Organ transplant: A strange heart in my chest
The idea of replacing body parts to ensure their survival is old. According to legend, the doctor Pien Ch’iao in China had already transplanted a heart in 300. It is a myth: With the technical possibilities of Chinese medicine at the time, such an operation was impossible.
It wasn't until 1967 that the first successful heart transplant was achieved and by the year 2000 more than 50,000 hearts had been transplanted. The following article shows the history of the transplant and provides information about the procedure and the chances and risks of such an intervention.
The history of the transplant
In Christianity, the fairy tale of the Hiligen St. Kosmas and St. Damian spread. This is said to have sewn the leg of a deceased black man to a white man. Very old is a magical charge of the Frankenstein motif, in which the transplanted organs should transfer the properties of the original owner to the new body.
Hinduism knows a completely fantastic “transplant”. Ganesha was the son of the god Schiva and his wife Parvati. The son guarded the mother's chambers so that no suitor could press her. Shiva wanted to go inside, but Ganesha blocked his entrance. The god was so angry that he tore off his son's head.
Only then did Schiva learn that Ganesha was his son. He regretted his deed, and in order to undo it, he ripped off the head of the next best being and planted it on his son's torso. Since then he has been wearing the head of an elephant.
Gaspare Tagliacozzi (1545-1599) reconstructed noses from their own tissue. He recognized the danger of rejection of foreign tissue and wrote that the "singular nature of the individual completely prevents us from doing this procedure on another person."
In the 17th century, surgeons successfully carried out bone transplantation. In 1668, the Dutch Job van Meekeren described a nobleman who had been given a dog skull transplant. Doctors also planned to replace human skin with animal skin.
John Hunter, a Scottish surgeon, performed transplants in the 18th century, for example with teeth and tendons. At that time there were also documented attempts to replace thyroid tissue.
In the 19th century, doctors successfully transplanted skin, first from individuals to animals of other species. From 1850, free skin transplantation became a recognized therapy.
Only in the 20th century did modern organ transplantation become a regular method: in 1900 Karl Landsteiner discovered blood groups A, B and 0. This made blood transfusions possible. Blood exchange, as banal as it seems to us today, is also about transplants.
Animal testing with kidneys
In 1902, Emerich Ullmann (1861-1937) transplanted the first kidney. He put a dog kidney on the neck of the same animal. In the same year, the first xenotransplantation took place - a dog's kidney was implanted in a goat, and the goat's organism accepted the foreign body.
Alexis Carrel and Charles Guthrie developed the sewn vascular connection. The era of transplantation began with them as an applied method of medicine: Between 1904 and 1920, the two doctors transplanted numerous organs and tissues from person to person. Carrel received the Nobel Prize for Medicine in 1912: the reason was an experiment in which he attached a dog's heart to the neck vessels of another animal to prove the functionality of the vascular sutures. This was also the first heart transplant.
Carrel and Guthrie realized that the metabolism slows down when the organs are artificially cooled and organs can be preserved better in this form. The two also conducted research on the biochemical reactions of the recipient body to transplants.
In 1906 Mathieu Jabouly (1860-1913) tried to transplant kidneys from pigs and goats. He failed. In the same year, however, the first successful corneal transplant was performed by the ophthalmologist Konrad Zirm.
The Ukrainian Voronoy transplanted the first kidney of a deceased person in 1933, but it did not work.
In 1944, Peter Medawar described how the organism rejects foreign tissue. This was the beginning of the knowledge about immunological tolerance.
The first successful kidney transplant
The first successful transplantation of a kidney was carried out in 1954 by Dr. Joseph Murray Boston by. The recipient lived on perfectly healthy. Donor was an identical twin, a tissue-identical person, and therefore there was no defense reaction.
The first kidney transplants for dizygotic twins then took place in 1959. Despite the genetic differences, the recipients survived 20 and 26 years, respectively.
It took until the 1970s to get the rejection under control. Medicines that suppress the immune system now allow organ transfers, in which the donor and recipient are not related.
Dr. Roy Calne was already testing thiopurine / azathioprine in 1960 to prevent a kidney transplant from being rejected. Only two years later, azathioprine became the first immune suppressant in therapy.
Liver, lungs and heart
In 1963, Dr. T. Starzl in Colorado's first liver, and Dr. J. Hardy's first lung in Mississippi; Dr. K. Reemtsma transplanted a chimpanzee's kidney into a human. A year later, Starzl exchanged a human liver for a chimpanzee liver and Hardy a human heart for a chimpanzee heart.
1967 saw Christiaan Barnard's first successful heart transplant in Cape Town based on research by Norman Shumway and Richard Lower.
The Dutchman J.J. van Rood demonstrated that the coincidence of the leukocyte antigen is decisive for whether the patient's body accepts the foreign organ and thus significantly influences the survival of the recipient.
On this basis, he developed Eurotransplant, an international organization to exchange suitable organs.
The first heart-lung exchange
In 1968 the first heart-lung transplant was carried out by Prof. D. Hooley in Texas. The first law on organ donation is passed in the same year in the USA: the relatives decide on a donation and willing persons carry an organ donation ID with them.
1969 brain death is defined. This includes absolute loss of consciousness, immobility and respiratory arrest, the complete absence of reflexes and the zero line in the EEG for at least 24 hours.
In 1976, Jean Francois Borel published an immunosuppressive drug obtained from ciclosporin in a soil fungus. The first clinical study was carried out in Munich in 1979. The first patient treated at Stanford in 1981 survived for seven years thanks to cyclosporine. A year later, cyclosporin A, called Sandimmun, came into circulation. Now the number of transplants is increasing rapidly.
In 1989 the 100,000th kidney was successfully replaced.
The Transplant Law
The Transplantation Act came into force in 1997. The criterion for death is the permanent loss of all brain functions. As in the United States, organ harvesting is permitted if the deceased expressly approves of it or if his legal relatives consider it his will.
In 2000, 470,000 kidneys, 74,000 livers, 54,000 hearts and 10,000 lungs were transplanted.
In 2015 there were 286 heart transplants in 22 clinics in Germany - a heart exchange is still not a common, but a regular operation.
It was a long way from the first patients who survived only a short time to a survival of years: the first person with a strange heart, Louis Washkansky, who Barnard operated on, died after 18 days.
Experience report of a person affected
Even today, the procedure is not routine. The affected person Hubert Knicker reports:
“In 2003 my heart let me down again. Ventricular fibrillation! Once again the doctors brought me back to life and when I left the cardiac center in Bad Oeynhausen after a transfer, I was enriched by a loyal companion. From now on, an implanted defibrillator brought my heart back to the right rhythm whenever it stopped.
But at some point my “Defi” would also no longer be enough. That day came in 2008. My heart pumping performance was now 15 percent and the last alternative that I had in a short amount of time was an artificial heart system.
I decided to do the operation again. The organ, which stands for man's will to fight like no other, may only have been a shadow of himself, but giving up was out of the question for me. How could I have done this to my wife, who had been through all the ups and downs with me?
I was fine with my cardiac assist system when a mechanical defect forced me to do my last battle in May 2010. Back at the heart center in Bad Oeynhausen it started, that almost unbearable waiting for a donor heart. Will you find a suitable organ for me? Would I be able to survive a transplant at all? Again and again I asked myself these questions and was secretly afraid of the answer to the first of them.
My lust for battle threatened to give way to the feeling of total helplessness, not least because I had to watch three of my attendants die. One donor heart came too late for two, another did not survive the transplant.
On July 24, 2010, the first question that tormented me was to be answered. Eurotransplant had a donor heart for me! Three months later, I was absolutely certain that the second question mark no longer played a role. After a successful transplant and small incidents around my lungs, I went home. ”
Why are hearts exchanged?
Patients are considered candidates for a heart transplant if they are prone to advanced heart failure and all other therapies are ineffective. Every second affected person suffers from cardiomyopathy, but also congenital heart defects or malfunctions of the heart valves sometimes make an exchange necessary.
When does a heart-lung transplant take place?
If the heart and lungs are both terminally ill, a complicated transplantation of both organs is recommended. This applies, for example, if a congenital heart defect leads to high blood pressure in the lungs or pulmonary fibrosis triggers heart failure.
Lungs are transplanted in Germany approximately as often as hearts. In 2015, the lungs were replaced in 296 patients, and 399 patients were registered for transplantation. Most of those affected suffer from chronic obstructive pulmonary disease.
There are different lung transplants depending on the basic disease. In the case of cystic fibrosis or bronchiectasis, the lungs must be transferred on both sides, in most other lung diseases a one-sided exchange is "sufficient".
At least until a few years ago, this was the case with pulmonary fibrosis or emphysema, but today, a bilateral transplant is also carried out for these causes. This improves the lung functions immensely.
However, the organ of a donor can then only help one patient and not two affected people as before.
Cardiopulmonary transplantations are now only necessary for non-correctable cardiac defects with an Eisenmenger reaction. If the heart fails with pulmonary hypertension, on the other hand, it will recover in a few weeks.
The exchange of a lung follows a fixed pattern today. First, the doctor cuts between the 8th and 9th rib. Then he removes the sick organ. He then connects the pulmonary arteries of the donor lung to the recipient's veins. In a bilateral transplant, the other lung is transplanted using the same method.
This often works even today without a heart-lung machine if the patient's second sick lungs get enough oxygen during the transplantation of the first healthy lung. If the second lung is transferred, it already breathes with the first healthy part.
If everything goes smoothly, the patients can move from the intensive care unit to the normal ward after just two days. In total, they stay in the hospital for about two weeks. Difficulties arise in every tenth to fifth patient and the stay in the clinic is extended accordingly.
Forms of organ transplantation
In allogeneic transplantation, the tissues, organs or cells are taken from another person; an identical twin is an isogenic transplantation. Since the tissue of the donor and recipient is identical, no immunosuppressive agents are required.
The autologous transplantation carries out an exchange within an organism. The most common are skin and hair transplants. After an accident, for example, skin can be transferred from the shoulder to a burned lower leg.
Xenogenic transplants refer to organ exchange from one species to another. It is more common than laypersons would assume. For example, transferring heart valves from pig carcasses to human hearts is an often practiced method of heart surgery.
What is transplanted?
Today, doctors transfer various cells, tissues and organs. Tissues are cell groups with the same functions: muscle tissue, nerve tissue or fat tissue. An organ is a delimited part of the organism that usually contains various cells and tissues such as the heart, kidney, lungs or liver.
Organ transplants include kidneys, livers, hearts, lungs, pancreas and the small intestine, tissue transplants skin, bones, cartilage, tendons, blood vessels and cornea.
Instead of using prostheses for amputations, surgeons are now sometimes transplanting limbs. For example, John Hopkins Hospital in Baltimore transplanted both arms to soldier Brendan Marrocco, who was lost to a road bomb in Afghanistan.
The rejection of the body is great in the arms of others, it is less when exchanging hands.
In Germany, doctors performed the first successful double transplantation of poor people in Munich in 2008. In 2011, the team of Spanish surgeon Pedro Cavadas managed the first double leg transplant.
Triple and quadruple transplants
In Turkey, triple and quadruple transplants appeared to be successful, but the two patients died when the doctors had to amputate some of the limbs again.
Atilla Kavdır had both arms and one leg transplanted. But the leg had to be removed shortly after the operation because Kavdir's body did not accept it. The case went around the world when the man was able to move his hands after a few weeks and the 34-year-old's son took his hand; Kavdir had lost his arms and leg due to an electric shock as a child. But shortly afterwards the patient died because he had contracted a urinary tract infection as a result of the transplants.
For Dr. Ömer Özkan, professor of the plastic, reconstructive and aesthetic surgery department in Akdeniz, it was a disaster.
A quadruple operation in Turkey also failed. Sevket Cavdar had to have his transplanted limbs removed.
An independent commission found massive deficiencies at both clinics, the Hacettepe University Hospital and the Akdeniz Hospital. The university hospital even lost its license to perform transplants.
The new arms generally don't work completely. They can only be used to perform simple actions such as tying shoes or eating with a spoon. The psychological effect is perhaps more important than the physical abilities: Young patients in particular see the transplanted arms much more as part of the body than good prostheses and are less afraid to go public with the foreign limbs.
Surgeons have been venturing facial transplants since 2005. The first person with someone else's face was a French woman who had disfigured dog bites.
Patrick Hardinson worked for the Mississippi Fire Department and suffered burns in 2001 that made him look like a monster. Besides, he couldn't close his eyes. More than 70 operations could not undo what happened.
The NYU Langone Medical Center helped with the most comprehensive face transplant ever. The operation lasted 26 hours. Hardison not only got a new face, but also a new scalp, new ears, ear canals and parts of the bones of the chin, cheeks and nose, new eyelids and muscles. Then he could close his eyes again.
It had taken more than a year to find a donor that matched his age, size, skin and hair color. The 26-year-old David Rodebaugh matched the profile and his mother gave permission for organ donation. The hospital paid the costs of the operation and the REHA.
American doctors transplanted a penis in 2016. A 64-year-old man suffered from penile cancer and is now wearing the limb of a dead man who had the same blood type. The operation lasted 15 hours and was the third in the world.
In 2015, doctors in the United States from the Anderson Cancer Center in Houston carried out the transplantation of a skull with scalp for the first time. The patient suffered from cancer that affected all of these organs. There was a leiomyosarcoma on the scalp, and a wound on the top of the skull caused by it did not heal.
The blood vessels were sutured together under the microscope.
Doctors successfully transplanted uterus in several European countries. The University Clinic Erlangen is planning such a transplant in Germany. For example, women who are unable to give birth to children should have their wish to have children fulfilled because they have no womb or their uterus is too small.
In Sweden in 2014, a woman with a transplanted uterus gave birth to a healthy child.
In Erlangen, the clinical director Prof. Dr. Matthias Beckmann: “We are currently preparing for the first uterine transplant. But first we have to get the necessary permits from the Bavarian Ministry of Health and train the intervention on the animal model. ”
A uterine transplant is not without risk, which is why the operation with vascular surgeons and plastic surgeons is trained to the smallest detail. The most important thing is to connect the donated uterus to the recipient's blood system with artificial blood vessels.
Beckmann sees a need for action, because in his eyes a uterine transplant is the only way to legally have a child if this was impossible for anatomical reasons. Egg donation and surrogacy are prohibited in Germany, and this legislation drives women into illegality.
A reproductive doctor in Franconia, for example, was sentenced to five years in prison for implanting the oocytes of women from women, which is prohibited in Germany by the Embryo Protection Act.
Uterine surgery would cost around 100,000 euros and would be the only way for up to 10,000 women in Germany to have their own child. In addition, up to 1,000 women a year lose their womb due to an illness.
The Italian physician SergioCanavero is considered Erich von Däniken of his guild: the surgeon wants to transplant a complete head. Edgar Bierner, who performed an arm transplant himself, said: “This is impossible. That is speculative, and there is no sign of the broadest horizon. ”
Canavero's idea: he wants to cool the bodies of the brain-dead donor and the recipient so far that the cells can survive as long as possible without oxygen. The spinal cord must then be separated cleanly.
Veit Braun, a neurosurgeon from Stuttgart, says: "If I separate a spinal cord from my head, it's gone, once and for all." In the best case, the result would be a patient with a functioning brain without control over his body.
Ethically cruel animal experiments preceded Canvero's fantasies. In the 1950s Vladimir Demikhov planted a second head for a dog, in 1970 Robert White transplanted a monkey head. The abused animals died after a few days.
Canavero was inspired by Ren Xiaoping, who transplanted a mouse head in 2013.
The head transplant is supposed to go like this: After the operation, Canavero would like to put the patient in a coma for a month, the next year the affected person should learn to speak and walk. The operation would take around 36 hours and cost ten million euros.
The surgeon has already found an interested party: The Russian Valeri Spiridonow is in a wheelchair and wants his head transplanted to a healthy body. He is aware that the risk of death from this operation is high.
He suffers from Werdnig-Hoffmann's disease, a muscle, tissue and organ loss that usually leads to death.
The paralyzed man is also thrilled. He says: "You feel like the hero of a science fiction novel, almost as if you were flying into the cosmos."
Canavero's colleagues consider his idea not just science fiction, but dangerous nonsense.
However, he considers his head transplant to be the greatest revolution in human history. He even dreams of more: “My goal is immortality. And I will get it because I work quickly! "
Transplanting a head is the solution to all diseases: "Do you have cancer? New body! Do you have diabetes? New body! Are you paralyzed New body! "
Reasons for transplants
Depending on the organ, tissue and cell, there are many reasons for transplantation.
1.) Heart: In general, heart failure that leads to heart failure in the long run is an occasion for heart transplants, including diseases of the heart muscle as well as the heart valve and congenital heart defects.
2.) Liver: Cirrhosis of the liver, Wilson's disease, acute liver failure, malformation of the biliary tract, several metabolic disorders.
3.) Lungs: chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, sarcoidosis, pulmonary hypertension
4.) Kidney: A kidney transplant is not always essential because dialysis can replace the function of the organ. With a donor organ, a patient can lead a normal life again without constantly connecting to the dialysis machine. In addition, some of those affected are no longer capable of dialysis.
5.) Pancreas: Doctors only transplant here if the person affected can no longer produce insulin, for example in type 1 diabetes. However, diabetes can also be treated with insulin injections, so that the doctors weigh up in individual cases.
6.) Bone marrow: Grafting bone marrow is often the last resort to cure leukemia and thalassemia.
7) cornea: Through the transplant, people can see clearly again if their cornea has been damaged.
8) skin: Skin grafts cover burns, burns and chronic wounds.
9) Hair: A hair transplant has no medical, but cosmetic reasons.
In Germany, only doctors are allowed to transplant organs in transplant centers. If the brain death of a person who committed to organ donation in life or if relatives give their consent, a coordinator from the German Organ Transplantation Foundation (DSO) comes.
He initiates the investigations, this primarily includes the typing of the tissue characteristics. This information is sent to Eurotransplant. The organization uses the computer to determine a suitable recipient. The DSO coordinator manages organ harvesting and transport.
The recipient immediately comes to the transplant center, where the operation is immediately prepared. The doctors are now taking the donor organ. It has to go very quickly now. Every minute lost increases the risk of functional damage.
A kidney transplant usually takes two to three hours, but a heart-lung transplant can take ten hours or more.
There is an acute rejection reaction immediately after the operation and a chronic one that continues for years.
Anyone who carries a foreign organ has to take immunosuppressive drugs for their whole life. These weaken the body's defenses. Unfortunately, this weakness cannot be focused on the new organ, and those affected are lifelong susceptible to infections, bacteria, viruses and fungi of all kinds.
Some organs can also be removed from living people, especially the kidneys. A healthy person can easily live with a kidney. Living people can donate part of the organ to the liver.
According to the Transplantation Act, a living donation is only permitted if no organ of a dead person is available. As with all operations, the healthy donor is at risk and the doctor must educate him. Psychological constraints or financial incentives must not play a role.
However, strictly speaking, blood donation also falls under transplants, since cells from other people also benefit a sick person. (Dr. Utz Anhalt)