UW Heart Transplant No. 162: -- Inside A Life-Giving Surgery

In the quiet, busy pace of the bright operating room, there is suddenly a pronounced lull. All six heads of the transplant team turn toward the green-clothed table; few words are spoken.

Margaret Allen reaches her slender hand into the icy slush of the stainless steel basin and gently turns the flaccid, beige-and-pink heart. Four times, five times she rotates the softball-sized organ, intently examining it through her owlish glasses.

"Okey-dokey," she finally declares. She gently places the heart on a gauze pad in her left hand and carries it six steps to the open chest of Bruce David McDonald, a 52-year-old Boeing worker.

At 8:40 a.m. on a sunny, spring day, it is the midpoint in heart transplant No. 162 at the University of Washington Medical Center.

It is the final check before Allen and her team will begin implanting the heart of another human - a young person killed in an accident - in a man who would die without it. Nearly 10 years after the UW's first heart transplant and 28 years since the first in South Africa, it is now a relatively routine operation.

"It was a little difficult; he has a deep chest," said Allen, the matter-of-fact, veteran transplant surgeon a few days later.

RESULT OF A TRAGIC ACCIDENT

As with almost all transplants, this one began as a result of a tragic accident.

After emergency treatment, tests show the accident victim's brain is no longer active and, therefore, death has occurred. Breathing would stop without a respirator. Family members agree to donate their loved one's undamaged heart and other organs for transplantation.

(To protect the privacy of the donor's family, and at the request of Allen, details of the accident, the donor's identity and the location of the heart retrieval will not be revealed in this story.)

Removal of the heart is relatively uncomplicated. Dr. Brad Hofer, a UW cardiovascular surgeon, travels to another hospital and performs the procedure with up to 12 nurses and resident physicians assisting with the heart and other organ removals. Hofer has done this before, sometimes traveling as far as Alaska to retrieve a heart to bring to the UW hospital.

Only one brief hitch develops in today's organ procurement. Midway through the procedure, unexpected fluid in the abdominal cavity causes the physicians some concern. But quick lab tests show it is free of any infectious organisms; the organs are safe for transplantation.

As doctors huddle over the still, brightly lit operating field, the donor's heart beats strongly and evenly, rising and falling in the chest cavity as the respirator-driven lungs expand and contract. Finally, as the major arteries from the organ are clamped shut and severed, it flutters to a stop.

Nurse Terri McLaughlin already has poured sterile saline solution and ice slush into two waiting steel basins. Hofer gently places the heart in one and nurse Steve Ma rinses the organ in both before quickly packing it in a plastic bag of ice slush and tying the bag shut.

He surrounds that bag with another, ties it shut, then packs it in a Tupperware container that goes inside a blue and white ice chest. The ice stills and preserves the heart and cushions it against jostling during transfer to the UW Medical Center.

In Seattle, McLaughlin and Ma, longtime members of the UW transplant team, climb into the back of an ambulance, steady the ice chest on a bench and take off in a speeding, swaying van, siren blaring. The heart can survive only four to six hours before it must be completely implanted in the recipient's body and perfused with blood.

Morning rush-hour traffic thickens as they approach the UW Medical Center, and the ambulance attendants are frustrated with the sluggish drivers.

"Yes, car to right," mumbles one as the ambulance tries to ease by one confused driver in the traffic jam at the Montlake Bridge.

ALREADY WELL UNDER WAY

As Ma and McLaughlin arrive at the UW at 7:52 a.m., Allen and her seven-person transplant team are already well into the surgery on McDonald.

His chest is held open by retractors and Allen and Dr. Kent Stephens, a general surgeon now training in heart surgery, are finishing preparations for removal of his disabled heart.

The heart is badly diseased and enlarged. The exterior wall is mottled with small white streaks where muscle tissue has died during heart attacks. Plaque or spasms in the arteries blocked vital, oxygen-carrying blood from reaching portions of the heart muscle, causing the tissue death.

"It's supposed to be pink all over," says Allen, lifting the heart out of the chest cavity. "That's what's wrong with him."

Allen finishes installing cannulas, or small tubes, in the aorta, the main artery from the heart and in the superior and inferior vena cavae, the principal veins returning blood from the rest of the body. The tubes will carry McDonald's blood to and from a nearby heart-lung machine, which supplies oxygen and other vital chemicals until the new transplanted heart takes over.

"On bypass," Allen announces at 8:29 a.m. The half-inch diameter tubes fill with deep-red blood, and nurse Pam Williams monitors an array of dials and gauges on the 5-foot-long machine.

Eight minutes later, Allen severs the diseased heart from the body and places it in a steel basin on a side table. For more than 10 minutes, the organ continues to pulse as Allen begins implanting the donor heart. A pathologist will soon take the old heart away to examine how coronary artery disease affected it.

On the heart-monitor screen hanging from the ceiling, the green and yellow lines have gone flat. Question marks appear at the end of each line.

At first, Allen places the donor heart on top of McDonald's chest, just beside the cavity, to begin the delicate suturing of tissue to tissue.

With an instrument in her right hand, she pushes a penny-sized, crescent needle through the beige tissue of the left atrium, one of the heart's four chambers. Then she pulls a blue strand through with forceps in her left hand. Running, looping stitches of the material will join the donor atrium to the small remaining piece of McDonald's atrium.

The idea, Allen explains, is to abut the two pieces so the interior walls will form as smooth a surface as possible. To prevent a hiding place for bacteria, no sutures can be crossed and the polypropylene material is monofilament, not woven.

For a surgeon, says Allen, the finely crafted joining - an "anastamosis" - is beautiful.

"It's like a work of art," she says, "if you don't mind a little blood."

Allen, with some assistance from Stephens, moves smoothly through the five anastamoses she must do this day: the left atrium, inferior vena cava, superior vena cava, pulmonary artery and aorta.

Her small hands move quickly and confidently, suturing and gently maneuvering the healthy pink heart this way and that.

The first three joined vessels are the most difficult because they are deep in the chest cavity. She often leans far over McDonald's chest and peers intently down through powerful magnifying glasses, or loupes, attached to her regular glasses.

"Well, I think I'll come up from this side here," she says as she pulls the heart back toward her.

The donor heart is a little smaller than the one McDonald had, so small strips of tissue must occasionally be trimmed from the circumferences of the vessels so they will fit neatly together.

"In general, the transplanted heart sits farther this way in the chest, so you have to cut down here and bevel it so it doesn't kink," she tells Stephens about the pulmonary artery.

As she works, she talks quietly with Stephens about technique and research that may someday improve patient survival. And she makes occasional requests of other team members: nurse Heidi Fast handling instruments across from her, heart-lung machine operator Williams and nurse Tami Grover.

"OK, plegia back on, please," she occasionally says to Williams. She is asking for a dose of cardioplegia, a cold saline and potassium solution pumped directly into the donor aorta, keeping the organ still and nourished.

On the other side of a short curtain from Allen, at the top of McDonald's head, is the anesthesiology team: Dr. Gail Van Norman and a resident-in-training, Dr. Craig Derby.

In a tiny, cramped space, they are surrounded by an array of tubes, screens showing the heart rate, function and blood pressure, and a small computer that records every evolution in the complex surgery.

Van Norman and Derby are key players on the team. They are the gatekeepers for a variety of drugs to keep McDonald stable and alive:

Blood thinners keep the blood from clotting. Narcotics keep the patient unconscious and stave off the pain. Another drug keeps muscles from contracting and using precious blood oxygen. Others stabilize blood pressure.

And when the time comes, still other drugs will return the blood to its normal thickness and stimulate the heartbeat.

WATCHING FOR DANGER

Plenty of things can go wrong during the transplant. Allen and the other team members are constantly watching for danger signs, ready to move quickly.

An air bubble could develop in the blood and travel to the brain, causing death.

At one point during the surgery, Allen asks for the head of the operating table to be lowered slightly, causing any air in the blood to move up and out of a venting device in the aorta.

Then she plunges a long needle into the left ventricle, sucking air out of the heart chamber.

Bleeding can occur at any time, even though tissue is electrically cauterized to cause clotting.

Suddenly, near the end of McDonald's surgery, a small pool of water-thin blood appears on the floor beneath his head. The source of the leak is not immediately apparent.

"I hate it when that comes up on our side," says Van Norman before the drip is soon stopped. It was from a leaky connection in an intravenous saline line that mixed with a little blood.

Dangerous, irregular heartbeats also can occur in the newly transplanted heart. And the recipient's heart disease can cause high pressure to develop in his lungs, making it difficult for the new heart to pump blood to the organ.

McDonald has few problems, however, and less than two hours after his diseased heart is removed, he is ready to try out his new heart.

STARTING THE HEART

At 10:10 a.m., with all five of the vessels sutured neatly to the vessels of the new heart, Williams begins to warm the blood circulating through the heart-lung machine. McDonald's body begins to warm up.

Eleven minutes later, Allen removes the cross clamps on the major vessels to and from the heart, and the warm blood floods into the transplanted heart.

Allen glances across the room at the big screen of the main heart monitor. In each hand she holds the wandlike paddles of an internal defibrillator, used to electrically shock an erratically beating heart into a steady, productive rhythm.

"Defibrillate," she says.

"Charging . . . ready," replies Van Norman.

But Allen holds the paddles in the air slightly above the heart, watching carefully. The heart moves slightly, but there is no irregular beat as with some new transplants. She puts the paddles down and touches, then massages the heart with her right hand.

A blip appears on the monitor screen and Van Norman declares, "He's trying!" Replies Allen, as she gently squeezes the heart: "I'm doing that."

Quickly, however, the heart begins a slow, steady rhythm on its own. It is an excellent sign that the organ is in good shape. Allen requests four electrical leads called pacing wires to be put on the heart muscle to speed it up.

Soon the rhythm is fast and even - the heart walls moving in and out like the belly of a panting dog.

"Everything looks great," Van Norman says as she scans the monitor screens.

Because the donor heart doesn't have direct input from the central nervous system - nerves don't cross the sewn-together portion of the vessels - a rapid rhythm is initially necessary to get it going fast enough. The heart usually needs electrical stimulation for several hours and a boost from medications for about four days. A few patients need the electrical pacing for days or, rarely, a permanent pacemaker.

The usual transplanted heart receives its signals only from hormones in the blood and from its own internal pacing mechanism.

Thus, the transplant patient's heart is stimulated by adrenaline during exercise and beats rapidly for much longer after such exercise than the heart of someone without a transplant.

McDonald's new heart is working without electrical pacing by the time his chest is closed, and he is sent to the recovery room at 12:30 p.m. He is already receiving drugs to ward off rejection by his body of the new heart.

NOT YET HOME FREE

That night, there is a problem: His new heart is not pumping out blood in sufficient volume. Worried that a serious rejection episode is beginning, cardiologists Dr. Wayne Levy and Dr. Dan Fishbein hook him to a plasmapheresis machine to filter out antibodies that might be reacting against the heart.

They later discover that the cardiac output monitor is not working properly and McDonald's heart is functioning pretty well. He is removed from the machine in less than 24 hours. But as with all transplant patients, doctors periodically use a long wire through a vein to snip tiny pieces of heart muscle tissue to check for rejection.

Within two days, he is taking his first steps to a chair in his hospital room. He has his first bites of solid food. And three days after his surgery, when he's well on his way to recovery, McDonald and his wife Kathy, 39, enjoy a special treat - a sunrise and a view of Mount Rainier.

"It's sort of a wonder to see anyway," he says a week later, "but this was a pretty special morning."

McDonald waited nine months for a suitable donor heart. On Dec. 28, surgery had already started on his chest before doctors discovered a problem with the donor heart.

Three other times he was notified that potential donors might have the correct blood type and size heart for him, but then the operation fell through.

Eight days after his transplant, McDonald goes home to his Kent rambler to be with his wife and two children.

His chest and back are still sore, and he is pretty tired by late afternoon. But his cheeks are rosy and he walks easily about the house and his sunny yard.

"I can just really feel that blood racing now," he says with a smile. He does not complain. His happy, relieved wife calls him "the most upbeat person I've ever known."

McDonald looks forward to returning to his job as a Boeing airplane parts expediter after several more weeks of leave. He says he doesn't worry about his heart. Nor has he ever.

"The good Lord has got me going down this path," he says. "Why, I don't know, but he must want me to continue on. . . .

"I've got to take this heart and do something with it. It's a tremendous gift."

--------------------------------- HEART-TRANSPLANT METHODS COMPARED --------------------------------- Heart transplants involve the delicate suturing of major blood vessels and chambers of the heart. In a recent transplant for a 52-year-old Seattle man, the University of Washington transplant team tried a new technique used by French physicians to improve blood flow through the transplanted heart. Here is the difference between the French technique and the usual method:

USUAL METHOD

Surgeons join the left atrium and right atrium of the donor's heart to the same small remaining portions of the recipient's heart. They also connect the donor heart's pulmonary artery and aorta to the recipients' same blood vessels.

FRENCH METHOD Instead of joining the right atria of the donor and recipient hearts, surgeons use all of the donor's right atrium and join the donor and recipient superior and inferior vena cavae -- the major vessels returning blood to the heart. This is intended to improve blood flow through the transplanted heart.