Salt Lake City, 2 December 1982
In 1882 a bored young doctor in colonial India passed the long hours between consultations by writing a ghoulish short story about an artificial heart. Ronald Ross had yearned to be a poet, but his father insisted that he study medicine. It was the right decision, since Ross became the world’s leading expert in tropical diseases, later winning a Nobel Prize for his discovery that malaria was transmitted by mosquitoes. Written when Ross was twenty-five but unpublished until long after his death, ‘The Vivisector Vivisected’ is a chilling tale about a physiologist who seeks to bring the dead back to life. He creates a mechanical heart, a pump which is filled with donkey blood, and successfully uses it to revive a cadaver. In true Gothic tradition the action reaches its macabre climax as a thunderstorm rages outside the dilapidated laboratory: the hapless scientist and his colleague realise that having started to pump they cannot stop without killing their experimental subject, who in a cruel twist turns out to be the physiologist’s brother. After hours of frantic pumping they become exhausted and are forced to abandon their hopeless task, as the briefly resuscitated corpse breathes his last for the second time.1
Ross’s story may not be great literature, but it shows remarkable vision. As a physiologist he understood the inherent difficulties of creating a device to replace the heart, and the contraption he imagined anticipated the work of researchers many decades later. His narrator describes a ‘double kind of pump’: a pneumatically powered contrivance like two bicycle pumps connected together, each operating at a different pressure to mimic the heart’s left and right ventricles, and equipped with valves to ensure the blood flows in one direction. Strangely it was exactly a century later – in December 1982 – that a device strikingly similar in conception, consisting of two plastic pumps powered by air, was implanted into the chest of a retired dentist from Utah – the first time a human had been given a permanent artificial heart. The realisation of Ross’s idea was a landmark operation, but deeply controversial; few judged it a success, and relentless press attention ensured that a distasteful melodrama was played out to an audience of millions.
The project to build an artificial heart had begun in a spirit of huge optimism, and was blessed with cutting-edge technology, generous financial support and the keenest scientific minds. In 1968 a government report predicted that within twenty years artificial hearts would become the second largest industry in America, with thousands of patients receiving them each year.2 It was soon apparent that this forecast was well wide of the mark, and that the difficulties of constructing such a device were greater than anybody had imagined. An endeavour which had begun promisingly descended into acrimony, blighted by accusations of malpractice, industrial espionage and theft. It was not until the 1990s that the ‘total artificial heart’ became a widely accepted therapy, and although it has scored several notable successes, fewer than 2,000 have ever been fitted.
The artificial heart was originally conceived not as a therapeutic device but as an aid to research. In the nineteenth century many physiologists had used perfusion pumps, crude devices which circulated blood through isolated organs, in order to study how specialised tissues functioned. In 1928 two investigators from London, Henry Hallett Dale and Edgar Schuster, designed something more ambitious: an apparatus capable of ‘producing a complete circulation of the heartless animal’.3 Their device had two pumping chambers, one operating at high pressure to replicate the systemic circulation, and a low-pressure chamber to propel blood through the lungs. Though this was the first attempt to mimic the function of the natural heart, it was only ever intended to enable study on animal cadavers rather than sustain life, and aroused interest only among specialists.
The perfusion pump unveiled in 1935 by two researchers in New York was, if anything, less sophisticated, yet it prompted a storm of publicity. Front-page headlines celebrated the invention of a ‘robot heart’, and fanciful claims were made about its likely application in humans. Fuelling this press hysteria was the identity of the pump’s inventor: Charles Lindbergh, revered for his feat in becoming the first solo pilot to fly the Atlantic nonstop. After the abduction and murder of his young son in 1932, Lindbergh had become a virtual recluse, and his sudden return to the public eye caused a sensation. For several years, it emerged, he had been quietly devoting himself to biological research at the Rockefeller Medical Center, assisting Alexis Carrel in his experiments. Lindbergh first approached Carrel after watching his sister-in-law die from rheumatic heart disease, an experience which made him consider whether a machine could briefly take over the circulation to enable operations to be performed on the heart.4 What he envisioned was something like the heart-lung machine on which John Gibbon would begin work a few years later; Carrel, however, suggested he channel his energies in another direction. He wanted a pump to perfuse organs outside the body so that they could be studied in the laboratory.
The apparatus designed by Lindbergh consisted of three glass chambers arranged vertically. Rhythmic pulses of gas propelled blood (or an artificial nutrient fluid) from a reservoir in the bottom chamber through the organ under study, which was placed in the upper chamber.5 After passing through the organ, the blood returned to the reservoir through the middle pressure-regulating chamber. One day, Carrel proposed, a similar device might allow surgeons to remove an organ from a patient’s body, operate on it in the laboratory and then return it to its owner.6 He certainly did not believe that it could be used as a substitute for the human heart. Carrel, though, was a canny operator who understood the value of publicity, so did not object when newspapers portrayed Lindbergh’s invention as something it was not. In 1936 he even authorised its use in a horror film, The Walking Dead, in which Boris Karloff stars as an innocent man accused of murder and sent to the electric chair. At the film’s climax, in a memorable sequence obviously indebted to Frankenstein, Karloff’s lifeless body is taken to a futuristic laboratory and revived by powerful electric currents. The camera pans across an impressive array of tubes and flasks before settling on the perfusion pump, as one scientist urges another to ‘keep that Lindbergh heart pulsating, Nancy – see that it doesn’t stop!’7
If Lindbergh was not (as has been claimed) the inventor of the artificial heart, it was undoubtedly his involvement that first gave the idea popular currency. And while the version of his device presented by Hollywood was pure science fiction, a researcher in Soviet Russia soon succeeded in making the real thing. As part of his experiments on transplantation in 1937 Vladimir Demikhov constructed a double pump which he used to replace the hearts of dogs. It was small enough to fit inside the chest, and consisted of two chambers with membranes which pulsated to propel blood through the animal’s vessels. Power was provided by an electric motor outside the body, with a driveshaft passed through the chest wall. Demikhov managed to keep dogs alive for as long as five and a half hours – the first time anybody had sustained life using an artificial heart. A driveshaft through the chest made this an obviously impracticable long-term measure, and it was not his intention to use the machine for any length of time: he saw it as a sort of storage system, a means of maintaining the circulation for a few hours at most, long enough to preserve organs which might be needed for transplantation.8
No other researchers attempted to construct a total artificial heart until the late 1950s; until then all their efforts were directed at assisting, rather than replacing, the organ. One quirky early attempt was made in 1949 by a medical student, William Sewell, while working on his thesis. This was not a high-tech affair: the parts for his device came from a toy shop and cost less than $25. Using an Erector Set (a construction toy similar to Meccano) he assembled a pump powered by compressed air which was used to bypass the right side of a dog’s heart, pumping unoxygenated blood from the vena cava through the pulmonary artery and into its lungs. The device was used for as long as eighty-two minutes, with the dogs making a full recovery.9 Again, this was intended only as an aid to physiological experiments, but offered valuable evidence that a mechanical pump could do the job of an organic one.
The advent of John Gibbon’s heart-lung machine in 1953 provided the final proof of this hypothesis, and several investigators were encouraged to explore the possibility of fully implantable devices, influenced by a burgeoning medical interest in the development of artificial organs. This was stimulated by the work of Willem Kolff, whose major contribution to the invention of the artificial heart – like that of Norman Shumway to transplantation – was overshadowed by the headline-grabbing work of others. Kolff was a physician from the Netherlands who had spent the war working in a small hospital in the city of Kampen, where he set up Europe’s first blood bank and was involved in the Dutch resistance. In 1943 he constructed an artificial kidney, a device to remove waste products from the blood of patients whose own organs were too diseased to function. The early models were ramshackle affairs, using 50 metres of cellophane tubing (Kolff used sausage skins) wound around a rotating drum immersed in saline.10 Most of his early patients died, but by the end of the war he had proved the efficacy of artificial dialysis, a technique which has since saved countless lives. In 1950 Kolff emigrated to America, where he continued his work at the Cleveland Clinic, building one of the world’s first heart-lung machines. Five years later he became the founding president of a new organisation, the American Society for Artificial Internal Organs, set up to bring together leading researchers in the field.11
At the third annual meeting of the ASAIO, Kolff’s successor as president, Peter Salisbury, urged his fellow members to devote more attention to permanent organ substitutes rather than temporary devices such as the heart-lung machine. He also presented his own work on a prototype mechanical heart, a hydraulically powered device based on the mechanism of a milking machine. Bizarrely, he suggested that it might be powered by a hand pump operated by the patient, an arrangement which left unanswered the question of how they were expected to sleep.12 Salisbury’s call to arms was effective, however, and in the next few years numerous researchers entered the fray – far more, in fact, than were working on the problems of transplantation. The first to demonstrate a viable device was Kolff, who in 1957 displayed a plastic artificial heart fabricated by his collaborator Tetsuzo Akutsu. To make it as anatomically accurate as possible, Akutsu made a mould of a dog’s heart in plaster of Paris, and used this to form a PVC replica. Unlike earlier attempts this mimicked the four-chambered structure of the natural organ, with separate atria and ventricles. It was successfully used to keep a dog alive for ninety minutes,fn1 the first time that this had been done outside the USSR.13
Kolff and his colleagues in Cleveland were the early pacesetters, but this soon became a truly international endeavour. A group in Tokyo developed a water-powered heart which kept a dog alive for more than five hours,14 while another in Argentina achieved thirteen hours.15 Initially there was little agreement on what an artificial heart should look like, or how it should work. Some imitated the natural ventricles, using plastic sacs which were compressed by fluid or gas to expel the blood. One ingenious design employed a pendulum whose oscillations squeezed each of the two artificial ventricles in turn. Another borrowed the pump used in the heart-lung machine, using rollers mounted on a wheel to push the blood through a plastic tube.
The choice of power source was also critical. At rest, the average human heart pumps around 7,200 litres of blood per day. Moving such large volumes of fluid requires significant amounts of energy, and researchers quickly realised that no conventional power source was small enough to be implanted into the body, making an external power unit inevitable. One option was an electric motor implanted into the thoracic cavity, connected to batteries by wires passed through the skin. Other devices used pneumatic or hydraulic power: the moving parts of the artificial heart were driven by compressed oil, water or gas which had to be pumped from an external unit via tubes passed through the chest wall.
With so many eminent researchers now entering the field, it is surprising that the first patent for an artificial heart was awarded to somebody who lacked even the most basic expertise in medicine or physiology. Paul Winchell was a ventriloquist who had enjoyed national fame as the star of his own TV show in the early 1950s, and later provided the voice for Tigger in Disney’s animations of Winnie the Pooh. He was also a tireless amateur inventor who registered patents for such indispensable contraptions as a ‘non-bulging garter fastener’ and an electric flour sieve. His 1963 design for an artificial heart consisted of four polymer sacs, with the ‘ventricles’ compressed by a pusher plate powered by an electric motor carried in a harness on the outside of the chest.16 The device, which was never built, was utterly impractical – but Winchell’s claim had serious ramifications, since he had established ownership of several design features which others wanted to use in their own devices. When Willem Kolff discovered the patent he was so concerned that he contacted Winchell to negotiate a settlement which allowed him to develop his own heart without infringing any intellectual rights.17
While some tried to build a machine that would entirely replace the heart, others took a different approach. In 1957 Bert Kusserow of Yale designed a ventricular assist device (VAD) – a small implantable blood pump intended to augment the output of one of the organ’s two pumping chambers.18 It was not a great success, keeping dogs alive for only ten hours, but the idea was an important one: such a pump could theoretically be used to support a heart that was still viable, but so impaired that it could only function to a fraction of its normal capacity. Much better results were achieved by Adrian Kantrowitz in New York, who used an elegantly simple VAD to augment the output of the left ventricle in dogs, many of which lived for several months with the device implanted.19 The first application of this technology to humans took place in Houston, where Michael DeBakey began work on circulatory support devices in the late 1950s. In 1961 he employed a young Argentinian, Domingo Liotta, who had constructed several prototype hearts at his base in Cordoba.
DeBakey and Liotta described their first workable VAD as a ‘left ventricular bypass pump’. It consisted of a double-walled tube of polyester fabric, with a valve at each end: one end was attached to the left atrium of the heart, and the other to the descending aorta. When air was pumped into the outer tube the inner one collapsed, forcing the blood within it into the aorta. Pulses of air were produced by an external compressor, which was cleverly synchronised with the patient’s heartbeat by means of an ECG machine.20 On 19 July 1963, DeBakey’s colleague Stanley Crawford inserted this device into a forty-two-year-old man who had failed to recover after being given a prosthetic aortic valve. The VAD took over much of the work of the patient’s diseased left ventricle, pumping as much as 2.5 litres of blood per minute. It worked perfectly, but the patient was already in a dire state when it was switched on, with brain damage and major organ failure, and he died four days later.21 It was a disappointing outcome, but a moment of real significance: for the first time in history, the human circulation had been sustained by a machine implanted inside the body.
Despite these developments, there was widespread dissatisfaction at the rate of progress. Few institutions had the resources to pay for the necessary equipment, animals and staff; more cash was needed, and lots of it. In 1963 Michael DeBakey appealed to the US government for funds, appearing before the Senate Subcommittee on Health to make his case. He had reason to expect a sympathetic hearing: the committee’s chairman, Lister Hill, was the son of Luther Leonidas Hill, the first American surgeon to suture a human heart. DeBakey was duly awarded $4.5 million to continue his research, but two years later the government earmarked the colossal sum of $40 millionfn2 for the development of an artificial heart, with the aim of implanting the first device by 1970.22
By 1964 DeBakey’s team had tried eight different designs of pump, both total artificial hearts and VADs. These included sacs which were placed inside the heart, like an artificial lining to the ventricle. Others were wrapped around the outside of the organ, helping it to contract. But none gave satisfactory results in laboratory tests, and DeBakey realised that the challenges remaining were formidable. The apparent simplicity of the human heart belies its many subtleties, in particular its ability to self-regulate. When the volume of blood returning from the body increases, the heart responds by increasing its output, a relationship named Starling’s law after the English physiologist who identified it. Although the two ventricles operate at different pressures, their outputs are finely balanced: in his animal experiments DeBakey found that the dogs usually suffered pulmonary oedema, a build-up of liquid on the lungs caused by unequal stroke volumes between the two ventricles. Though any device needed to be powerful, it also had to be gentle with the delicate red blood cells – otherwise they would rupture, causing serious damage to the patient’s kidneys. Another problem lay in the materials at his disposal: the plastics available at the time were not sufficiently durable and had a tendency to cause clots, which could escape into the bloodstream and cause catastrophic blockages in the brain or lungs.23
Faced with this succession of obstacles, DeBakey decided to set aside the artificial heart for the time being, and to focus his attention on the development of VADs, which seemed more promising in the short term. Within a couple of years his team had developed a new model powered by carbon dioxide, and tested it on hundreds of calves – some of which lived for as long as three months.24 More precisely, this was an LVAD (left ventricular assist device), since its purpose was to help the larger and more powerful left ventricle. At a meeting of the New York Heart Association in February 1966, DeBakey gave a talk about his work, suggesting that he would soon be ready to implant the new LVAD in a patient. His remarks caused a frenzy of interest, with one TV company stationing a van outside Methodist Hospital to cover the great moment, whenever it should occur.25
They had to wait a while, since the first clinical use of the new LVAD took place more than two months later. On 21 April a sixty-five-year-old retired coal-miner, Marcel DeRudder, was taken into theatre for surgery to replace a diseased aortic valve. When the procedure had been completed, his heart proved unequal to the task of supporting his circulation. Every time the surgical team tried to stop the heart-lung machine his blood pressure fell alarmingly: the cardiac muscle was too damaged to pump enough blood to keep him alive. After a quick discussion, DeBakey decided to use the LVAD, in the hope that its temporary use would allow the weakened myocardium time to recover. One end of the device was attached to the left atrium, the other to the axillary artery, a large vessel in the armpit. The pump itself, which was left outside the body, was a dome-shaped chamber containing a plastic membrane, on one side of which was blood and on the other gas. When carbon dioxide was pumped into the dome the membrane flexed, expelling the blood; when it was sucked out the blood chamber refilled, beginning the cycle once more.26
DeRudder never regained consciousness and died five days later, after a massive rupture to his left lung. Although DeBakey had not sought publicity, the resulting blanket media coverage irked his colleagues. One of those who reacted with disapproval was Adrian Kantrowitz, who remarked, ‘We don’t do things the way Dr DeBakey does – television cameras and all.’27 He had reason to be irritated, since two and a half months earlier he had performed a similar operation using an LVAD of his own design. This was a simpler device than DeBakey’s, a U-shaped tube of plastic which was fitted across the aortic arch and powered by compressed air. Its other merit was that it had no valves, which meant that it could be used intermittently or switched off entirely without fear of clotting. His first patient died within twenty-four hours but the second, operated on in May, recovered consciousness and seemed to be on the mend until a stroke ended her life a fortnight later.28
While treating this woman Kantrowitz was struck by an observation. At one point the pump had been turned off to see if her heart was now strong enough to carry the circulation, and after two hours she was evidently in congestive heart failure, disorientated and having difficulty breathing. When LVAD support was resumed her lung function immediately improved, and she became alert and aware of her surroundings. Kantrowitz became convinced that a less invasive, temporary device for circulatory support would be a valuable way of helping cardiac patients through periods of crisis.29 He now took a different approach to the problem, one which built on research he had begun more than a decade earlier.
In the early 1950s Kantrowitz was working in the laboratory of Carl Wiggers, a physiologist celebrated for his study of the cardiac cycle, the events which take place during a single heartbeat. He was particularly interested in coronary perfusion, the flow of blood through the arteries that supply the heart muscle. When the heart contracts in systole, the arteries inside the myocardium are twisted and compressed by the high pressure of the ventricles, squeezing blood back towards the aorta. This means that most perfusion takes place during diastole, the pause between contractions, when the vessels are relaxed. To study this sequence in more detail, Kantrowitz enlisted the help of his brother Arthur, a brilliant physicist, and after analysing the complex flow of blood throughout the cardiac cycle they concluded that forcing more blood into the coronaries during the lull of diastole might be a feasible way of improving the condition of patients with heart failure.30
Their efforts to exploit this insight came to nothing, but others had more success, notably Dwight Harken, who used an external motor to suck blood from the aorta during systole and pump it back in during diastole.31 He called this technique counterpulsation, because it created a second pulse in the pause between heartbeats. Although it succeeded in improving coronary perfusion, it had the significant drawback of damaging the red blood cells. Another, more promising, idea involved inserting a catheter into an artery in the neck or chest and threading it downwards towards the heart until its tip lay just above the aortic valve, next to the openings of the coronary arteries. At the end of the catheter was a tiny latex balloon which could be inflated with carbon dioxide.32 A timing circuit attached to an ECG machine synchronised the inflation of the balloon with diastole, so that blood was propelled into the coronaries.33 Several people, including Willem Kolff, investigated this approach, but none succeeded in making it work satisfactorily until Adrian Kantrowitz refined it by using helium, which could be pumped more quickly through the narrow catheter than carbon dioxide, and a firmer polyurethane balloon which, unlike latex models, would not stretch and occlude the aorta.34
Following successful tests on dogs, Kantrowitz first used this device clinically on 29 June 1967. The patient was a forty-five-year-old diabetic woman who had been admitted early in the morning after suffering a major heart attack. She was ashen-faced, her skin was cold and clammy and her cardiac function was so poor that her pulse was undetectable. After concluding that the prognosis was more or less hopeless, Kantrowitz decided to use the balloon pump. It was inserted through an artery in her thigh and manoeuvred upwards through the aorta until it lay just above the heart. For the next seven hours it pulsated in alternation with the heart, pushing extra blood into the coronaries. Periodically the pump was switched off so that doctors could check the condition of her heart; the first eight times this was tried she seemed to relapse and its use had to be resumed. On the ninth attempt, however, there were unmistakeable signs of improvement. Her blood pressure gradually increased and the colour returned to her face.35 After three months of convalescence she was well enough to return home from hospital. The only lingering effect of her ordeal was a limp, caused by the incision in her leg, and she remained in good health until her premature death in a road accident eighteen months later.
Although it was slow to catch on, Kantrowitz’s balloon pump soon proved its worth, and it still plays an important role today in the management of patients whose hearts cannot sustain the circulation unassisted. When the myocardium is injured the consequence is typically a condition called cardiogenic shock, in which cardiac output is greatly reduced and the major organs no longer receive adequate oxygen. What makes this so dangerous is the body’s response, a complex combination of compensatory measures which actually have the effect of exacerbating the original heart failure. Without intervention the patient can rapidly enter a downward spiral, terminating in cardiac arrest and death. The balloon pump is often highly effective at interrupting this vicious circle, increasing cardiac output by as much as 40 per cent and much improving the patient’s chances of recovery. But it is an acute measure, useful only for short periods; for chronic conditions a longer-term solution was needed. And this meant either VADs or an artificial heart.
An important milestone was passed in August 1968 when Michael DeBakey used his LVAD to treat a sixteen-year-old Mexican beautician, Esperanza del Valle Vasquez, whose short life had been blighted by rheumatic heart disease. Already in severe heart failure, she was admitted to hospital for replacement of her mitral valve. Surgery presented a grave risk, and DeBakey was not surprised when she could not be weaned off the heart-lung machine. The LVAD was attached, and this was enough to keep her alive for the next four days, until her heart muscle had recovered sufficient function to support her circulation on its own. An extraordinary photograph taken shortly after the operation shows her sitting in bed grinning broadly, with the pump – a plastic object the size of a grapefruit – dangling from tubes implanted in her chest. Esperanza became the first patient to make a complete recovery after the use of an LVAD; it was a promising omen for the greater challenges that lay ahead.36
DeBakey’s decision to prioritise VADs over the total artificial heart was a pragmatic one, but it did not go down well with some colleagues. Domingo Liotta had joined his laboratory six years earlier hoping that he would soon be able to see one of his prototypes working in a patient, and was upset when his project was effectively sidelined. Late in 1968 he met DeBakey to express his frustration, only to leave his boss’s office feeling that he had been brushed off. What he did next might be seen as simply naïve or downright underhand: he arranged a meeting with Denton Cooley.
The relationship between DeBakey and Cooley had never been particularly close, but in the late 1960s it became distinctly chilly. After a decade of collaboration at Methodist Hospital their partnership had ended in 1962 when Cooley moved to St Luke’s, a hospital a few hundred yards away – though he remained on the staff of Baylor University College of Medicine, where DeBakey was chairman of the department of surgery. What began as a clash of egos became, with the dawning of the transplant era, a case of mutual antagonism. Cooley was the first Houston surgeon to emulate Christiaan Barnard, performing three transplants in the space of a few days in May 1968. DeBakey, a cautious and methodical man who would only apply a new technique after months of assiduous laboratory work, took the strong view that Cooley had entered the field prematurely and without doing the requisite preparation. By the time he finally chalked up his first transplant in August, Cooley had eleven to his name. Nor can it have helped that the photogenic Cooley suddenly became the best-known face in American surgery, the protégé outshining his mentor.
When Domingo Liotta entered Cooley’s basement office in December 1968 he must therefore have understood that his actions would be seen as a betrayal. He told Cooley that he doubted DeBakey’s commitment to the artificial heart, and asked whether they could work together with a view to implanting it in a patient. Cooley readily agreed: the thrill of his early transplants had already given way to disenchantment as patient after patient died from rejection, and he saw the device as a promising alternative. Neither felt the need to tell DeBakey about their arrangement, and for the next four months Liotta kept his work with Cooley secret from the man supposedly employing him.
It soon became apparent that Liotta had acted prematurely. The following month DeBakey authorised animal testing of the artificial heart, his interest in the programme evidently very much alive. The results were deeply underwhelming: four of the seven calves died on the operating table, and none of the other three regained consciousness or lived for longer than twelve hours.37 This only confirmed to DeBakey that months or years of work were still needed before the machine would be ready. On 4 April 1969 he travelled to Washington to attend a meeting of the National Heart Institute, and was just about to go to bed when he received a phone call from a colleague in Houston, who told him that Denton Cooley had performed the first implantation of an artificial heart. DeBakey was dumbfounded: as far as he knew, Cooley had never tried to develop a device, or shown any interest in doing so. The next morning he switched on the television to see Liotta and Cooley being interviewed, showing off a mechanical heart which looked suspiciously like the one from DeBakey’s laboratory. When he arrived at his meeting he was surrounded by colleagues anxious to hear further details of the operation; to his intense embarrassment, he was forced to confess he knew as little as they did.38
DeBakey flew back to Houston intent on finding out what had happened. He quickly came to the conclusion that Cooley had been determined to be the first to implant an artificial heart, and that Liotta had enabled this by taking DeBakey’s prosthesis without permission; in his view it was a straightforward case of theft. Cooley told a different story, claiming that the device was a new model which he and Liotta had developed in secret, and that the operation was not planned in advance but had been a last-ditch effort to save the life of a dying man.
The uncontested facts are these. On 5 March Haskell Karp, a forty-seven-year-old print worker from Illinois, was admitted to Cooley’s hospital with advanced coronary artery disease. After two major heart attacks his cardiac muscle was ruined: angiograms showed the left ventricle ballooning with each contraction, indicating that its wall had been terminally weakened by a mass of dead tissue. Cooley recommended a transplant, but Karp was firmly opposed to the idea.39 Instead he agreed to a less radical operation, myocardial excision with ventriculoplasty, known as the ‘wedge procedure’. This entailed cutting out a wedge of dead heart muscle and suturing together the remaining tissue in the hope that it would be enough to keep the organ pumping. Cooley was frank about the risks: Karp stood only a 20 per cent chance of surviving the operation. He offered his patient one glimmer of hope. In the event of failure he could implant a mechanical heart, in the hope that it would keep him alive for long enough to enable a transplant. Karp agreed: if death was otherwise inevitable he would drop his opposition to receiving a new heart.
The operation was scheduled for 4 April, Good Friday. When the anaesthetist, Arthur Keats, went to see Karp at lunchtime that day he found him mottled and blue, struggling for breath; he was so alarmed by his condition that he rushed him straight into theatre. Cooley was quickly summoned, the patient attached to the heart-lung machine, and the operation began. As soon as Cooley opened the pericardium to reveal Karp’s heart it became clear why he was at death’s door. It was vast, with a grotesque balloon of scar tissue the size of a cantaloupe melon.40 He excised this useless mass and reconstructed what remained. Attempts to restart the organ were unsuccessful, and – assisted by Liotta – Cooley implanted the prosthesis and switched it on.41 For the first time in history a human life was being sustained by an artificial heart.
Karp regained consciousness shortly after the chest incision was closed, but could not be moved from the operating theatre since his life depended on a large console pumping compressed gas to the artificial heart through tubes in his chest. How long this machine could keep him alive was anybody’s guess, so the race was now on to find a replacement heart. That evening Cooley and Liotta gave a hastily convened press conference at which they described the operation and appealed for a donor organ. Karp’s wife Shirley contributed a handwritten note which was widely reproduced in the newspapers:
Someone, somewhere, please hear my plea. A plea for a heart for my husband. I see him lying there, breathing and knowing that within his chest is a man-made implement where there should be a God-given heart. How long he can survive one can only guess … Maybe somewhere there is a gift of a heart for my husband. Please …42
A suitable donor was eventually found in Massachusetts, but only arrived after a nerve-wracking delay. The jet carrying the comatose patient developed a mechanical fault in mid-air, and had to make an emergency landing at a military base with its brakes out of action.43 A replacement plane was quickly dispatched, and the donor was delivered to St Luke’s at 5 a.m. the following morning, just as her heart was beginning to fail. The transplant, Cooley’s twentieth, was performed quickly and without incident. Cooley was cautiously optimistic about his patient’s chances, but his hopes were soon dashed. Within hours, X-rays started to show a worrying shadow on Karp’s right lung. It was a fungal infection, and the immunosuppressant drugs Karp was taking left him powerless to fight it. A day later he went into cardiac arrest and died.44
While the attempt had been unsuccessful, Cooley’s feat prompted reams of adulatory press coverage. But a storm was brewing. DeBakey was not the only one who wanted answers; the National Heart Institute, which had provided generous financial support for DeBakey’s research, demanded to know whether the device used by Cooley was that developed in the Baylor College of Medicine laboratories. If so, its use in humans was subject to strict ethical protocols and approval in advance by a special committee – permission which Cooley had neither sought nor received. Within hours, Baylor initiated the first of several inquiries to investigate the matter. Cooley was defiant, telling journalists immodestly, if accurately, ‘I’ve done more heart surgery than anyone else in the world. I believe I am qualified on what is right and proper to do for my patient. The decisions are made by me with the permission of the patients.’45
Cooley claimed, both in public and to the authorities, that he and Liotta had tested no fewer than fifty-seven different configurations of ‘their’ heart, and that this included implantation in nine calves, of which four had been long-term survivors. But he was unable to provide documentation to prove that any such experiments had taken place, and his story continued to unravel when Liotta admitted that both construction and testing of the device had taken place in the Baylor laboratory, using resources paid for by the government grant.46 The findings of the various inquiries into Cooley’s operation made painful reading for the surgeon, and tarnished his achievement considerably. They found that he had misappropriated a device developed with government funds, and failed to seek ethical approval for an unsuccessful experiment on a human subject.47 He was also censured for his conduct by the local medical society and by the American College of Surgeons,48 and subsequently resigned from Baylor. To add to their woes, Cooley and Liotta were then sued for malpractice by the widow of Haskell Karp, who alleged that the surgeons had failed to explain exactly what the operation entailed. The case against them was dismissed, but only after one of the most protracted legal battles in medical history.49
The echoes of the Karp affair would reverberate for decades. Cooley soon attempted a reconciliation with DeBakey, but the older surgeon cut all ties with his former collaborator, describing him to friends as a ‘non-person’. In a private conversation with a would-be biographer he was still more vicious, accusing Cooley of megalomania, greed and dishonesty. But he saved his harshest words for Liotta, whom he described as ‘stupid’ and ‘unbalanced’.50 Colleagues in Houston started to refer to the short distance between the offices of DeBakey and Cooley as the ‘demilitarized zone’, and their falling-out was even the subject of a cover story in Life magazine.51 Although officialdom had painted Cooley as the villain of the piece, public opinion was divided. The influential New York Post columnist Max Lerner offered a perceptive assessment of the pair that showed that he well understood the dynamics and egos of the world of heart surgery:
Neither is wholly right or wrong because both types of men are as necessary and complementary in the progress of the medical arts as the systole and diastole of the heart itself. We need the Cooleys to rush pell-mell along the lines of least resistance in heart transplants and artificial hearts. We need the DeBakeys to make sure that the revolutionary pace proceeds ‘with all deliberate speed.’ If my older judgment is with Dr DeBakey, my young, temperamental impulses are with Dr Cooley.52
This drawn-out soap opera rather overshadowed the important matter of assessing the outcome of the operation, and how the heart had performed. Although it succeeded in keeping Haskell Karp alive for almost three days, there was evidence that the device was highly unsatisfactory in its current form. While it was being used, Karp had suffered serious kidney damage, a complication also noted in the few animal tests which had taken place.53 Any sober appraisal of the data suggested that the device was far from ready for human use.
The episode dealt a fatal blow to DeBakey’s artificial heart programme, although others persevered with their research. Much of the available funding was diverted to a more ambitious aim: the design of a self-contained device which could be fully implanted into the body, rather than remaining tethered to an external power unit. It was hard to imagine anybody attached to such a thing leaving hospital, let alone living a normal life. The main difficulty lay in developing a battery which could provide the power to pump thousands of litres of blood per day while lasting for weeks or months. There was only one energy source with the potential to meet these exacting specifications: nuclear power.
The fascinating but abortive attempt to build a nuclear-powered artificial heart began in the mid-1960s. At about the same time as the US Atomic Energy Authority initiated research into nuclear pacemakers, it received a proposal from a private corporation for a cardiac prosthesis using similar technology. This was a more daunting proposition, since a mechanical pump requires far more energy than a tiny electronic circuit. The project was given the go-ahead, and in 1971 several teams, including one led by Willem Kolff in Utah, undertook the ambitious task of designing a substitute for the human heart, complete with its own miniature atomic power station.54
The technology used to power the nuclear heart was an appealing and innovative blend of ancient and modern. A sample of plutonium-238 weighing around 50 grams was enclosed in a hermetically sealed capsule made from tantalum, a hard and chemically inert metal, to minimise the escape of radiation. Through radioactive decay the plutonium heated the walls of the capsule to over 500°C, and this heat was transferred to water vapour which expanded to drive a piston, which in turn provided rotary power to the shaft of the blood pump.55 The device was, in fact, a tiny steam engine, built on principles which the pioneers of the early nineteenth century would have recognised. Tests showed that the fuel cell would have a minimum lifespan of ten years – more than adequate for the needs of an artificial heart.
Unfortunately the system also had some pretty hefty drawbacks. Scientists asked to assess the device’s safety found that it presented a substantial threat to the health not just of the recipient, but of their immediate family. The fuel cell emitted so much radiation that patients were likely to develop leukaemia, and it was virtually certain that they would become sterile – women in as little as a year. Even a spouse sleeping in the same bed as the owner of a nuclear heart was likely to suffer the same fate. The study also suggested that simply coming into contact with a recipient might be enough to cause birth defects.56 A more outlandish possibility, albeit one taken seriously, was that a recipient might be kidnapped and murdered by hostile agents in order to obtain the plutonium for use in nuclear weapons.57 But rather than national security concerns, it was the prospect of creating an army of silent killers, capable of giving a stranger cancer merely by standing next to them at a bus stop, that eventually put paid to the nuclear heart: in 1973 funding for the project was withdrawn, and research continued along more conventional lines.58
Though largely unheralded outside medical circles, the most encouraging progress was being made by Willem Kolff and his colleagues at the University of Utah. In 1969 his associate Clifford Kwan-Gett made an important breakthrough by designing the first pump that obeyed Starling’s law, adjusting its output to compensate for changes in the volume of blood returned to the device.59 Two years later Kolff asked Robert Jarvik, a twenty-five-year-old medical student, to join the team and help improve the device. This was an inspired move, if a brave one: Jarvik had failed to complete degrees at any of the three institutions he had enrolled at, but what he lacked in application he more than made up for in imagination. He also had a background in engineering, and Kolff immediately recognised his flair for finding mechanical solutions and applying them to the artificial heart. Within a year he had produced the Jarvik-3, which used polyurethane membranes powered by air to pump blood out of the two artificial ventricles.
After more than a decade of research and millions of dollars in funding, the artificial heart could only be seen as a disappointment: nobody had managed to keep an animal alive for longer than three days. But in 1973 this sequence of failures finally came to an end. In Minnesota, Tetsuzo Akutsu’s device sustained eight calves for a week, and one for ten days.60 The following year Kolff and his team surpassed this, using the Jarvik-3 in a calf that lived for eighteen days after implantation.61 Steady progress was made elsewhere, too: groups in Cleveland and Berlin finally achieved survival times measured in months.62 Jarvik continued to tweak his device, experimenting with a wide range of materials and designs. In a series of trials which began in 1976, nine calves given a Jarvik heart lived for five months or longer. Among a menagerie of experimental animals which eventually included a sheep called Ted E. Baer and a pair of calves named Charles and Diana,63 the winner was a Jersey called Alfred, Lord Tennyson, which remained alive and well for 268 days, almost nine months, after implantation.64
Most of these devices were designed specifically to replace a cow’s heart, but Jarvik also produced a slightly smaller model suitable for humans, which he called the Jarvik-7. Although Kolff had now been working on the problem for over twenty years, he was reluctant to take the momentous step of testing it on a patient. That all changed in 1979, when a young heart surgeon joined his team. William DeVries had worked briefly with Kolff many years before, and when he returned to the university after a break of almost a decade he was astonished by the advances made in his absence. Walking through the building that housed the experimental animals he saw numerous healthy looking cows and sheep with artificial hearts, and was soon convinced that the device was ready for human implantation. It was not easy to persuade Kolff, who was worried about the implications for his funding should the attempt fail, but after several months of nagging he finally relented.65
As it transpired, it was not DeVries but Denton Cooley who implanted the next artificial heart. His second venture with the device in July 1981 was no more successful than the first: the pump caused serious complications in the three days it was in use, and the patient died a week after it was removed and replaced with a donor organ.66 Cooley again incurred official wrath for his behaviour, earning a reprimand from the Food and Drug Administration for using a device which had not been approved for use in humans.
DeVries and Jarvik were attempting something far more ambitious, since their device, once inserted, would remain in situ for the rest of the recipient’s life. In the autumn of 1982 they finally found a suitable patient. Barney Clark was a local dentist with a chequered medical history stretching back to his thirties, when he had contracted hepatitis. A heavy smoker, he later developed emphysema and idiopathic cardiomyopathy, a progressive heart failure of unknown cause.67 At the age of sixty-one he was almost totally disabled, and drugs had failed to check the degeneration of his cardiac muscle. The amiable Clark was fascinated by medical innovation, so DeVries took him to see his experimental animals with artificial hearts beating in their chests, and invited him to watch as he implanted one in a calf. Clark was at first unenthusiastic, pointing out that the cows were in perfect health when operated on, whereas he was already an invalid.
It did not take long for him to change his mind. At the family Thanksgiving dinner a month later he was so sick that his family were forced to carry him downstairs, and he could eat only a few mouthfuls before returning to bed. He told his wife that he would go through with the operation; not because he thought it would save him, but because he wanted to make a contribution to medical knowledge.68 When admitted to hospital he was in a pitiable condition, with an enlarged liver and pronounced swelling caused by fluid retention all over his body. To ensure that he could not possibly be accused of any ethical breach, DeVries went through an unusually elaborate consent procedure. Clark was interviewed by a six-strong panel of experts, before being asked to read and sign an eleven-page consent form that listed unambiguously all the many things that might go wrong. He was also shown graphic photographs of Cooley’s first operation to leave him under no illusions about what he was about to put himself through. Finally, to guard against any second thoughts, he was made to sign the form again twenty-four hours later.69 This extraordinary protocol had been the subject of endless discussion by the hospital’s ethics committee, and was designed to avoid any repetition of the malpractice allegations that had blighted Cooley’s operations.
The regulatory authorities had decreed that DeVries was only permitted to operate if death was imminent; until then he could do nothing but wait for Clark’s condition to deteriorate. On the first day of December it started to snow, and when a few flakes turned into a full-blown blizzard DeVries asked his surgical staff to stay on site in case the roads became impassable. That afternoon Clark had an episode of heart arrhythmia which caused him to pass out, and doctors told his family that he was likely to die within hours or days.70 With a patient who was already comatose and whose blood pressure had plunged to almost nothing, DeVries feared that his experiment was over before it had even begun; but somehow they managed to get him into theatre, open his chest and attach him to the heart-lung machine, and the seven-hour operation was underway.
The procedure had a brutal simplicity to it, and from a technical point of view was not particularly difficult. DeVries began by making two small stab wounds near Clark’s navel to accommodate the air tubes which would power the device. Then came the most drastic step: lifting the heart out of the chest cavity, DeVries made an incision which cut it in two, entirely severing the ventricles from the atria. He cut through the aorta and the pulmonary artery, and the redundant portion of the heart – both ventricles, the bulk of the organ – could be discarded. The artificial heart was put in its place, and its Dacron outlet tubes trimmed so that they met the stumps of the major arteries perfectly; if the grafts were left too long they might kink and kill the patient.
The device itself was made of smooth polyurethane, and consisted of two roughly spherical chambers designed to replace the ventricles. Each contained a plastic diaphragm whose pulsations, powered by pressurised air, would propel blood through the body. Their edges were lined with a cuff of Dacron by which each of the two artificial ventricles was carefully sutured to the remaining tissue of the corresponding atrium. It was therefore only the pumping chambers that were new: before entering them, blood would pass through the remnants of Clark’s own right and left atria. DeVries attached the drive lines and passed them through a tunnel of muscle so that they emerged through the incisions in the abdomen. The artificial heart was switched on, but was allowed to take over the circulation from the heart-lung machine only when DeVries was satisfied that any air in the blood chambers had been completely evacuated.71
It was seven o’clock in the morning when Barney Clark was finally wheeled out of theatre and taken to intensive care. He woke up shortly afterwards and asked for a glass of water, before turning to his wife and saying, ‘I want to tell you that even though I have an artificial heart, I still love you.’72 For his part, DeVries had been working flat-out for twenty-four hours, but knew it would be some time before he would be allowed any rest. Journalists had started to arrive at the hospital while the operation was still in progress, and within days their number had swollen to over 300. Police were summoned to prevent unwanted intruders, and visitors were incessantly questioned for any snippet of news.73 The hospital administrators had learned the lessons of the transplant era, and regular briefings were organised to satisfy the journalists’ insatiable appetite for fresh information.
DeVries found these sessions difficult: he was just thirty-five and had little experience of dealing with the media. What made it all the worse was that he rarely had any good news to pass on. Although Barney Clark regained consciousness within a few hours of the operation, he soon experienced the first in an escalating series of setbacks. On the third day he had to be returned to theatre so that a small lung rupture could be repaired, and this was rapidly followed by kidney failure and mysterious seizures. On 14 December, less than a fortnight after implantation, the artificial heart failed when one of its valves broke, and Clark had to undergo surgery for a third time to replace the entire left ventricle. Further complications followed, but in late February there were finally signs of improvement. Barney was able to talk to his wife, ate normally, and received physical therapy; there was even talk of his discharge from hospital.74 To give the wider world some evidence of his recovery a short interview was filmed and broadcast on 2 March, though Clark was patently very sick and gave his answers in a monotone while staring into the middle distance. The public reaction to this spectacle was not as positive as DeVries and his colleagues had expected.
Any hope that Clark might ever go home soon vanished. Shortly afterwards he developed pneumonia, and the story thereafter was one of inexorable decline. One by one his organs began to fail, and on 23 March his condition became irretrievable when his lungs and brain stopped functioning. The heart was the last part of his body to keep working, and at 10 p.m., after beating approximately 12 million times, it was finally silenced when DeVries switched it off with the turn of a key. Outside the building it was snowing, as it had been 112 days earlier when Barney Clark became the first person in history to receive a permanent artificial heart.
Clark’s survival for more than three months confounded the predictions of the many surgeons who had been pessimistic about his prospects. Surprisingly, even Denton Cooley spoke out against it, suggesting that ‘the artificial heart is not ready for elective implantation and cannot even approach the expectation of cardiac transplantation today’.75 Michael DeBakey criticised Clark’s poor post-operative condition and minimal quality of life, while Norman Shumway dismissed the device as a ‘clot machine’ which was likely to kill patients by giving them strokes.76 William DeVries had to endure personal as well as professional abuse, receiving threats from anonymous correspondents outraged at his meddling with nature.77 To cap it all, the medical establishment effectively turned its back on him later that year when the bodies funding research into artificial hearts decided that their resources should instead be concentrated on the simpler and less problematic ventricular assist devices.78
DeVries, however, had no intention of giving up. Under the terms of his original agreement with the regulatory authorities he was permitted to perform six more implantations of the Jarvik-7, but the University of Utah raised concerns about the cost. After two years trying to raise funds he admitted defeat and accepted a private healthcare company’s offer to fund his work at a hospital in Kentucky.79 On 25 November 1984 he implanted a second Jarvik heart into Bill Schroeder, a fifty-four-year-old who had been rejected for transplant because of diabetes. By the end of his first week he was walking around his room, but his recovery was marred by a stroke and repeated infections. Nevertheless, three months later he was able to take part in a rehearsal for his son’s wedding in the hospital chapel, and was eventually allowed to move to a nearby apartment. His progress was again followed eagerly by the media, and the by-now familiar face of Robert Jarvik made frequent appearances on the news bulletins. With his weakness for garish ties and air of a superannuated rock star he was an arresting figure, and became something of a celebrity. Playboy magazine even accorded him the honour of an in-depth profile, an eccentric interview in which he was described sculpting a unicorn-shaped dildo for an unnamed paramour.80
In early 1985 DeVries performed two further operations, and for a brief, heady period the hospital housed three patients all living with an artificial heart. The undoubted highlight of Bill Schroeder’s recovery came in September, when he was taken on a fishing trip with a portable air pump strapped to the back of his wheelchair. Alas, this was a pleasure which would not be repeated. Shortly before the anniversary of his operation he suffered a major stroke from which he never fully recovered, beginning a slow decline to his death on 6 August 1986.81
Bill Schroeder’s death was also the end of a chapter for DeVries, signalling the conclusion of his trial of the Jarvik heart. Of his four patients one had died after ten days, but the others were long-term survivors – two for more than a year. These results, he believed, justified his clinical experiments, but he conceded that there were serious problems with the device; in particular, he acknowledged that it had frequently caused strokes, tacitly admitting the truth of Shumway’s earlier criticism.82 Other surgeons in Europe and America used it with some success, however, including Terence English in London. By the time of the last implantation of a Jarvik-7 in 1992, 226 patients in Europe and America had received artificial hearts, most as a bridge to transplantation. Not all of these were Jarviks: ten other models had been used, and often with excellent results. More than a third of patients lived for a year, and two-thirds survived long enough to receive a transplant.83
Research into artificial hearts continued, but by the early 1990s many believed that the dream of a permanent substitute for the heart was over. It had been supplanted by the concept of ‘bridge to transplant’, a compelling new therapy for those with end-stage cardiac failure. The ‘bridge’ did not have to be a total artificial heart, since VADs had also proved effective at achieving the same goal: in 1984 the Stanford University surgeon Philip Oyer implanted an LVAD into Robert St Laurent, a fifty-one-year-old who was desperately sick after a coronary bypass operation had failed to salvage his diseased myocardium. Developed by the former nuclear physicist Peer Portner, the device was revolutionary in its design, powered by an electric motor rather than compressed air. This removed the need for a bulky external drive unit; instead, a wire passed through the skin was connected to a battery pack which the patient could wear on a belt. A week later the device was removed, and in its place Oyer transplanted the heart of an eighteen-year-old student who had died in a road accident.84 St Laurent was the first person to successfully receive an LVAD as a bridge to transplant, and lived for another twenty years, in the process also becoming one of the longest-surviving transplant patients.85
The first generation of VADs were pulsatile: they pumped blood rhythmically, seventy or so times per minute. This seemed logical, since it simulated the action of the heart. But the late 1980s saw the appearance of a new type of device which drove fluid continuously, like the propeller of a boat. Physiologists had long debated the significance of the pulse, and whether it was an essential feature of the circulation. Some argued that organs had evolved to function with a pulsatile blood supply, and that kidneys, for example, would sustain damage if the blood flow were continuous.86 Others believed that the pulse was nothing more than ‘an expression of the limitations of organic heart design’87 – a consequence of evolution, but one of no great importance. In 1984 researchers at the Cleveland Clinic put these rival theories to the test by the inventive means of creating a pulseless cow. They took four healthy calves and bypassed their hearts with a pair of blood pumps – one for each of the ventricles – mounted on the animals’ backs. These pumps used rotors to propel the blood continuously, so for the duration of the experiment the calves had no heartbeat. All four lived quite happily without a pulse for a month, suggesting that the same might also be true for humans.88
In April 1988 a pulseless LVAD was implanted in a patient in Houston by Bud Frazier, a surgeon of immaculate pedigree: after training with Michael DeBakey he had moved over the road to become Denton Cooley’s right-hand man. He used the Hemopump, a clever little device which was small enough to be inserted through a blood vessel. An incision was made in the femoral artery in the groin, and a catheter containing the pump, just 7 millimetres in diameter, passed up through the aorta until the device was wedged in the opening of the aortic valve. Rotors spinning at up to 27,000 rpm propelled blood from the left ventricle into the aorta, almost entirely taking over the circulation.89 The patient, a sixty-one-year-old man suffering an episode of rejection following a heart transplant, was sustained with this device for two days before making a full recovery. He was eventually discharged, having briefly become the first human being to live without a pulse.
Like the intra-aortic balloon pump, the Hemopump was intended only as a short-term measure to help patients through a brief crisis. In the late 1990s, however, a new generation of continuous-flow LVADs intended for longer-term use appeared on the scene; the first was developed by Michael DeBakey, the surgeon responsible for establishing the field more than thirty years earlier. At the age of ninety, and still as energetic as ever, he supervised clinical trials of a device he had designed in collaboration with NASA. This partnership was instigated by a former patient, Dave Saucier, an engineer at the Johnson Space Center who had received a heart transplant from DeBakey in 1984. Using NASA’s expertise in aerodynamics and technology invented for the space programme, the team designed a pump the size of an AA battery which resembled a miniature jet engine.90 The device was placed inside the chest so that it pumped blood from the left ventricle to the ascending aorta at rates of up to 6 litres per minute.91
DeBakey’s continuous-flow pump, introduced in 1998, was the first of several second-generation LVADs to be put to clinical use. By the time they appeared on the market, specialists had over a decade’s experience with temporary devices, and had noticed that patients often did well even if they failed to receive a transplant within a couple of years; in some cases, the diseased heart even began to recover its function. Clinicians now realised that they might also be useful as ‘destination therapy’ – a permanent treatment for those patients deemed ineligible for transplant because of age or significant additional health conditions. A major trial was organised involving 129 patients in end-stage heart failure who were not candidates for transplant. They were split into two groups: 68 were given LVADs, and the remaining 61 received the best possible drug therapy. The results of the snappily named Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial (REMATCH) were published in 2001, and showed that LVADs reduced the risk of death by almost 50 per cent.92 American regulators approved one device as destination therapy the following year; NICE, the British equivalent, finally followed suit in 2015.93
Today’s LVADs are a world away from the bulky, wheezing monsters first used in the 1960s. Easy to implant and almost totally silent, they allow the patient to live a virtually normal life, constrained only by the battery pack that keeps the motor spinning. For many patients unsuitable for transplant they represent the only hope of prolonged survival – and for doctors they represent a real and necessary alternative to giving somebody a new heart. When transplantation began in the 1960s, surgeons could count on a steady stream of organs from young and healthy donors killed in traffic accidents. But in the developed world, at least, roads, and the vehicles we drive on them, are incomparably safer than they were in the 1960s, and the number of donor hearts has fallen correspondingly. Some of those given a VAD as a bridge to transplant will never make it to the top of the waiting list, but if the device keeps them alive and active the result may be almost as good. One surgeon I spoke to told me firmly that transplantation will come to be seen as a needlessly crude and expensive aberration: why cut out a patient’s heart if you can simply insert a tiny pump?
While VADs have in the last twenty years attracted more attention and funding than the artificial heart, they are not a panacea. Many patients with bilateral heart failure, in which both ventricles stop working, will only benefit from a total prosthesis. On 10 September 2011 a 55-year-old Italian, Pietro Zorzetto, was given a transplant after spending 1,374 days – close to 4 years – with a total artificial heart. For much of this time he was in such good health that he was able to go cycling, and asked to be removed from the transplant waiting list.94 After a quarter of a century of slow improvement, the total artificial heart finally seems to be realising the dreams of its pioneers in the 1950s, becoming a viable means of sustaining the lives of those whose own hearts have long since given up the ghost.
When the pioneers of mechanical circulatory support began their work, they little imagined the decades of controversy, frustration and pain that were to come. But in 2007, the same year that Pietro Zorzetto finally realised their dream by posing for pictures astride his bike, the most bitter and protracted episode of the whole saga finally came to an end when Denton Cooley and Michael DeBakey shook hands for the first time in forty years.
DeBakey was ninety-nine, his former colleague a stripling of eighty-eight. Their reconciliation was engineered by Cooley, who had been reading a book by a former patient, Gene Cernan, the last man to walk on the Moon. Cernan’s portrayal of the antagonism between American astronauts and their Soviet counterparts, and how it was transformed into collaboration and finally friendship, moved him, and he decided it was time to seek a truce with his old rival.95 His initial overtures were rebuffed, but after he wrote a warm letter explaining his motives DeBakey accepted his offer. At a meeting of the Denton A. Cooley Cardiovascular Surgical Society on 27 October 2007, Michael DeBakey was made an honorary member and presented with an award. He was recovering from aortic surgery, and gave a short speech from his mobility scooter.96
Both men spoke warmly of each other’s surgical achievements, but there were no apologies.