The Controversy Behind the First Artificial Heart Transplant
When an operation is performed for the first time, or a medical therapy given its initial testing, the identity of the first human subject is only rarely revealed, or even of interest. But the comfortable anonymity that surrounded the life of the first total artificial heart recipient, Haskell Karp, was shattered forever by the spectacular publicity that surrounded his decidedly unnatural death. Chapter Nine from A Time for All Things: The Life of Michael E. DeBakey explores the decidedly unethical circumstances in which this procedure was initiated.
Haskell Karp
By early April 1969, Karp had been an inpatient on Denton Cooley’s service at St. Luke’s Episcopal Hospital for a full month. He was 47 years old, and had been married for 23 of those years to his wife, Shirley. The couple had three sons, ranging in age from 11 to 22. The Karps had come to Houston, like so many others, because he was suffering from severe heart disease. Haskell had endured four known heart attacks over the previous 10 years, and these had damaged so much of his myocardium that he dwelt in a sort of constant unstable congestive heart failure, liable to drift over the edge at the slightest provocation. As a consequence, Karp’s level of activity was extremely curtailed. This profound fatigability was a source of immense frustration for Karp, beyond the obvious threat to his life.
At this point in time there were always at least several individuals on the wards at St. Luke’s who, like Haskell Karp, were awaiting heart transplants. During the first great rush of excitement after Barnard’s operation in Cape Town, and then the successes in America and elsewhere, finding donors was not much of a problem. By this time, though, not only was the novelty of the whole thing wearing off — and with it the widespread, sensational media coverage — but the results of the operation were turning out not to be so good — of Cooley’s 18 recipients, only three were still alive by this time. Donors were drying up.
On the evening of Wednesday, April 2, Cooley came to Karp’s hospital room, where his patient was resting alone, with a new idea. Instead of waiting for a donor heart, which might well never come, there was another option. They could proceed with a ventricular wedge procedure, and, if this turned out badly, Cooley could place a temporary, implantable pump to bridge the gap in time until a donor heart became available for transplantation. The temporary pump was new, but it was ready. Cooley was prepared to operate any time Karp wanted — the sooner, the better.
This was news indeed. Karp asked Cooley to return the following day, when his wife would be present to hear the brash proposal. It was near 7 pm on Thursday when Cooley reappeared, with a consent form in hand. He wanted to operate the next day. After a full month at St. Luke’s Hospital, Shirley was stunned to hear that surgery was suddenly on the tentative schedule.
Convinced by Cooley of the necessity to proceed and to do so with urgency, the Karps signed the consent form. They were not sure what the hurry was all about and were far from clear as to what Cooley’s contingency plan was, beyond the fact that the form said it was a “mechanical device.”
The Device
Less than four months previously, in late December 1968, Cooley had contacted Domingo Liotta, an Argentinian research fellow working on the total artificial heart project.
As Baylor Surgery Department faculty members, Cooley and Liotta were acquainted, but, given their disparate ranks, they moved in very different circles. Liotta hoped to be a clinical cardiac surgeon someday but was relegated at this point to the laboratory and animal surgery. Cooley, on the other hand, was at the very top of the profession: one of the most famous and successful surgeons in the world.
Cooley wanted to know how the work on the artificial heart was coming. Liotta expressed his view that the research was making insufficient progress. Liotta despaired of the work ever coming to its natural culmination: human implantation. Cooley listened to this tale of woe, then — in what must have seemed to Liotta the angelic voice of divine intervention — asked a pointed question. Did Liotta want to work on his mechanical heart at St. Luke’s with Cooley? The goal would be implantation in a patient, as soon as possible.
A star-struck Liotta accepted Cooley’s offer. He told no one but his wife.
By the end of 1968, the combined artificial heart research project at the Baylor Department of Surgery and the Rice Biomedical Engineering Labs had been under way for more than four years. The first animal tests of the artificial heart began on calves. None of the animals survived.
While the pumps themselves were functioning at something less than an ideal level, the power and control mechanisms devised by the Rice engineers worked well. On January 17, even before the first calf experiment, Domingo Liotta contacted one of the Rice engineers, William O’Bannon, about constructing another such console. Liotta asked O’Bannon to keep the offer secret and, in particular, not disclose that Cooley was behind it.
…the results of the operation were turning out not to be so good — of Cooley’s 18 recipients, only three were still alive by this time. Donors were drying up.
By Wednesday, April 2, the artificial heart pumps were ostensibly ready, and O’Bannon had completed and delivered his 400-pound garage-built power console to St. Luke’s. The only thing missing, from Cooley’s standpoint, was the right patient candidate or, more accurately, the proper scenario. That evening he visited Haskell Karp’s hospital room to spell out the new plan.
The Operation
The next morning Cooley telephoned Herb Smith, the head of Medical Communications for the Baylor Department of Surgery. He requested that still and motion picture cameras and photographers be present at Karp’s surgery the following day.
April 4, 1969, was Good Friday. Denton Cooley had scheduled five open heart surgery cases for the day. Karp was the fifth.
Haskell Karp was rolled into the OR and quickly anesthetized. His chest was shaved, slathered with iodine prep, and draped with sterile cloths and sheets in the time-honored fashion. The operation commenced.
After opening the chest and initiating cardiopulmonary bypass, Cooley examined the aneurysmal left ventricle. The scar tissue encompassed more than two-thirds of the left ventricle myocardium and extended into the interventricular septum. As experienced with ventriculoplasty as anyone in the world, Cooley recognized at this point that the procedure was probably hopeless but he felt “obligated” to try. When the wedge resection was accomplished, and the healthy edges sutured back together, the all-important step of weaning from the bypass machine began. Within minutes it was obvious that it was impossible: there simply was not enough functioning heart muscle left to do the job. Cooley did not hesitate: he swiftly removed Karp’s heart.
He left enough native atrial tissue to attach the prosthetic pump, just as if he were doing a transplant. One of the artificial hearts — the medium-sized one — was brought onto the operative field, tailored to fit the remnants of Karp’s heart, and sutured into place with continuous, “running” stitches. This suturing took Cooley longer than for a heart transplant because the prosthetic material was stiffer and, besides, it was the first time he had ever implanted such a thing. The surgeons then activated the pump and, seeing it function apparently as designed, removed the bypass cannulae and closed the chest.
Within minutes Cooley was in front of reporters for an impromptu press conference. A dreamy-eyed Liotta flanked him. During the improvised presentation Cooley got word that Karp was awake and responsive, and he seemed to tear up.
April 4, 1969, was Good Friday. Denton Cooley had scheduled five open heart surgery cases for the day. Karp was the fifth.
Karp survived the night, although his condition was certainly tenuous: urinary output had been poor from the beginning of the postoperative period, and, ominously, it was getting worse. Keeping his blood oxygen levels up also became challenging just a few hours after the operation was complete: something dire was happening to his lungs. Anyone familiar with the calf experiments would have recognized this pattern. The need for a donor heart was becoming acute, and a certain controlled panic was beginning to creep into the medical team.
Consequently, Cooley convinced Shirley Karp to go before the television cameras and radio microphones and, standing alongside him, make an impassioned nationwide plea for a donor heart.
On Sunday night a heart which they could accept became available. It belonged to a 40-year-old woman from Lawrence, Massachusetts, named Barbara Ewan. Mrs. Ewan, who was a widow, had been in a coma at the local hospital for more than two weeks. On Saturday, April 5, she had experienced a brief period of cardiac arrest and tests indicated that she had suffered irreversible brain damage. After seeing Shirley Karp’s tearful televised appeal, Mrs. Ewan’s children had decided to donate her heart. On Monday morning, Denton Cooley proceeded with his 19th human heart transplant. By the time of its removal, the artificial heart had been pumping in Karp for 64 hours.
After the operation, Karp was on full mechanical ventilatory support, as well as circulatory support from constant intravenous infusion of the medication Isuprel. Karp had been “virtually anuric” since the time of the prosthetic implantation. The filtering function of the kidneys was rapidly deteriorating, with elevated — and worsening — blood urea nitrogen and creatinine concentrations. Karp was also dangerously acidemic. A chest x-ray showed pulmonary congestion, with fluid in the right chest compressing the lung.
Haskell Karp’s spectacular four days in the public eye came to a relatively quiet end. He died at 3:15 pm on April 8, 1969. A postmortem exam was performed, and this demonstrated a number of findings of importance. Most of the organs and tissues had evidence of circulatory congestion. The immediate cause of death was felt to be pneumonia caused by the bacterium Pseudomonas aeruginosa.
Cooley and Liotta
Aspects of the behavior of both Cooley and Liotta during this episode defy understanding.
Liotta could not have failed to see that his work with Cooley on the prosthetic heart pump was unethical and possibly illegal. Cooley’s feigned ignorance of proper protocols for human experimentation, and his later wholly unconvincing posture that the prosthetic pump implantation was a spur-of-the-moment decision are equally unbecoming. It has so far proved impossible to identify documentary evidence that Karp’s condition had drastically worsened just prior to the attempted ventriculoplasty, which was Cooley’s justification for proceeding with surgery. Then, when it was obvious that the artificial heart could only last a short time, why did Cooley wait until the morning after the artificial heart surgery to make a national appeal for a human heart donor?
The pump itself now resides in the Smithsonian’s Museum of American History, floating in a formalin-filled Lucite box on the shelf of a glass cabinet. Its official designation is “The Liotta-Cooley Artificial Heart.” The name is at once both accurate and entirely wrong, which seems eminently fitting.
Craig A. Miller, MD, is an author and vascular surgeon who lives in Columbus, Ohio. His books have been published in several languages and editions. He has been a Scholar-in-Residence at the Ohio State University Medical Heritage Center and a Michael E. DeBakey Fellow in the History of Medicine at the National Institutes of Health.
