Since Jan. 9, a middle-aged Orange County man with congestive heart failure has been tethered to a beeper.
The device means he has passed a battery of tests--blood tests, a heart catheterization, an intense psychiatric evaluation--to become the leading candidate for the first heart transplant to be performed in Orange County.
It could happen any day now.
When the beeper sounds, signaling that a replacement heart is ready, the patient must be prepared to rush to Hoag Hospital in Newport Beach to endure four to six hours of cardiac surgery, the prospect of severe infection if his body rejects the donor heart and a lifetime of taking toxic drugs.
That is the price of a transplant that, overnight, could give him new life.
"With heart transplants, you see instant results," said Douglas R. Zusman, one of his cardiac surgeons. "You see people who are basically dying and within a week they're on a stationary bicycle and can basically lead a normal life again."
But donor hearts are scarce.
Across the nation, transplant registries list 681 people, 15 in the Orange-Los Angeles-Ventura County region, as urgently needing new hearts. These are people who are beyond the help of drugs or coronary bypass operations. Their only hope is a transplant.
So for now the Hoag patient and his doctors are waiting.
His surgeons estimate that he can live another six months without the transplant. But it isn't much of a life.
The patient, who asked his doctors not to identify him for now, is confined to his home, unable to walk more than a few steps without gasping for breath. At night, he must hook himself up to an intravenous line, injecting adrenaline and other cardiac support medicines to keep his frail heart beating until morning.
"He knows he's deteriorating," said Aidan Raney, another of his surgeons.
For doctors and prospective recipients alike, the wait for a new heart can be agonizing, because 20% to 30% of all transplant candidates die before a suitable heart can be found.
But if and when a donor heart is found, its arrival sets in motion a precisely choreographed medical drama in which the actors--cardiac surgeons, highly skilled nurses, anesthesiologists, respiratory therapists, pathologists and more--begin a race against time to save a patient's life and then keep him alive.
This, then, is the anatomy of a heart transplant--the story of how a hospital and its leading players are preparing for that drama.
When Dr. Christiaan Barnard performed the world's first heart transplant in Cape Town, South Africa, in 1967, it was considered experimental surgery. And there was little doubt that that initial surgery was risky. Barnard's patient, a 54-year-old man with congestive heart failure, died of pneumonia 18 days later.
In the next two years, doctors around the world performed more than 100 heart transplants. But enthusiasm for the procedure waned quickly; most of the patients died several days or months after a transplant.
In 1979, Sandoz Pharmaceuticals in East Hanover, N.J., introduced a new immunosuppressive drug, cyclosporin A, that greatly improved survival rates from a heart transplant. The Food and Drug Administration initially approved the drug for "investigational use" at a handful of transplant centers around the country. In November, 1983, the FDA licensed cyclosporin as safe for widespread use in transplants.
Overnight, the impact was extraordinary.
At Stanford University Medical Center, cardiac surgeon Norman E. Shumway had been one of the few doctors in the world who had continued to implant new hearts and perfect heart transplant techniques. Only 20% of the people who received a transplant in 1968--the first year of Stanford's program--were alive one year after their surgery. But with the advent of cyclosporin, that one-year survival rate rose to 68% in 1984. Currently at Stanford, it is 81%.
The American Council on Transplantation reports that 83% of all heart transplant patients in the United States now live for at least a year after their surgery and that 62% are still alive five years after a transplant. There are also reports that some transplant survivors have lived as many as 18 years after their surgery.
As the survival rate has increased, so has the number of hospitals eager to perform transplants. In 1984, there were only 37 transplant centers. Now there are 117, all certified to perform the surgery by a national transplant organization, the United Network of Organ Sharing in Richmond, Va.
Hoag was accepted by the network Jan. 1, joining four other Southern California transplant centers--UCLA, Sharp Memorial Hospital in San Diego, Loma Linda University Medical Center and UC Irvine Medical Center, which has not yet done a heart transplant.
Enter Raney and Zusman.
When Hoag hired the two doctors away from the transplant program at Sharp last February, they were only trying to replace two cardiac surgeons, not start a heart transplant program.