and prepare the patients for the next day, after first checking all the data. At 7:30 in the morning, we started operating, and when the cannulae for the heart-lung machine had been inserted, the technician called Lower. This routine, to my great surprise, was applied from my very first day before he knew what I was capable of.
One evening when I returned home I found Margaret behind the door holding a cute little puppy in her arms, a cocker spaniel with a golden coat and long ears. She was waiting in agony to see how I would react because she knew I had never had a dog in my life.
The program required staying in the hospital for 24 hours, every day and often on Sundays. For 4 months I lived as if I was a boarder at MCV. There was a small room for the doctor on duty in the ICU, with a shower and a little refrigerator for the week’s food supply: salads and cheese. After the first 2 or 3 weeks, you knew who Lower’s resident was from the way he behaved in the hospital, paper white and walking like a zombie. Saturday was no better, as we had to deal with any remaining cases. Neither did Sunday offer any respite. For some mysterious reason, the pediatric cardiologists referred newborns to us with patent ductus arteriosus then.
Sherlock.
I shall never forget those 3 weeks that I stayed continuously at the hospital. By the third Sunday it had begun to get to me. With all the pending work dealt with, I was ready to leave at midday, when the pediatric cardiologist sailed into the unit. A snowstorm was approaching and the chances of my leaving the hospital were diminishing. Without more ado, I took the three babies into the OR, one after the other, and at about 6:00 in the evening when it was already dark I decided to make a heroic exodus. Dense snowflakes were already falling and my anxious colleagues all told me I would be crazy to leave in the storm. But I wouldn’t listen. I got into the car and with the windshield wipers working at their fastest made my way through the white quilt that hemmed me in. Visibility was barely 5 feet, so I opened the window to keep myself on the road by looking at the curb. God knows how I got home to wolf down the home cooking and then fall into a coma. How many times have I thought about this episode and how many more have I rejected the complaints of my subordinates about the workload and the sleepless nights once every 5 or 6 days.
From the outset my interest was caught by valve replacement, with which I was already well acquainted because of Harken and Mitchel. Here, however, things were different. Lower had a rigid system for everything and especially for the placement of sutures. They had to be inserted with absolute accuracy, with the surgeon’s hand descending from a certain direction towards the valve ring and the needle holder pointing at a certain angle according to the quarter it was entering. Lower was continually emphasizing the importance of accuracy and not speed. He demanded complete concentration from the trainee and was fond of saying that if after an aortic valve replacement you didn’t have a headache, that meant that you hadn’t done your work properly!
Lower’s routine, to help from the left, also held good for my first heart transplant in September 1978, although I have to admit that I was not sure what I was suturing. The procedure is simple and technically easy, but underneath “serpents” are lurking and if a mistake occurs it is unforgivable because the graft cannot stand mishandling after 3 or 4 hours of ischemia in the ice. In my 2 years at MCV, we did seven transplants together and they all went well, except for one young man who was bedridden for weeks before the operation. The autopsy showed repeated small pulmonary emboli that had gone undiagnosed. He died on the table. From this I learned that no one should be accepted for transplant without a recent catheterization of the heart, to check the pressure in the lungs.
At the end of the 4 months with Lower, Margaret and I planned to go on holiday in Australia, following the loss of her father that spring. We went from Sydney to Brisbane and from there by single-engine plane to the paradise of Fraser Island, where her parents lived. We landed on the sand and there at the edge Mrs. Beryl Sinclair, a character taken from a Victorian novella, was waiting for us. Rather on the short side and a little overweight, but with undoubted presence, she had an aristocratically rounded face and perfect English pronunciation (she was a teacher), not the rough Australian accent that reminds one of London cockneys. There was something theatrical about her, like a veteran actress. Her stage was now her home and she moved around it with ease and grace. We stayed there for the next 2 weeks, because at the end of November I was to take the written exams of the American Board of Surgery.
The social event of the city was the annual Christmas dinner at the “Bull and Bear”. That year all the surgical department was present and the striking thing was that all the native Virginians sat together on the central table, while the “foreigners,” Americans from other states, sat at the other tables along with the trainees. They call anyone who comes from the northeastern states a Yankee! The antithesis of this southern aristocracy was the cultured, cosmopolitan Jewish pediatric surgeon Arnold Salzberg. “Arnie” was a true iconoclast, not only because of his liberal behavior but because, the height of boldness, he had married a delightful, well-educated, and very intelligent African American woman whom he proudly accompanied to all public events, to the great discomfort of the white Virginians. Arnie and I did a large number of pediatric cases together, tracheoesophageal fistulas, chest tumors, and many others. Of all the attendings, I definitely had with him the warmest of human relations. When I left MCV in June 1981, only Arnie bade me farewell with real human interest, saying to me: “Peter, you are really good and you deserve a very good position. I don’t know how you will get it, though. Good luck!”
Animal Laboratory
And so on July 1, I landed in the building next to MCV, where the labs were situated. Albert Guerraty, an excellent cardiac surgeon from Mc Gill University had already started working to preserve a dog’s heart for 24 hours and then transplant it into another dog. If this could be applied to a human, it would ensure the transfer of a donor heart from America to Europe and vice versa. At that time there were only four teams in the world doing transplants, and so it would be possible to receive a heart from another country or even from another continent. Albert had already discovered the “recipe” for the solution that would keep the heart alive after its removal.
However, the laboratory was in disarray. The technologists had the upper hand, taking advantage of Albert’s innate politeness and goodness. It was then that I made a decision and with the “prestige” of the resident speaking on behalf of Richard Lower, I risked a bluff: “Whoever doesn’t toe the line will be fired tomorrow.” It worked. Under my watchful eye, they started to work as they should. From time to time we reported back to Lower on the progress of the transplants. The master, having done countless experiments during the previous decades, asked how many dogs we had operated on and said: “When you get to 20, they will start to live.”
After the success in the laboratory, we collected the material for presentation at the annual meeting of the American Thoracic Association in Washington in May 1981. We started to write the summary but when we presented it to Lower he said scornfully: “How is it possible for you to do such good work and write such crappy papers?” Albert was hurt and never forgave him. But I just smiled and set about writing it again. I gave him the text five or six times and after he had made his corrections each time, I gave it to Sally. The sixth time, when I bemoaned the fact that “poor” Sally would have to type it again, he turned to me in annoyance and fixing me with eyes that threw off sparks, he said: “She will type it 5, 10, 15, 20 times until it is “p-e-r-f-e-c-t,” emphasizing each letter. When at last it won his approval, we sent it and it was accepted. Indeed, such was the interest that it was read at the first session before the famous American cardiac surgeons, Norman Shumway and John Kirklin.
That was our first project that year. The second was an idea of Lower to create a model of a spare heart using a graft, as there was not yet effective mechanical support for adverse events, such as a massive myocardial infarction with shock. The procedure, technically more difficult, was entrusted to me by Lower and I completed it during the next 6 months. It was accepted and published in an important American surgical journal.
The year 1980-1981 at the animal laboratory gave me the opportunity to see transplants from a different perspective, that of the retrieval of the organ. Albert and I would go to various towns of the South for hearts on a mission headed by Tracy, a very experienced coordinator at MCV and former Marine, who organized the whole enterprise like a military operation.
The retrieval of the heart from the beginning had excited me; I found the whole process exceptionally thrilling. Later I would learn that, apart from the adventure, there was a very important reason for doing the evaluation yourself on the spot, and for the future this was what I always did.
With Albert Guerraty, colleague, gentleman , borne surgeon and loyal friend, in the Animal Laboratory(1981).
Teresita, 6 months after the heart transplant, with her puppies (1981).
Rushing back to Richmond with the precious graft.
England, Great Ormond Street (1981)
We flew over the Atlantic during the night, as always, and early in the morning we were in London. The first impression was of the lengthy ringing of the telephone when I called the hospital, of course different from the immediate response to a call in American hospitals. We took a cab and found ourselves in front of the old 19th century building of the hospital, paid for by the famous writer Charles Dickens.
The flat (apartment) was quite spacious, if a little untidy compared to our previous accommodations. Again, in next to no time Margaret had transformed it into a beautiful, comfortable home. It had a view of the road and later, with the snow falling, it looked like a Christmas card. A little further down was the church. Its clock struck the hours, and the sweet sound of its bell as I went to the hospital at spot-on 8:00 made my day. Crossing Queen’s Square, with its neurology center, you came to Russell Square with its hotel of the same name and, a little further on, the British Museum. This was our neighborhood, beautiful, compact, with the unmistakable air of propriety and the style of a past age. I liked it from the first moment.
The hospital had cardiac surgery and cardiology departments and consequently there were consultants for both specialties. Ours were Mr. Jaroslav “Jarda” Stark and Mr. Marc de Leval. The former, a Czech, had fled to the West during the Prague Spring of 1968 when Olga, his dynamic wife, loaded her husband, her son, and their few possessions into their small car and crossed into Austria before the Soviets closed the borders. With incredible effort and unimaginable hard work, he had managed to make his mark in the mercilessly racist and class-ridden system of English medicine.
Marc de Leval was the exact opposite. He was a Belgian and a hedonist. He owned a Porsche, which showed a certain daring and flair. He had trained at the Mecca of the Mayo Clinic under the famous Dwight McGoon, who considered him one of his best students. He was a gifted surgeon.
A dream-like view of Great Ormond Street in the snow
from our hospital flat.
Russell Hotel, close to Great Ormond Street.
Most of the children were English but there were many foreigners from Lebanon, Egypt, India, Pakistan, and Greece. They were referred by their embassies mainly to private hospitals, such as the Harley Street Clinic in central London. There I was troubled by the money-making aspect of Greek medicine when I saw Greek cardiologists recommending the tying of an arterial duct or the closing of an atrial septal defect—operations carried out by first-year trainees—”at a large center abroad because this operation cannot be performed in Greece.” With this phrasing on the certificate, expenses would be covered by the national insurance, and you could assume what you liked about the integrity of the cardiologist who signed the paper.
The warmth and humanity of the nursing staff were unique. Before Christmas 1981, a baby admitted for surgery was visited every day by his young mother alone. A husband did not appear. On all the beds there were toys, teddy bears, and monkeys brought in by the parents when they visited. But this little child’s mother was too poor to buy anything for him. This did not go unnoticed. One morning on rounds we saw a big, beautiful bear on his bed. Of course, we all wondered about it and before long we realized that Margaret, a young Scottish nurse, had bought it from her meager salary. I can still see her sweet face blushing to the ears when we found out. A nurse’s salary was not more than £250 a month and the bear had certainly cost half that. A great sacrifice for this amazing girl with the most innocent blue eyes I have ever seen. She held the baby awkwardly, clearly distressed by our praise. Unfortunately, the months passed and I found myself again facing the daunting question: What would happen in July when the year ended.
Sir Magdi H. Yacoub
Again I was confronted by the granite block, but this time the top was instantly visible. This is why it is almost impossible to describe a genius, the most talented heart surgeon of our time.
I met Mr. Magdi Yacoub in his private consulting rooms near Harley Street, where the most celebrated doctors have their offices in London. Mr. Stark had managed to make an appointment for me at the beginning of August when I returned from Athens. He received me in a simple, friendly manner, sitting behind a large desk devoid of any sign of paperwork. Knowing him better later on, I would say that he probably never used it. He had to receive me somewhere and chose this virtually empty room. It was better like that because I was able to concentrate completely on his appearance without having my attention caught by a diploma or a photograph on the wall. The impression was astounding, as if some pharaoh had risen from the grave. The same swarthy skin, the same ancient, calm gaze in a perfectly noble face gave the impression that my interlocutor had lived and seen everything 3,000 years before. As a surgeon I was impressed by his exceptionally delicate fingers, with unusual flexibility and dexterity, as I could see when he inspected my papers. After two or three typical questions, he asked when I could start. The answer was immediately.
And so it was arranged that we should meet again at the small makeshift hospital of Hillside in Ealing, my old neighborhood. There, the following Saturday, I was to meet the whole team, or rather the troupe that lived and existed thanks to Magdi and for Magdi. Among them two stood out, the Milanese Gloria, a beauty of Botticellian grace, and the statuesque Viking-like Eva, from Gothenburg.
Magdi Yacoub, Egyptian and a Christian Copt, got to England with the help of Rosemary Radley-Smith, a pediatric cardiologist whom he later worked with, since the Muslim regime in his country would not have allowed him to develop his talents in the same way.
Sir Magdi Yacoub practiced the whole gamut of cardiac surgery—adults, children, and transplants—unattainable even for Denton Cooley. In spite of the technical perfection of the latter, Magdi was undoubtedly the greater genius, not only because he introduced new concepts and new operations, especially in pediatric surgery, but also because he could change the plan with the greatest skill if a different situation emerged, suiting the operation to the patient and not, as so often happens, bringing the patient in line with the operation that had been programmed. This is the supreme test of a really great surgeon.
His industry and stamina were monumental. He could work days and nights on end, finishing at 3:00 in the morning, snatch a little sleep, usually a couple of hours, before starting the new day at one of the two hospitals, Harefield or the National Heart, and then in the evening, after more than fulfilling his obligations to the National Health Service, he would operate at the Harley Street Clinic or the Princess Grace.
In surgical dexterity Magdi’s technique was unlike any other; it was completely his own. It was like looking at a painting of Michelangelo or Raphael that shouts out who the master is. His movements, without being in any way theatrical, had a princely grace and delicacy. When he operated, he created. You could not be unmoved by the perfection of what he was doing, especially when it was a child with congenital heart disease.
I have never seen anyone else who could cut a circular patch to close a hole in the heart while looking at the hole and not the patch. He had a supernatural three-dimensional perception that enabled him to cut it the right size and shape without looking at it, his eyes glued to the hole. I did not exaggerate then and I do not exaggerate now when I call Sir Magdi Yacoub the real Leonardo da Vinci of heart surgery, and I consider myself fortunate to have worked those 2 years with him.
In 1986, he was appointed a university professor and in 1992 he was knighted. A higher honor came later when he became a member of the Royal Society of Great Britain in 1999. Finally, the greatest honor of all came in 2014 when he was presented with the Order of Merit by Queen Elizabeth II.
Sir Magdi H. Yacoub, FRS, the “Leonardo da Vinci” of heart surgery.
A heart in the hands of Sir Magdi, ready for implantation.
Surgery as an Art.
The first combined heart/lung transplantation in Europe, performed
by Sir Magdi H. Yacoub at Harefield Hospital.
Harefield
The first donor Magdi, Radley-Smith, and I retrieved a heart from was in the large London Royal Free Hospital, mainstay of the National Health Service and later an important center for liver transplants. We entered the operating room and while Rosemary prepared the cold solution to preserve the heart, Magdi and I scrubbed. Very quickly he removed the heart, cutting the pulmonary veins and the inferior vena cava, then cutting off the pulmonary artery, aorta, and superior vena cava. He plunged the still-beating heart into the bowl with the cold solution and, clamping off the aorta, he infused 2 liters of cardioplegia solution, ensuring its protection for the next 3 or 4 hours. We packed the heart into three plastic bags, one inside the other, placed it in the small refrigerator, and after changing our clothes went down quickly, leaving poor Rosemary to collect the instruments.
Outside, a patrol car of the Metropolitan Police was waiting for us with two unsmiling “bobbies” as driver and co-driver. They politely opened the doors for us and we got into the back with the cooler between us. The car was a Rover Vitesse, especially souped up and lowered for more speed and stability. Before we set off, the driver asked Magdi: “Do you wish, Sir, a quick trip or a fast trip?” “Very fast, as fast as possible, please,” replied Magdi. Without comment they closed and locked the doors and the co-driver immediately turned on the patrol car’s two sirens and the red and blue flashing lights. Before we understood what was happening, the car roared forward and flung itself downhill towards the London Orbital. I felt my stomach fall to the floor but I saw the driver calmly pushing the other cars to the side of the road, easily taking the turns at 90 miles an hour. I drove this route every day, as we lived in north London, so I knew that we would shortly come to a 90-degree bend. I imagined the driver would slow down a little. Nothing of the sort! He continued undaunted and the car went around the bend on two wheels. We were literally flying and I saw Magdi clinging tightly to the hand-hold above the door. At the junction with the Oxford motorway, police motorcyclists were waiting for us as instructed and had stopped the traffic so that we could continue our journey at breakneck speed.
When we arrived outside the OR at Harefield, the two policemen smoothly opened the doors for us again and we thanked them “for the good journey.” As soon as we had gone a couple of steps, Magdi said, “That was not driving, that was madness.” The following evening when we met at Harley Street, he asked me with a twinkle in his eye: “Have you recovered from yesterday’s ride? I’m still trying!”
Two or three more transplants were carried out in the same way, but then one day we received a message that there was a donor in a provincial hospital at a time when Magdi was on bypass doing a difficult case on a child. Up to then only Magdi had collected the heart. He clearly hesitated but finally gave in to Rosemary’s vociferous insistence and entrusted me with the task, saying: “ I want a detailed report by telephone every 10 minutes about the blood pressure, the heart rate, and the general condition of the donor.” I promised I would do this and set out on the mission. All went well, and from that day forward I became the designated surgeon for the retrieval of hearts.
This was one aspect of my work. The other was to staff and organize the team. Little by little I began to bring in the other subspecialties from Harefield and the neighboring hospital of Mount Vernon. In this way the team was put together, with the participation of the nursing staff, the social worker, and even the hospital dentist, so that the prospective patient would undergo a detailed examination before being seen by Magdi for the final decision.
During this period, heart transplants came thick and fast. When I joined the team in the fall of 1982, a total of 40 transplants had been performed and the survival rate, before the introduction of cyclosporine, was only 30%. In 1983, we did 34 cases with a spectacular rise of survival. It was now clear that there would be an increase in the next few years, and this is exactly what happened. The soul of the whole enterprise was the Anglo-Irish coordinator Maura Markert who, although married and the mother of a young son, spent endless hours at Harefield following our patients with unusual dedication. She had a real passion for her work and I doubt if we would have ever managed without her help.
In November 1983, Magdi progressed to a new procedure, the first combined transplantation of a heart and two lungs in Europe. The patient was a Swedish journalist, 33 years old, who had already been rejected by Stanford, California, as a lost case. And so he asked Yacoub to operate on him, knowing that he would be his first such patient. I was impressed by the fact that Yacoub did not go to the animal laboratory as my American training led me to expect. The operation was “one-off,” the only difference being that we brought the donor intubated to Harefield from the other hospital. In two adjacent rooms Yacoub first removed the heart and lungs from the donor, immediately afterward doing the same thing with the recipient.
Sir Magdi as the press saw him.
The lovable ‘Hamsters’, Britain’s first heart transplants.
With Jake Lambert in London before my return to Baylor (1983).
Maura Markert, the devoted heart transplant coordinator at Harefield Hospital, with Annette, Peter Samuel’s mother (1988).
He then proceeded with the transplant operation without the slightest hesitation, underlining the difference between an excellent surgeon and a genius. Unfortunately in the long term the patient did not survive, not unexpected since Norman Shumway himself had given the case his seal of unsuitability. Of course this did not stop Yacoub from continuing, and even today Harefield still has the greatest experience in the world in this combined transplantation.
Towards the end of 1983, I heard the “song of the Sirens” when my old friend Jake Lambert came to London with his wife for 2 or 3 days and told me that Ben Mitchel and his team wanted to start doing heart transplants at Baylor. He asked me to think about whether I would like to go back to America and organize the program. Knowing Mitchel, I was sure this was a serious offer, and so the question was whether I wanted to do it. I had no doubt: I didn’t want to. Yet, at some point, I had to stand on my own feet.
And so in March 1984 and with a heavy heart, I decided to move back to America for the third time. Again it was Margaret who gave the final boost when she said: “Remember your old competitiveness and your ambitions. Push yourself. Just one last time.” I spoke to Magdi, therefore, explaining to him that I had to leave. There was no doubt that I was his main assistant at that time. However, with dignity and understanding, he said: “You will need money for this change” and wrote a check for £2000 as a gift. I have not forgotten, nor shall I ever forget, his generosity at that crucial juncture.
Up to April 1984 when I left, a total of 95 transplants had been carried out, and from the day I took over the care of the Harefield patients, we had done 55 operations with a short-term survival rate of 83%. Meanwhile, Magdi made the historic prediction that “cyclosporine would not be a substitute for clinical excellence.” Future developments proved how right he was.
This time Sherlock came with us on the aircraft, in a special cage for the transatlantic flight. And so, on April 17, 1984, we crossed the Atlantic with British Caledonian, stopping for an hour at the familiar airport of St. Louis, Missouri. From there it was straight on to Dallas, Texas, USA.
America for the Third Time: A Different Baylor
There had been many changes during the 10 years we’d been away. We got a first taste of it during the journey from the new Dallas/Fort Worth airport to the city: there were now buildings all along the highway where formerly there had been empty fields. But Baylor had also changed. The eye was caught by the white tower of the Roberts Building, soon to house the surgical activities of the center. The other important change was in the leadership of the hospital. The legendary Boone Powell Sr. had been succeeded by his son, Boone Powell Jr., who had previously been the CEO of a hospital in another Texas city. He did not have his father’s leonine personality, but this did nothing to diminish his pristine integrity or his natural kindness. In the following years he proved to be enterprising and a visionary, transforming Baylor into a multihospital health care system and a national leader in multiorgan transplantation. The worst thing, however, I realized when I arrived: the enforced departure, actually the dismissal, of Jake to whom I owed my return to Baylor. His self-destructive character had made him come to blows with the establishment.
Loyal secretary and associate Nancy Pennington soon became
a member of the transplant family.
I entered the fray in organizing the transplant team and, helped by my loyal secretary, Nancy Pennington, I began to visit everybody, from the department chiefs to the hospital chaplain, a colorful preacher whose trademark was his brilliant green jacket and his flashy tie. Every morning he would read a prayer over the hospital PA system. Nancy arranged at least 30 meetings as well as group discussions at the center. I went first to the president, Boone Powell Jr., who received me in very friendly fashion although I perceived a certain reservation in his answer: “Your observations will be placed in the requisite file for the plan.”
Bad news was not long in coming. In July Baylor organized a big reception at the illustrious Country Club to which all the high society of Dallas and Fort Worth was invited, including the important benefactors of hospitals and museums. The guest of honor was the famous liver transplant surgeon Thomas Starzl of the University of Pittsburgh. It was then announced that the hospital would create a liver transplant program and that the heir apparent was Starzl’s Swedish disciple, Göran Klintmalm, from the Karolinska Institute in Stockholm. Not a word was said about heart transplants, which caused Mitchel to express his displeasure openly.
The Battle for Leadership
Ben Mitchel had discussed with Mr. Powell the plan to organize the heart transplant program at Baylor, but without the kingmaker “Hal” Urschel, Mitchel’s longtime rival, who entered the fray by bringing in his own candidate. Thus, in July 1984, Ivan Crosby landed in Dallas and with Urschel’s help started making contacts similar to my own.
Ivan was an Australian who had done his general surgery training in Brisbane, the city Margaret was from. During his training he had done some experiments in the “piggyback,” Christiaan Barnard’s heterotopic heart transplant. Then he had tried to obtain clinical experience through short visits of a few days each to the big centers, Stanford, MCV, and Harefield. With this quick dip into transplants and the academic title of associate professor at the University of Virginia, he set out to take over the leadership of the program. He quickly gained allies, among them Jesse Thompson, president of the Transplantation Review Committee and chairman of the Department of Surgery, a meticulous, weasel-faced vascular surgeon who spoke with the honeyed pronunciation of the South. He privately threw his weight behind the promotion of Ivan.
There followed a long discussion in the cardiac surgery section during which two opinions were expressed. The first was that a heart transplant was an operation that would bring a great deal of publicity and that therefore the man in charge should be internationally recognized—in other words, Dr. Crosby who had an academic title. The second opinion, endorsed by everyone, was that the transplant program should be manned by the cardiothoracic surgeons, who were independent practitioners and not hospital employees. In other words, the new project would be separate from the hospital-based programs that were being created. This fundamental difference would in the future create friction as to the authority of the so-called “transplantation services” created by the hospital administration over the privately run cardiothoracic transplantation program.
In the face of this apparent deadlock, the hospital administration decided to convene the Transplant Review Committee in the presence of Boone Powell. A preliminary plan had already been circulated describing the composition of the transplant team, without mentioning names. Therefore, on May 7, 1985, a day that would prove to be historic for the program, the committee assembled, with Ivan and myself also in attendance. Thus, the following day the plan of action was circulated, approved by the all-powerful Transplant Review Committee, naming me director and Ivan codirector. This was essentially interpreted as a joint directorship.
However, before the final decision was made, Dr. Thompson asked Ben Mitchel to talk to us both to see what the chances were of our cooperating. There was no chance and we would not have gotten anywhere without a further meeting in Boone Powell’s office at which his father, Boone Powell Sr., was present. After a brief summary of the problem, with each one giving his opinion, I referred to the obvious lack of a hierarchical pyramid and the deliberate confusion over the titles “director” and “codirector.” Up to that moment the old lion had been following, alert but silent, in his lair. Suddenly he roared. Turning to me, he said, “You are making a huge mistake if you think you have two equal positions. You are the director, the pilot of the plane, and he is your copilot, in other words your assistant. Do you understand?” We were all thunderstruck and that was the end of the discussion. We stood up and it was all we could do not to click our heels like Prussian officers before their general. And so the program finally took off. With all the upheavals, we were now at the beginning of November 1985; in other words, a year and a half had been wasted over administrative disputes.
At Last – a Transplant
Finally, at the end of December, a suitable candidate for our first heart transplant appeared. Paul, 39 years of age, was married to a second-generation Greek girl and so, from a Roman Catholic and a former marine, he turned to a Christian Orthodox and a private-sector employee. He had had two infarcts in the space of a week and these left him with a completely destroyed heart. His cardiologist, Mike Donsky, a very intelligent man but with no experience in transplants, realized that the game would be lost if he sent him for a coronary bypass and so he referred him to us. The necessary tests were done, and in 1986 Paul was put on the waiting list for a heart.
The great day was March 6, 1986, Alamo Day in Texas, the day when the Mexicans entered the historic monastery in 1836 and slaughtered its defenders, something like our Cretan Arkadi in 1866. Both Texans and Cretans were unaware that you can’t resist the cannons of an organized army, especially in a position with no natural fortification. The donor was a 23-year-old from Atlanta, Georgia, victim of a motorcycle accident. The predicted ischemia time was borderline, around 4 hours, and so to speed things up we organized the transfer by helicopter and a flight by Learjet. We went to Atlanta with the coordinator of the organ bank, the dynamic, enthusiastic Mike Baker. The heart appeared to be in good condition and I removed it rapidly, infusing the cardioplegia solution in the bowl, as Yacoub did. Then, with the cooler on my knees, the helicopter took off and a few minutes later we were at the Atlanta airport. I cannot deny that while we were taking off I had tears in my eyes. After 20 years of strenuous training, I had at last done something significant in my life. I thought how unfair life had been to my parents who would not be able to share in my success, because intuitively I knew that the transplant would go well.
In the airplane I went over the procedure step by step, as Harken had taught us. There were, however, anxious moments because the wind had changed and was now head on, so the return took half an hour longer than the outward journey. We landed, leaped into the second helicopter, and went straight to the Roberts Building heliport. Holding the box in my arms, I raced down the stairs and entered the operating room. I must say I have never seen such pale faces as those of President Boone Powell and Göran, both wondering what would happen “if the damned heart didn’t start,” as Mitchel had said.
I scrubbed and went into surgery where the patient was ready to go on bypass, with Ivan as first assistant and Ben Mitchel and Jeff Stoltenberg, a superb resident, as second assistants. As soon as we unclamped the aorta and without the necessity for an electric shock, the heart began to gallop like a foal. The patient came off by pass to the accompaniment of sighs of relief by all present. Boone Powell’s congratulations were not long in coming.
Our first transplant was immortalized by David Woo, who that year won the national prize for the best photography. He did the same with the trip to a neighboring Texan town for a heart for Becky, our third transplant patient. I chose the best photographs for the collages that for years decorated the walls of the transplant offices, first at Baylor and then at the Onassis Center. In both of them they were taken down after I left because my replacements, in Dallas and in Athens, considered that the previous history of the program harmed their prestige. No comment.
There were two more heart transplants in 1986: a 45-year-old man from Oklahoma and 46-year-old Becky, whose medical expenses were covered by the hospital because she didn’t have insurance. They went very well and indeed the second, who received her transplant in July 1986, is still alive 37 years later.
At the end of 1986, I met the prospective patient who was destined to change the course of the program. Eleanor Belanger was 61 years old when she and her husband, Ed, came to my office. What I saw was anything but encouraging: a white-haired woman who looked 80, emaciated because of her heart failure and walking with difficulty into the room. My first instinct was to say no. Besides, the regulations for accepting patients had stipulated 55 as the upper age limit. Consequently, there was reason enough to reject her. What militated against this negative were her eyes: two beautiful, youthful gray-blue eyes showing an indomitable thirst for life and action. It wasn’t long before I forgot about her body, except for those unique eyes, and I immediately decided that I couldn’t leave her. I arranged a preoperative workup and wrote to the president of the hospital’s institutional review board to request raising the age limit of transplant candidates to 65. Eleanor fulfilled all the other requirements of the program and so, at the end of January, her operation took place. A few months later, after we had done three more transplants, she and they formed the nucleus of a group that Eleanor and Ed named NewHearts.
In the spring of 1987, my new associate, John Capehart, arrived in Dallas. He had also been Lower’s student, and his coming was to prove decisive for the course of the program. John was an impressively well-educated surgeon with a huge fund of knowledge and a completely unusual dedication to his patients.
We had started to have patients referred to us. This had been helped not only by the appearance of the first patients in the newspapers and on television, but also by the publicity given to the program by the visit of the president and secretary of the similar group of transplanted patients at Harefield, the “Hamsters.” One of the English transplant recipients had named them after the endearing little rodents with the bulging cheeks because they resembled the patients with their characteristic moon faces after taking large doses of steroids during the first 2 years of the program. After the reception given in their honor at Baylor, they invited Eleanor, as president of our group, to the annual dinner that took place every October outside London. It was decided that Eleanor should go, accompanied by another of our patients, Melba Allen, a beautiful, sweet-natured African American girl. Three days before their departure, however, Eleanor fell, breaking her arm and spraining her ankle. Unfazed, she declared that the trip would go on and the two of them, escorted by Ed, attended all the Hamsters’ gatherings, returning with a treasure-trove of photographic material.
The final establishment of the program, in the hospital at least, was brought about by the heart transplant of our Cuban doctor, Juan Macho, who had trained with me in 1972-1973. Juan, perhaps because of his overeating and smoking, perhaps because of his second marriage to a much younger woman, suffered a devastating heart attack during his honeymoon. He was referred to us by Walter Berman, a sensitive and well-mannered cardiologist, a real prince who a few years later fell victim to cancer of the pancreas. With remarkable delicacy he asked me if I would take Juan on, because he understood what dreadful repercussions there would be for the program if we failed. I assured him that for me it was an honor and a challenge, and so Juan got his new heart and continued to work for the next 20 years.
At this time I lived through an adventure of a different sort. I was at a cardiology conference in Atlanta when I was informed that there was a donor. I took the morning flight and before midday I had landed at DFW Airport in Dallas. John had gone to retrieve the heart while the team opened the patient’s chest. Tom was a giant, almost 7 feet tall. It had been arranged that my transfer from the airport to Baylor would be by helicopter, but the weather had other ideas. It was blowing a gale and we felt it as soon as we took off. The real ordeal started when we approached the city and the pilot, who should have been a cowboy, not a pilot, decided to ignore the gale-force winds and fly between the high-rise buildings in downtown Dallas to save time. The helicopter was buffeted by the wind, first toward one building and then the opposite one, missing them by a few feet. It seemed certain that we would crash into them. I was seized by a strange feeling of apathy. In the end, what could be more beautiful than to expire in the execution of your duty and not ingloriously in your bed: Nelson on the deck of the flagship Victory or Demetris Mitropoulos conducting his orchestra at La Scala. We finally managed to land at the Roberts Building heliport and for years afterward Tom was our mascot, a gentle giant who always came to the New Year’s party at my home.
In July 1988, when a new patient appeared, a 45-year-old after a devastating infarct. He was sent to us intubated and in shock, and after a cursory examination I could see that his end was not far off. So I called Kim Jett and the patient was quickly taken to surgery where this time the two Abiomed pumps, right and left, were inserted. As soon as the patient was stable, we gave his name to the organ bank and asked urgently for a heart. We were offered a donor in Los Angeles and in spite of the unfavorable ischemia time that would exceed 4 hours, we decided to accept it. And so the patient went to surgery for the second time, 9 days after the first procedure, where the mechanical device was removed and the transplant performed.
That summer I went for a few days’ holiday in Corfu. It coincided with the illness of Andreas Papandreou, then prime minister of Greece. I received a phone call from my friend and fellow student, Georgos Ktenas, member of parliament and deputy minister, asking me where, in my opinion, the prime minister should be operated on for an aortic valve replacement and coronary bypass. He was already a patient at St. Thomas’ Hospital in London and I knew that Mr. Bainbridge, the cardiac surgeon there, was not as good as Magdi, whom I recommended unreservedly. The next morning a seat was booked for me on the flight to Athens. Georgos first took me to the ministry and then to the Parliament, where we discussed the matter extensively with the prime minister’s staff. Then they opened the room where government meetings were held and from there I telephoned Magdi. He accepted the prime minister as a patient as long as the family requested it and he would be transferred to Harefield. Fortunately for the patient, Magdi took him over and gave him 8 more years of life. The episode appeared in the newspapers after Georgos Ktenas reported it in Parliament.
The graft upon its arrival inside the three plastic bags
…is inspected in the basin
…prepared
…and placed in its new home.
Eleanor before surgery…
…and six months later, as the founder and president of the transplant union “NewHearts”.
The first nine NewHearts (1987).
Charlie, the first combined heart-kidney transplant, in Intensive Care (1988). A total of three identical, successful transplants were performed.
Kim Jett, M.D., a BUMC cardiac surgeon and NIH researcher, implanted the first Abiomed assist device as a bridge to transplantation (1988).
Michael A. E. Ramsay, M.D., chief of the Department of Anesthesiology, is recognized by the NewHearts and Lungs group for his leadership in all of BUMC’s “firsts.”
Dale, the first successful bridge to transplantation using the Abiomed pump,
during his convalescence (1988).
The first dozen transplanted (“the dazzling dozen”) with Sherlock (1988).
With Melba at the celebration for the first 50 transplants (1989).
Rachel, one of the best transplants of the Program, in our house (1989).
Transplant party at the house on Edmondson Avenue (1989).
Paula, two hours after surgery (1989).
New Year 1992 at our home in the wake of the “annus horribilis.”
Eleanor’s Farewell (1993).
Baylor University Medical Center’s first heart transplant, “Alamo Day,” March 6, 1986.
«Domino» (1989)
Tom Lee lived with his wife in Garland, a suburb of Dallas, and in spite of the dyspnea that forced him to use oxygen around the clock, he worked as a manager in a printing house. He had been diagnosed with the rare absence of an enzyme that was insidiously but steadily destroying his lungs and would lead to his death. Up to the 1980s, there was no cure for the pulmonary emphysema he was suffering from, as there was not for many other lung diseases. This changed with the first combined heart/lung transplant at Stanford in 1981. In the years that followed, large centers, including Harefield, offered this difficult operation with good short-term results. At first the operation was destined for patients with simultaneous cardiac and pulmonary disease. It was soon extended, however, to those who only had lung disease but whose heart was healthy. It was the only operation available at that time. Of course, Joel Cooper at the University of Toronto had already started transplanting just one lung, but this procedure was still in its infancy. Clearly, the correct operation for patients with lung disease was the replacement of the lungs only, without the unnecessary removal of the heart. It was good, then, for the standards of the day, that in December 1988, after assessment by pulmonologists and cardiologists, Tom was placed on the waiting list for the combined transplantation of two lungs and a heart. The difficulty of finding a suitable donor was increased by the fact that he belonged to the rare blood group B.
Cliff Hamilton, 65 years old and a retiree, had previously had a coronary bypass operation because of a series of infarcts. He lived with his wife and four children who watched his progressive deterioration every day. Although he had been on the waiting list for a heart transplant since March 1988, his blood group B, like Tom’s, did not help in finding a donor. Furthermore, it was getting near the time he would be taken off the list because of his age, even with the recent raising of the age limit to 65.
In April 1987, Magdi Yacoub had impressed the scientific world with a new achievement. Instead of discarding the healthy heart he had removed with the diseased lungs, he thought he could use it for someone else who was waiting to have a heart transplant only. And so the term “domino transplant” was born, from the tiles used in the game but also from international politics where the fall of one influences the whole. Up to March 1989, very few such operations had been done and nothing had been heard about them in the southern and southwestern states, such as Texas.
At the beginning of January 1989 at one of our weekly meetings, the idea was mooted that perhaps a combined domino operation could be performed on Tom and Cliff. Such an operation was not to be undertaken lightheartedly. In this I worked with my friend Albert, who had already carried out such experiments at McGill in Montreal. I made a trip there and in his turn Albert came to our laboratory to help us get started. A transplant team for the experimental animals was organized in which, apart from myself and John, the German Peter Thiele, unfortunate former associate of Mitchel, who was still doing great work, and the talented Syrian and Orthodox Christian, Maruf Razzuk, former associate to Urschel, took part. The team was completed by Hashmukh Shah, a reliable Indian and a man of few words, an expert in thoracic surgery. From time to time we were also helped by two American colleagues, the cardiac surgeons Richard Wood and Tom Meyers. Thus, in the last 2 years we had already performed more than 80 combined heart/lung transplants in dogs, transferring the triple graft from one animal to another.
The long-awaited phone message came at 5.30 in the morning of March 9th. On the line was Harold, an enthusiastic coordinator at the organ bank, who with undisguised excitement asked me if I was awake and ready for work. He had a suitable donor, a 32-year-old who had shot himself and, fortunately for us, had been brought to Baylor. His death was soon certified and, very unusually, his family immediately gave their permission for the donation of his organs. Our luck was more than outrageous: the donor was blood group B!
Things moved quickly. I spoke to Albert in Montreal and the cardiac surgery department was put on alert. All operations were postponed and additional specialized staff was enlisted for early afternoon. It was my responsibility to ask each one for particular help according to his experience and his ego, taking into account the chemistry between the surgeons.
In the first room with the donor, Albert was in charge and, assisted by Maruf and Dr. Shah, was to remove the block of three organs. In the OR next door, I was to remove Tom’s heart and lungs, helped by John Capehart and our chief, Maurice Adam. In the third OR, where it would be necessary to dissect the heart from the previous coronary bypass operation, Carl Henry was to open the chest assisted by Rick Hebeler, with Richard Wood coming in for the main part. The scrub nurse in the most important operation, the heart and lungs, was Anne, a rough and ready adherent to the old school who had assisted me over the years with difficult operations. Although something was wrong with her leg, she had more stamina than her younger colleagues.
The grafting of the three organs into Tom was unexpectedly easy, confirming for the umpteenth time the saying “practice makes perfect.” When we started to warm him up, I left Albert in charge of getting him off bypass and went to the third OR. We brought Tom’s heart from next door and started the last part of the operation, its transplantation into Cliff. Tom’s operation finished around 11:00, while I was still suturing Cliff’s new heart.
At one stage I had counted around 40 people in the three ORs, each one with his own task. Only a huge hospital like Baylor could rise to such a challenge. It was reported in newspapers all over America, and I later even saw a cutting from the Japanese press. John and I spent the next few weeks in the hospital as we had in the good old days when we were Lower’s residents in Richmond.
Tom and Cliff, having made life difficult for us with their complications for 5 weeks after the operation, were now ready to go home. The event was preceded by a big press conference with President Boone Jr. at the head of the table and the two patients on each side of him. Cliff stole the show when he made the moving comment: “It is lovely to see the sun rise each morning.” This phrase was engraved on the trophy for the annual golf tournament organized by NewHearts, the association of transplanted patients. And then he caused general hilarity when he was asked: “How do you feel with Tom’s new heart?” “Marvelous,” he answered, and then he added the clarification: “As long as my wife doesn’t have too many expectations.” Eleanor brought in an enormous cake on a trolley and Boone and I cut it together. The photograph of the two Dioskouroi transplant patients in the parking lot before they got into the car was published everywhere and from that time has decorated my office wall.
It was the peak of the program’s success because soon the combined transplantation of heart and lungs would be overtaken by the rapid development in the transplanting of lungs without the heart. Even so, we carried a total of four such operations (three of them long-term survivors), but never another domino.
Tom, next morning, in Intensive Care Unit.
«Domino».
The preparation…
…with the participation of 40 people.
OR #1. The retrieval of the triple graft (heart and two lungs) by Albert. Next to him is Hashmukh Shah and opposite the intellectual of surgery, Maruf Razzuk.
The triple graft is inspected.
OR #2. The implantation of the triple graft into Tom.
Opposite me are Albert and Maruf and beside me John Capehart.
Implantation completed.
OR #3. Preparation of Tom’s heart for implantation into Cliff.
Tom with the triple graft of heart and two lungs and Cliff with Tom’s heart
on the day they were discharged.
Lung Transplantation (1990)
The next important step was the start of the lung transplantation program in 1990. Our first patient was Gene Gaillard, a 46-year-old man from South Carolina, who had emphysema like Tom. At first we scheduled him for a combined heart/lung transplant. Since we had been waiting a year for a donor, however, we changed him to a candidate for the left lung only, an operation we had already done experimentally on pigs. Meanwhile, Gene worked as a volunteer in the hospital and had become a popular figure as he went up and down with his scooter, running errands.
At the end of July, the long-awaited donor was found and indeed all his organs were donated to Baylor—kidneys, liver, and heart—something that was given a great deal of publicity on television and in the newspapers. Everything went well with Gene’s left lung transplant until the second day when he, still intubated and on a respirator, was not taking in the expected volume of air and was in extreme danger of cardiac arrest. An air bubble in his own right lung had broken and there was a continuous leak of air into the closed thoracic cavity.
We took him back to surgery and put the “bad” lung right. There followed for Gene 2 months in the ICU, during which he went through all the complications in the book. Without John Capehart giving him round-the-clock care, he wouldn’t have made it. Three months later, after the customary press conference and photographs in front of the hospital fountain, he returned to South Carolina. This was how the lung transplantation program started. More than 50 patients followed.
During 1990, our program was ahead of its rivals. St. Paul’s came next with 25 heart transplants fewer and then Methodist with 50 fewer. The survival rate in the first year was 85% and in the next 3 years, 80%—rates above the international level. Thus, in July, the federal government officially recognized the Baylor heart transplantation program, awarding it the title “Medicare Approved.” In the American system, the government insurance covers the expenses of the insured only in hospitals with this recognition, something that gave the necessary green light for other insurance organizations to follow. Our program was the first and only one in our area to be crowned with government acceptance. Everything was going amazingly well and we were flying. At least that’s what we all thought.
John E. Capehart, M.D., also a Lower trainee, joined BUMC in 1987. He had intelligence, erudition, and a fine sense of humor in combination with a solid surgical background.
Gene, the first lung transplant recipient, on the day of his discharge (1990).
There was a total of 43 single-lung transplants.
Medicare approval.
Annus Horribilis – The Finest Hour (1991)
When 1991 arrived, we had done 85 transplants, among them three combined heart/kidney and two heart/lungs, the only ones in the region. We continued to accept high-risk patients, following the extended donor criteria introduced in 1987. The Transplant Review Committee was fully aware of our new course, and in my letter to Dr. Ron Jones, its chairman and chief of surgery, I had declared in no uncertain terms that “the program is governed by the philosophy of helping patients and not statistics.” The program was the victim of its own success, accepting all the difficult cases.
The year 1991 was our most productive, with 30 transplants—we had never done so many before—but it was also catastrophic for the program. In 8 months, from March on, we lost the same number of patients, all high risk. Since long-term support with an artificial heart was not available at Baylor, the dilemma was merciless: transplant with whatever marginal graft was offered or death. Naturally, the combination of a high-risk recipient, with serious problems and frequently infection, and a marginal or unacceptable donor, in the classical sense of the term, could never be the recipe for success.
It was my responsibility to call a meeting with the team’s cardiologists and surgeons at the beginning of November. When we were all gathered, it was with great surprise that I heard from Tom, the senior nephrologist who belonged to the Dallas group, that the matter had already been discussed the previous day and the conclusion had been that the Transplant Review Committee should be informed and asked to appoint an impartial auditor to examine the data of the eight deaths.
And so it happened. On November 11, “the gang of four,” * two cardiologists and two nephrologists, submitted a memorandum to Dr. Jones requesting the initiation of an audit by an outside auditor. He therefore called a committee meeting which entrusted the investigation to Michael Emmett, a close associate of Tom, also a nephrologist and member of the Dallas group. Against expectations, he proved to be upstanding and impartial.
Dr. Jones was known for his integrity and proved it with the choice of Dr. Emmett as chairman of the investigative committee. During this period, however, the program for all intents and purposes stopped functioning because the news spread quickly both inside and outside the hospital. Everyone was waiting with arms folded for the committee’s verdict. I remember how I would fall into bed at 11:00, beat from exhaustion, only to awake again at 2:00 in the morning, reading about the naval battle of Midway in 1942 in the Pacific and committing to memory which squadron of American dive bombers sank the Japanese aircraft carriers. At around 5:00 I would fall asleep again for about an hour and then I would get up and begin another hectic day trying to prevent the destruction of the program. It was hell.
The findings were published at the end of December. The transplant team was exonerated. It was recognized that the acceptance of high-risk patients had forced us to accept donors of lower specifications. There was criticism of only one case when I was away for a few days in Greece.
However, from the committee’s investigation emerged exceedingly useful conclusions for the future course of the program. Thus, whereas up to 1991, even accepting marginal donors, we had 10% mortality after 30 days, this rose to 30% when combined with high-risk candidates. Even more significant, all five hearts from donors over 40 years old led to the death of the recipient, but grafts from donors below 30 resulted in success for all the patients. Even this small sampling proved what common sense dictated: it is not possible for two bad ingredients to make something good. At the meeting of the Transplant Review Committee, the measures that had to be taken were also discussed: strict selection of candidates for transplant, acceptance of donors presenting the classical criteria and good prospects for graft function, as well as the reorganization of the Patient Selection Committee by the chief of cardiology, Dr. John Hyland, known for his clinical experience and judgment.
In spite of the fresh, traumatic memories and the uncertainty surrounding the program, we did celebrate New Year 1992 at our home along with 100 members of our transplant family. The picture taken then has subsequently adorned several articles and has been presented at meetings, a reminder that determination combined with hard work may eventually be rewarded.
The team now had to be remade from scratch. Two new and hardworking cardiologists, J. R. Bret and J. Schumacher, where appointed. We also needed a new coordinator and I therefore persuaded my former colleague, Sue Pierson, to come back and reorganize the transplant team.
The moral was tersely enunciated by Margaret: “It has been shown once again that you fight the establishment, as you did at the Hippokrateion in Greece. Only then I didn’t know you well enough.” What she really meant was that the crisis was not about bad results, it was about power.
Many years have passed since those cataclysmic events, yet I still get a bitter taste in my mouth when I recall them. All concerned agreed upon a change of policy, already adopted by several reputable programs as a deviation from established medical practice, and those who effected it were pilloried. Moreover, for the first time I felt like an outsider in a system that I had so faithfully served.
*I called them this after the team that worked with Mao ze Dong during the Chinese Cultural Revolution. It consisted of four officers of the Chinese Communist Party, and the leading light of the group was Mao’s last wife.
The irrefutable proof of the transplantation program’s full recovery,
two years after “annus horribilis” (1994).
Serving Two Masters
The road to recovery was long and arduous and it sometimes looked as if we were not going to make it. The worst thing was everybody’s shattered morale. So for the whole of 1992, I stayed at the hospital from morning till night.
In 1992 we did 12 heart transplants, all successful. The same happened in 1993, with the 18 patients we operated on, making the unprecedented number of 30 patients without a single loss. This raised our standing in the hospital, reversing the unfavorable atmosphere, including the discontinuation of our work in the animal laboratory. The administration, however, had one more anxiety: would there be a reduction in patient referrals. But this was something that I was aware of, so I started to travel around North Texas, taking a coordinator with me. Every week we would go to a different town to visit local cardiologists and pulmonary specialists, even in areas that traditionally referred their patients to Houston. Along with the hearts, we were determined to do lung transplants. Up to the end of 1992, we had done 10 single ones, taking on candidates who had been rejected by other programs because of their high risk.
The same year, the Onassis Cardiac Surgery Center, which had been years in the building, began to publicize its readiness. From the outset my mother had had the feeling that one day I would work there and regularly telephoned friends and acquaintances to ask how things were going. Was it her sixth sense? Was it destiny? Whatever the truth of the matter, my childhood friend, Makis Gregoropoulos, considering it a “matter of honor” that I should return to Greece, undertook to investigate and put me in contact with my future colleague, Professor Dionysis Kokkinos, a member of the first board of trustees.
In the summer, the senior positions were advertised, correctly stipulating that the person responsible for transplants should have at least 5 years’ experience.
Having a very low opinion about the establishment in Greece after my painful experience in 1975, I didn’t think there was any chance that I would be selected, although the announcement in the press and in the American newspapers that the “Public Benefit Foundation Alexander S. Onassis registered in Vaduz, Liechtenstein” was the driving force behind the cardiac surgery center was a guarantee. So I decided to apply, after coming to Athens and making a courtesy call on Spyros Metaxas, the owner of the brandy manufacturing company, at that time chairman of the center’s board of trustees.
Spyros Metaxas, the perfect gentleman, did not hesitate to say what he believed. He was disappointed at the state of Greek society and gave me numerous examples of corruption, degradation of institutions, and abandonment. I felt as if icy water was being poured down my spine. He politely accompanied me to the door and there delivered the final blow: “Just wait, Dr. Alivizatos, and you will see how the Greeks will ruin the Onassis. They will make it as dirty as the cancer hospital in Piraeus built by my family. Now you are ashamed to enter and see the graffiti on the walls.” He wished me good luck and I have never forgotten his prophetic words, which with the passing of time became ever more apt.
On September 21, 1992, a telegram arrived unexpectedly, signed by Professor Konstantinos Tountas, vice chairman of the center’s board of trustees. It informed me that Professor Anagnostopoulos, who was working in New York, and I had been selected as the first directors of the center.
It was obvious during my first trip in November that we spoke a completely different language. They could not conceive of there being no infrastructure to enable us to start “immediately,” as they were insisting. At the first board meeting I was present at, with Professor Tountas in the chair, I addressed him directly and in no uncertain terms: “Professor, you do not have a cardiac surgery center, you only have an empty shell since you do not even have medical services.” Also it would not be possible to run the center only with cardiologists and cardiac surgeons. I pointed out that the patients would present many other problems that would require the participation of all the specialties.
Unfortunately, we had not yet realized the suffocating political pressure being applied for the Onassis to open. The government of the time did not want to be saddled with the political cost of a delay. And so the vice chairman of the center made contact with other heart surgeons in Athens. A few days earlier, these ill-conceived designs had caused Professor Anagnostopoulos’ resignation with long-term repercussions for the center. I signed the contract with the Onassis on June 10, 1993, with reservations, adding in handwriting that I would join when “the necessary terms for the operation” of the transplant program had been fulfilled. Having signed the contract with the Onassis, even with stipulations, I now had to prepare the succession at Baylor.
A few days later, at the beginning of July, the United Network of Organ Sharing (UNOS) approved Baylor’s lung transplantation program as the only one in the region. Both the lung and the heart programs were doing exceedingly well, and a review of the waiting list at the local organ bank showed 20 candidates at Baylor, whereas there were only 30 altogether in the other four programs it served.
The year 1993 was full of unpleasantness. First of all, Sherlock died in August, after a struggle that lasted for weeks during which his back legs became paralyzed. I was still with Margaret and one evening I came into the house to find her crying over him while he breathed his last. But there was no time for expressing my grief. There was a donor in Sherman, a town north of Dallas, and I was going with Dr. Shah to retrieve the graft.
At the beginning of October, we lost our dear Eleanor Belanger, grande dame and president of NewHearts. From the time of her first post-transplant check-up, we knew that she was in the early stages of chronic rejection and it was truly a miracle that she had lived for 6 years. Her funeral was well attended, with all the transplant community present. Her work was continued by worthy successors on the board of NewHearts until 2010, when it was dissolved.
However, the year ended triumphantly with 18 successful transplants. The main event of the year, of course, was the transplantation of two lungs into a 30-year-old with pulmonary hypertension. This woman from Oklahoma, the mother of two, needed constant oxygen administration. She was left on her own when her wretched husband, seeing how dismal things were, abandoned her. Without losing hope, she came to us, was given two new lungs, and at Christmas, at the wedding of our secretary, she sang in the church, enchanting the whole congregation.
At the beginning of 1994, the program caught fire. There were 16 heart transplants, 12 single-lung transplants, 3 double-lung transplants, and the fourth combined heart and lung transplant in a 40-year-old from Austin. In the years that followed, she would send me cards and photographs.
Another innovation was the introduction of the technique of the “triple” transplants, taking from a suitable donor the three organs of heart, right lung, and left lung, which we separated into three different plastic bags. Returning to our ORs, we started with the heart. When I was happy about the first two anastomoses and that the graft was in the correct orientation, I left Kim and John to complete the procedure. Then, going to the OR next door, I first did the right lung transplant, assisted by Dick Wood or Tom Meyers, and by the time I had finished the three anastomoses, they had opened the next patient, with Dr. Shah heading the team in the third OR for the transplantation of the left lung. Thus, within a few hours, we had three newly transplanted patients in the ICU. We performed four such “three-bag” transplantations, and at one of these our pathologist at the Onassis, Loukas Kaklamanis, was present.
So, by the end of 1995, we had done 45 lung transplants, leaving the university hospital of St. Paul’s, with only 12 single-lung transplants, in the dust. In June 1995, we did our 200th transplant, and at the Friday grand rounds and in front of all the medical staff in the auditorium, Boone Powell presented me with a framed commemorative photograph showing Paul, our first transplant patient, Dillard, the 200th, the transplant supervisor Sue, and myself.
In Athens, the countdown had begun. From June 1993 when I signed, I had been going back and forth, trying to protect the Baylor program and also to organize that of the Onassis. Pressure on me to return was mounting, and not without good reason because it was obvious that my short visits were not productive. Every time I left, the list of consultants would change through the actions of various shrewd operators.
Meanwhile, in 1994, the two prospective transplant coordinators from the Onassis, Chrysoula Louri and Demetra Kollia, trained at Baylor at the expense of the Public Benefit Foundation. The latter indeed brought back a huge dossier of translated (by her) work protocols, which impressed me greatly.
During my next visit to Athens, our first transplant operation was performed with complete success on April 26, 1995. Georgos Sarris and I, with coordinator Demetra Kollia, retrieved the heart. For the record, the surgical team consisted of myself, Georgos Sarris, and my Cypriot associate, Louis Louka, with the American Gill Balantine as pump technician. The anesthesiologists were Stavroula Lakoumenta and Fani Antoniou. Fani, a pupil of Tasos Triantaphyllou, would develop in the next few years into a pillar of the transplant program. Responsible for the majority of the heart transplants and for all the lung transplants, she was always willing and tireless. Later she would be assisted by two more fine anesthesiologists, Apostolis Thanopoulos and Giotta Rellia.
From August 1995, I had been sounding out the possibility of cooperation between the three hospitals, Baylor, Methodist, and St. Paul’s. There was no other solution. The unification of at least two of the big programs into one larger one, on a national level, would also ensure the survival of our transplants. And so with the utmost secrecy I made the first contacts with Steves Ring, director of the rival program at St. Paul’s, in the kitchen of his house. So, at the beginning of January 1996, I submitted a detailed 12-point plan with the terms of the cooperation and put myself at the disposal of the hospital. One last satisfying achievement was the survival rate of the lung program reaching 70% in the first year, a necessary prerequisite for federal Medicare approval. It was approved and remains the only certified program in the whole state of Texas.
After all this, my return to Greece was finalized. At my own expense, a grand farewell party was set for March 23, 1996, the 10th anniversary of the start of the program. It was organized by Paula Flatley, a loyal friend who had received her heart transplant in 1989 and had been featured on the cover of the hospital’s magazine. She looked after everything, from the country club to the chamber music quartet.
There were around 300 guests, and commemorative plaques were given to all who had contributed to the creation of the two programs. The “first” transplant patients received special plaques given by my associates who had taken part in the operations. The guest of honor of the evening was John Sinclair, Margaret’s brother, whom we invited because he had been declared “Australian of the Year.” He spoke about how he had saved Fraser Island from the American companies digging for copper, even risking his life since huge interests were at stake. His speech received deafening applause as an example of courage in the face of adversity, whatever it may be. Then Margaret asked to say a few words. She said she would always be my friend but that our divorce was for the best because my work meant more to me than anything else. One more piece of recognition, very significant for me, came when the members of NewHearts gave me their golf trophy as a present, even though I had never played. On it was engraved: “To Doctor Peter A. Alivizatos who restored the pulse and the breath of life” and on the base Cliff’s comment: “It is nice to see the sun rise every morning.” And the “hard nut” Sue Pierson, transplant supervisor, gave me a beautiful porcelain cocker spaniel with the same supercilious expression as Sherlock.
The farewell reception in March 1996 before my departure for Greece.
John Sinclair, honored guest speaker at the 10th anniversary dinner
of the NewHearts and Lungs group. This morally and physically erect
activist was named “Australian of the Year” for his heroic struggle
to save Fraser Island from mining.
John E. Capehart, M.D., the program’s anchor— honest, inexhaustibly knowledgeable, and omnipresent—being recognized as its cofounder at the farewell party.
Joyce, the first to be transplanted with two lungs, recognized at the farewell party by team cardiac surgeon Thomas Meyers, M.D.
Susan Reid, our fourth combined heart/lung transplant (1994), being recognized at the farewell party by team cardiac surgeon Richard Wood, M.D., “for resourcefulness in pursuing transplantation.”
Dillard (left), the 200th transplant patient (1995), with Paul, the first (1986).
Three “firsts”: Paul (heart), Gene (single lung), and Joyce (double lung)
at NewHearts annual dinner (2000).
Baylor Coordinators Jobeth Pilcher and Sue Pierson. The former started the Program (1986) and the latter revived it (1993).
The golf trophy with Cliff Hamilton’s moving quotation.
Twenty years later (Dallas, 2016). Doyle, third from the left, 28 years from the
time of surgery; Becky, in the middle, 30 years; David, first from the right, 25 years. Also present, as at the outset in 1986, are two loyalists: my former wife
Margaret and Nancy Pennington, next to David.
BUMC’s cardiothoracic transplantation team and its backbone, the four transplant coordinators, before my departure (1996).
And so, after 12 years, the resettlement came to an end and a new challenge began in the old country. Before our final farewells, Hashmukh Shah, my Indian friend and philosopher, gave me a word of advice: “Peter, be careful where you’re going. Don’t let them win you over with rewards and positions. They will do it to corrupt you and from then on you will be one of them. Unfortunately, the main feature of our countries—equating Greece with India—is corruption.” And he added sadly: “Corruption, corruption, corruption.”
In spite of the ominous forecasts and the doubts when I started the program, middle-aged and without support, within 10 years we had performed 233 transplants: 178 hearts, 51 lungs, and 4 heart/lung combinations. The program had also dared to carry out pioneering (for the region) transplants, such as combinations of heart and kidney, the first transplant using an artificial heart as a bridge, the domino combination of heart/lung-heart, and the first single- and double-lung transplants.
Summing up these facts for the board of trustees, I thanked them for the opportunity they had given us and for their confidence. In response, the hospital board listed these achievements in a Resolution in February 1998 with the congratulations of the president, which they published and sent a copy to me.
The Dallas Morning News Interview
The issuing of the Resolution could not have been more timely, coming on the heels of a combined interview given by the director of transplantation services (Göran Klintmalm) and the incoming transplant cardiology director (Clyde Yancy) to the Dallas Morning News on December 20, 1997. The statements were made after UNOS had published Baylor’s early 1990s results, compromised, as already narrated, by the 1991 debacle. In a sense, the report was both old news and incomplete, as it did not mention the spectacular recovery of the program between 1992 and 1996. In this way the reader was led to believe that the merger was dictated by the “poor” results, fortuitously bringing about the immediate recovery of the program. The truth, as has already been detailed, was entirely different. There was also the regrettable omission of my efforts of more than a year to carefully orchestrate the transition, making it as smooth as possible, before my voluntary departure for Greece and the Onassis Cardiac Surgery Center.
After an official complaint filed with Baylor’s medical board, there were two important developments. The first, in a combined written statement (January 7, 1998), Mr. B. Powell Jr. and Dr. R. Jones unequivocally declared: “We fully understand that our transition in leadership … was necessitated by your acceptance of heading up the new program at the Onassis Cardiac Surgery Center in Athens, Greece. In fact, you helped us secure the new leadership by your own efforts, which are deeply appreciated by us.” The second was the, albeit belatedly, written retraction (7/17/98) by the director of transplantation services, calling the published article “highly unfortunate” and stating that he was “sincerely sorry for having been involved in this interview.” On the other hand, the incoming cardiologist, holding fast to his gratuitous flattery of the administration, neither retracted his assertion nor answered the letter I sent him asking him to recant, thus demonstrating the difference between a seasoned statesman and an inexperienced newcomer to Baylor’s ethos.
The most important lesson of the whole adventure was that, even late in life and a foreigner, by working harder and more persistently than the natives, you can make your mark in the American system, because it is based on meritocracy—the only one in the world, as far as I know.
The fact that we resurrected the program from the ashes was partly due to the superhuman efforts that were made, but mainly to the integrity of the American system. Our noble intention to help “patients and not statistics” was recognized, and so they gave us a second chance to reform and regroup. We did and we won.
I would make use of these lessons during the next 12 years at the Onassis.
The Resolution of Baylor University Medical Center’s board of trustees.
(Issued in February 1998)