THE HUNT FOR A BEATING HEART

DOUGLAS MARSHALL January 1 1969

THE HUNT FOR A BEATING HEART

DOUGLAS MARSHALL January 1 1969

THE HUNT FOR A BEATING HEART

DOUGLAS MARSHALL

THERE’S A GRIM, almost gruesome way of looking at the whole business of heart-transplant surgery. For instance, if you happen to become one of the 5,850 victims the Canada Safety Council predicts will die on our roads in 1969, you could be doing medicine a great service if you somehow contrive to be killed cleanly. Avoid wasteful collisions that crush the abdomen and reduce a perfectly good heart to pulp. Ideally, try to arrange an accident that produces instant unconsciousness and irreversible brain damage. Such an injury could mean that your system lingers on long enough for you to be rushed to the nearest hospital with an intensive-care unit and hooked up to an artificial respirator. Given those circumstances, together with a doctor versed in cardiology and next of kin who aren’t too squeamish, you too could be a heart donor. You will have gained a measure of fame, unfortunately posthumously, and a certain organic immortality in the sense that bits and pieces of your body will survive to function at the service of other people’s minds.

That, it must be confessed, is roughly how I viewed the “miracle” of heart transplants until quite recently. I’m an average healthy man with a sound heart and no immediate prospect of needing a spare. I was convinced that nothing would ever induce me to sanction the donation of a heart by any of my immediate family. Nor, should my own loyal ticker start to fail, would I ever allow it to be replaced by a palpitating lump of alien tissue snatched from a near-cadaver. While applauding the surgical skills that make the operation possible, I couldn’t repress a shudder of disgust at the coldly mechanical implications. Kidney transplants are all very well. They are faintly plebian organs and, besides, we have two of them. But the heart, the archetypal pump, the prime symbol of human emotions, was too fine and private a part to be treated so cavalierly. They’d be trying brain transplants next. Ugh.

My distaste deepened when I read a newspaper account of Canada’s fifth and the world’s 55th heart transplant,

performed at the Montreal Heart Institute last September 29. (At that time 26 of the recipients were still alive.) The donor in this case was Gary Mercereau, a five-foot-10, 160-pound grade-11 student from Edmundston, New Brunswick, who would have been 17 on November 9. The recipient was Rosaire Brien, a 58-year-old laborer from the Laurentian village of St. Esprit de Montcalm who had been suffering severe coronary artery disease for five years and whose time was fast running out. The operation, said the report, had been remarkably successful with Mercereau’s heart beginning to beat spontaneously in Brien’s body moments after it had been sutured into place.

Although details were scanty, three aspects of the case troubled me. First, Mercereau’s young athletic body had proved to be something of a treasure trove for transplant surgeons. Not only had it yielded an excellent heart, but two anonymous recipients had each been given a kidney and both eyes were later used for corneal grafts on separate patients — making a total of five people physically in Mercereau’s debt. Second, the case dramatically underlined one of the soul-searching problems raised by transplants, the question of when a patient can be considered officially dead. The operation had been delayed for several hours until neurological specialists were satisfied that, although a pulse was still being maintained by a respirator, there was no flicker of “life” in Mercereau’s brain.

The third and, to me, most macabre aspect of the case was simply that the donor had been brought all the way from Edmundston, 350 air miles from Montreal. Mercereau, skull fractured in a motorcycle accident, had lain unconscious for six days. On the seventh day an elaborate and much-publicized emergency airlift was mounted with the co-operation of Quebecair. This was a mercy flight with a difference. Speed was essential but in this case the urgency was not an attempt to save the dying boy’s life. It was an attempt merely to keep him alive long enough for his heart to be given to somebody else.

It was a dash-for-life drama; it will happen again and again

‘The donor must show brain death, but he can’t be too dead’

So when I set out to learn more about the Mercereauto-Brien heart transplant, I carried some highly emotional prejudices with me. I fully expected to have these prejudices confirmed. Instead, what I found changed my thinking entirely. There’s a second, more rational way of looking at transplant operations; the way they are viewed by Dr. Pierre Grondin, head surgeon on the Montreal heart team. It can best be expressed like this: between the time I write these words and you read them — about six weeks — half a dozen terminal heart patients in the Montreal institute alone will likely have died. Each would have stood at least a 50-percent chance of still being alive had there been enough donor hearts available.

One reason the life-saving hearts aren’t forthcoming is because, as yet, too few local doctors are thinking in terms of possible transplant donations when treating dying patients. All transplantations must be conducted under emergency conditions since the best chance for success comes when the donor heart is still beating. A heart that has been stopped more than an hour is useless. Thus the time it takes to move a donor from the scene of an accident or an emergency ward to a heart-surgery theatre is crucial.

“I’m sure we’re missing a lot of good hearts because some doctors aren’t thinking fast enough,” says Dr. Grondin. “They are busy playing golf or are wrapped up in their own special field. I’m trying to find some way of telling every doctor in Canada that we are ready and waiting for hearts. Even if the only available donor were in Vancouver, I’d seize the chance and fly him in by jet if necessary.”

However, assuming increasing co-operation on the part of doctors, there’s still the more formidable problem of winning the co-operation of the general public — the only source of supply. On an abstract level, heart transplants undoubtedly have stirred the popular imagination. But the concept of new hearts for old suddenly becomes unpalatably grisly in the particular. Too many laymen still cling, as I did, to a vague secular superstition about the sacred heart.

But for Dr. Grondin, there is nothing sacred about the heart at all. It’s simply an organ, like other organs; and a transplant, which surgically is no more complicated than a heart-valve operation, is simply another method of treatment. This doesn’t mean that Grondin’s outlook is purely clinical and dispassionate. Warmth and humanity are registered in every frown and grin of his faintly Fernandellike face. He appreciates the qualms many people have about transplants but his concern is with saving lives:

“There’s no getting around the fact that transplantations involve special circumstances. We’re operating in a twilight zone. The donor has to be dead enough to show brain death but he can’t be too dead.

“Once we’re morally and physically certain that there is nothing more that we can do for the donor, our attention shifts to the recipient. Here’s a guy who is fighting for his life. He can’t afford to wait. But finding a heart for him involves an enormous amount of public participation, a conscious awareness of what is going on. There’s no point, for instance, in donating your heart in your will. The heart won’t survive the opening of the will.

“Two steps should be taken immediately to make transplant operations less complicated. First, more people should be encouraged to donate their hearts while they are still alive and well. Second, this should be rendered legal with a parliamentary bill that says people have a right to

give their bodies to science. There’s no such bill in Canada at the moment, although other countries have them. As things stand, your body legally belongs to the next of kin.”*

Seen in this light, Rosaire Brien was a very lucky man. An extraordinary set of circumstances combined to smooth away the legal, medical and emotional difficulties that normally would have stood between him and a new heart. Whereas I, at first glance, had considered the case bizarre, more enlightened opinion regarded it as a textbook example of how heart-transplant operations should and no doubt soon will be conducted as a matter of routine.

The story began, as every transplant case must, with a tragedy. Gary Mercereau was the youngest of three sons (Paul, 21, is studying technology in Toronto; Roland, 19, is in his last year of school). He was also, if such an old-fashioned term still carries meaning, an outstanding boy. People I talked to who knew him went out of their way to praise his personality and potential. “He was into everything,” mused his father Alder, a quiet pipe-smoking train engineer with the CNR. “Cubs, Scouts, the school band, the Air Cadets, summer camp, boxing, skiing, you name it. He was full of life and always had a joke.” Something in Alder Mercereau’s tone conveyed the dimensions of his grief. He had not only lost a son but, something that is rarer in today’s families, a friend.

Last summer Gary bought himself a 160-cc Honda motorcycle. “We didn’t want him to have it,” said his mother, Thérèse, “but he’d done so well in school, had saved his own money and had badgered us for so long that we couldn’t say no.” About half an hour after midnight on Sunday, September 22, Gary set out on his bike for a pre-bedtime snack at a local café. A friend, 19-yearold Gaston Veilleux, sat behind him on the pillion. Both were wearing crash helmets. A couple of blocks from his home, Gary shot past on the inside of a car stopped at a through street and smashed into another car that was crossing the intersection. As the police later measured it, Mercereau and Veilleux were thrown 24 feet, four inches. Veilleux suffered a broken leg and severe facial lacerations. Mercereau had a fracture at the base of his skull and never recovered consciousness. Both victims were in hospital within 10 minutes.

It’s important at this point to realize that had the accident happened anywhere else in New Brunswick, Brien would very likely have never received his new heart. Edmundston is a predominantly French-speaking community of 14,000, tucked up in the northwest corner of the province on a loop of the Madawaska River. It’s so remote from other centres that it likes to call itself the Republic of Madawaska — a sort of make-believe Canadian Liechtenstein, built on lumber. But in spite of the city’s isolation, it has a modern, fully equipped hospital with a brand-new intensive-care unit. It also has the services of Dr. Guy Savoie, a lean and dedicated vascular specialist, the only one in the province. Savoie, 36, trained at Laval and in the United States and has always kept himself wellinformed about developments in his field.

Minutes after Mercereau was admitted to the HôtelDieu Hospital, Savoie was on the scene. First he performed an emergency tracheotomy to ease the boy’s breathing. Then the heart beat became irregular and finally stopped. Savoie began an external heart massage and issued a “Code 99“ signal, internationally understood shorthand to indicate a case of cardiac arrest. This summoned, among others, Dr. G. H. Lévesque, a specialist in internal medicine, to Savoie’s aid. The two doctors resuscitated the patient and then, since the vital signs looked good, moved him to the intensive-care unit. Savoie continues the story:

*There is a controversy in Ontario over an amendment passed in 1967 to the province’s Human Tissue Act. The amendment defines a “donor” as someone who in writing at any time or orally and in the presence of two witnesses during his most recent illness requested that his body or a part of it be used for therapeutic purposes. Clause 2 of the amendment says that if such a donor dies in hospital the administrative head of the hospital may authorize the use of the body or part.

2.30 a.m.: ‘Death beyond all doubt...’ The transplant began

“There was no sign of lateralization or a transfer of activity from one side of the brain to the other. This and other neurological tests told us that the whole brain was damaged. Open-skull surgery wouldn’t have done any good. The best we could hope for was that there was a temporary swelling that would pass away in time. Meanwhile, we had to keep his system going. We couldn’t have done that without the facilities of the intensive-care unit. Our most valuable piece of equipment in this case was an automatic temperature-control unit linked to a cooling mattress. Without it, Mercereau’s temperature would have soared to 107 degrees and he’d have died.

“Then at 6 a.m. Thursday, five days after the accident, the boy stopped breathing on his own. This told us that the brain damage was irreversible. We then placed him on the artificial respirator, something we always do for at least 24 hours in these cases in order to let nature take its course. By Friday I was wondering whether this might be an ideal heart donor and whether Grondin, who I had never met, would consider it feasible to come such a long way. I also had to take the feelings of the parents into account. By by this stage I realized that, in Mrs. Mercereau, I was dealing with an extremely intelligent person, a woman in a class by herself."

Thérèse Mercereau, for the last 12 years secretary of the Edmundston office of the Canadian National Institute for the Blind, is indeed an impressive woman. Throughout that harrowing week she had met the situation with courage and fortitude. Then on Friday, when it became clear that Gary was being kept alive only by the respirator, she requested that the machine be turned off and her son's eyes saved for the eye bank. Gary, along with the rest of his family, had signed a form donating his eyes three years before. On Saturday morning, shortly before the respirator was scheduled to be stopped. Dr. Savoie talked to Mrs. Mercereau and asked if she’d also allow Gary to donate his heart. She understood the implications of the request at once and gave her permission without hesitation.

“We knew Gary was done,” she explained to me. “It was a shame to lose him but, my goodness, if we can help somebody else I don’t see why anybody should hesitate.” As I was talking to her, I happened to glance up and noticed not three but four pairs of gold-painted baby shoes mounted above the living-room door. “Yes, you see we’ve had rather bad luck,” said Mrs. Mercereau softly. “Our fourth son, John, died of meningitis at seven months.”

Once Savoie had the family’s permission, events moved quickly. Dr. Grondin, reached by phone at 11 a.m. Saturday in Montreal, was immediately enthusiastic. He asked a few preliminary questions, hung up, and then called back 30 minutes later to say a DC-3 was on its way, courtesy of Quebecair. He also dictated the wording of the release form that the Mercereaus would be required to sign. The plane landed at Edmundston’s small, gravel-runway airport at about 4 p.m. Edmundston time, which is an hour later than Montreal time. On board was a team from the Montreal institute, headed by the chief anesthetist, Dr.

Bernard Paiement. They were greeted by a delegation of Edmundston dignitaries, including the mayor, who had been tipped off by Quebecair.

Escorted by police to the hospital, the Montreal doctors quickly satisfied themselves that Mercereau would make an excellent donor. “The boy’s lungs were clear and his heart was in good condition,” Dr. Paiement recalled. “That meant he’d had really good care. The only question was whether he would survive the trip back to Montreal. We switched him over to a hand-operated respirator — it looks like a plastic squeeze-bag — but his blood pressure started to drop on the way to the airport. We gave him two units of plasma and two units of blood before the plane took off. We didn't want to give him too much blood because it might complicate immunization procedures later.”

Mr. and Mrs. Mercereau, white-faced but under perfect control, watched as their son was lifted aboard the aircraft. Dr. Savoie accompanied his patient on the trip to Montreal. The DC-3, given priority landing clearance, touched down at Dorval shortly after 7 p.m. Blood and tissue samples were taken immediately and dispatched to the Institute of Microbiology for compatibility tests. Mercereau, police sirens screaming, was whisked at 80 miles an hour to the heart institute for his long-delayed rendezvous with death.

Dr. Grondin, meanwhile, was busy making preparations for a transplant. Two potential recipients were washed and shaved from neck to knees — a necessary preliminary for all open-heart operations. At this point they were both told only that a transplantation was a possibility. The decision about which of the two got a new heart — and a new lease on life — depended on the results of the compatibility tests. These came in about 9 p.m. and showed that, out of five categories, Brien had a Grade B match with Mercereau. Only close blood relations could have been more compatible. In the protracted poker game with fate that had started with Mercereau’s accident a week earlier, Brien had drawn the final card that won him the jackpot.

The only thing now holding up the transplant was the unsettling fact that Mercereau wasn’t dead. An encephalograph still registered slight electrical activity in the brain. Two neurological experts were called in from Notre Dame Hospital to perform a special dye test on the brain. It proved the damage was irreversible. “The neurologists were the Devil’s, or perhaps I should say the donor’s advocates,” Grondin explained. “They were there to protect us by establishing death beyond all doubt. When a final encephalogram failed to reveal any flicker of life, they gave us permission to go ahead. By that time it was about 2.30 a.m.”

A few minutes later, Mercereau and Brien were wheeled into the green-walled, double-roomed operating theatre. The first step was to expose Mercereau’s heart and hook it up to a heart-lung machine. The machine perfused the heart with cool, richly oxygenated blood and restored it to a healthy pink condition. Next Brien’s diseased heart was removed and his system attached to a second heart-lung machine. Then, at 3.27 a.m. Mercereau’s heart was snipped out and his aorta clamped off — the moment of absolute death. By 3.40 his kidneys, eyes and, for further immunology tests in the lab, his spleen had all been removed. The final grafting of the heart was completed at 5 am. and the entire operation was over by eight. For Dr. Grondin and his team, everything had gone without a hitch.

continued on page 56

HEART from page 54

After a postmortem, Mercereau’s remains were returned by rail to Edmundston. The funeral was held the following Tuesday. Three members of Brien’s family attended. The Mercereaus received more than 600 messages and telegrams of condolence, including a huge red wreath in the shape of a heart from Brien himself. More than three weeks after the operation, Brien was still in excellent health and rumbustious spirits. Dr. Grondin was having a difficult time persuading him that he couldn’t leap out of bed and run about. There was no sign Brien’s body was rejecting the new heart.

The problem of rejection continues to cast a creeping shadow over transplant operations. It’s as if nature, outraged by man’s versatility in thwarting death, were determined to make the triumph as difficult as possible. New immunizing drugs may eventually provide the answer but even the most sanguine of heart specialists will admit that no immediate solution is in sight. But in spite of that drawback, heart transplants are obviously here to stay. As I write, Toronto Western Hospital has just completed its second transplant — also involving kidney and eye donations — and the heart-surgery team at Toronto General Hospital is making preparations for its first operation. Society will learn to accept transplantations in the same way that our ancestors, not so many decades ago, learned to accept the repulsive concept of blood transfusions.

“We had been studying heart transplants for two years,” Grondin told me. “But we abandoned the project in 1965 because we thought a recipient would only live a week. It took Dr. Christiaan Barnard’s courage and convictions to prove that the operation is worthwhile.”

I asked Dr. Grondin whether he would ever consider giving a recipient a second heart transplant. His reply was almost angry: “I’d go ahead with a second graft without giving it a second thought. After all, we do a second heart-valve operation if the first fails. Once you begin treating a patient, you’ve got to finish it. You’ve got to live up to what you started Any surgeon who didn’t do a second graft would be chicken.”

As we parted, Grondin shook hands and then, eyeing me speculatively, asked if I was driving. I said I was. “Well, you look like you’ve got a robust heart. You’d better drive carefully or you’ll wind up here." A couple of months ago I would have considered that joke in excruciating taste. Today I merely drive carefully. □