Leaders in ten days time European Commission president has been meeting the u. K. Prime minister in brussels with a reason why admitting differences remain on a number of issues crucially the status of northern ireland. With all of our top stories much more news coming up and twenty five minutes time well have a full bulletin for you thats after inside story which starts now. Its been fifty years. Made history how far have we come. And. Help shape the future this is inside story. Thank. You and. With hello there and welcome to the program im Laura Carlisle this week marks a significant milestone an experimental surgery one that would be cheered and debated and for ever talked about fifty years ago South African surgeon Christian Barnard successfully performed the first human to human heart transplant since then thousands of lives have been saved by this groundbreaking technology mostly in developed nations well get to our guests in just a moment but first tony page looks back at this historic surgery. Floor to scale hospital is home to a Museum Dedicated to the worlds first heart transplant it happened in this room under the steady hand of dr christiane who died in two thousand and one the surgery has barely changed in fifty years what has of course dramatically changed is the postoperative immunosuppression postoperative care and that led to for norman survival rate you have today seventy eighty percent of transplant Patients Living after ten years in one thousand nine hundred sixty seven the first transplant triggered a debate on whether it was ethical all not letters written at the time show a mixed response to the surgery one doctor in the former yugoslavia describes it as the most important event in the history of the human spirit a man in turkey wants to send everyone on the Surgical Team a new pair of shoes congratulations but some were negative as well one man in a stray or his father complaint with the police he thinks the operation was illegal and this woman and italy said never men shall be able to replace a human heart as man cant replace god as well half a century later a lack of education and awareness continues to prevent people from bridges storing as organ donors but without them none of these men would be alive today three of them have new hearts the fourth a transplanted kidney we dont have a very strong tradition of people becoming organ donors so why not consider living on through somebody else and giving somebody else a Second Chance and to aid in a little it is one legacy of dr bonnets pioneering surgery is inspiration the Cardiology Team at the hospital where he worked is continuing to break new ground just launching a new plastic heart valve that could revolutionize the treatment of remeasured Heart Disease the significance of what we do now is a practical significance because we talk about thirty three million patients. Who would otherwise start these training nurses have come to be inspired by dr barnard work by looking at the first six hearts he transplanted some see the vital organ as the center of our emotions others as a pump but its only understood as well as it is because of dr barnard interesting tiny a page out zero cape town. With. Well heart transplants have become increasingly common sense that first one back in one thousand nine hundred sixty seven just one year later more than one hundred transplants were performed and now there are nearly four thousand around the world every yet most of them in the u. S. Even still more people are waiting for hearts than ever before in the u. K. The number has more than doubled from ninety five in two thousand and eight to two hundred and forty nine this year and the supply of Organ Donations has been nowhere near able to meet this growing demands. Lets bring in our guest now and in oxford we have dr steven west of a professor at roll brompton hospital in peril college in london the tale of a girl thats assistant professor at Wake Forest Baptist Medical Center and joining us via skype from cape town james dion author of the book heart break a christian and the first heart transplant welcome to the program all of you james lets first start by taking a look back at that extraordinary procedure just how groundbreaking was it it was grab it i mean a chair is the world. For for millennia surgeons that been very fearful just to work on the human heart the heart was considered the home of the soul that was considered this mystical organ that was untouchable surgeons that been working for millennia for centuries on every part of the body but the hearts and the heart was further complicated by the fact that you couldnt work on a while while it was beechy so it required a whole bunch of a groundbreaking technology the open heart lung machine first to be developed to actually get people to be able to work on the organ so. Christian by not actually managing to show that you can transplant a human heart into into somebodys body who is dying literally dying and revive those patients provided hope to people who had no hope before why did happen in south africa and not another country for example i believe the u. S. Was coming quite a close second. I think the know it has to be the name christian but not to a large extent the americans were throwing billions at this program it was unpopular with the moon with the moon race to then a man on the moon so that we it was a government owned a State HospitalPublic Hospital but it had one difference it had a guy who so believed in his way to and he was so confident in his ability and that that it would work that he was willing to take the chance where many of the americans perhaps werent they yet we have to remember that it took cutting out the heart of a desperately ill person but somebody whos still alive so you if it had not worked imagine the rip a question is on your professional career you bought hundred or no like youd have been charged with murder might have lost his career might have gone to jail if wash gonski louis which gonski receive all the. Organ donor heart hadnt woken up again and that kind of reach to be able to say its going to work im going to do it i think that was the major difference. Dr livia operation has barely changed in the fifty years since it was first performed and that struck me and tanya as report how difficult is this procedure. Well there are there is a transition time and really a two part procedure in terms of the procurement of the organ which has its own technicalities to be able to preserve the hearts in its most optimal form the transportation of the heart again trying to focus on the preservation of the tissue and then the actual implantation so rather than just a single procedure really to surgical operations and really this transport process has also become an area of great focus in terms of the importance for preservation of the organ limiting the amount of time in the transport as well as optimizing the conditions so really i think its very complex just to speak of all three aspects. I dont feel even as james was saying the key to this first transplant success or acceptability was that the patient survived but if we look at a year only lasted eighteen days due to complications he got pneumonia didnt he whats the Life Expectancy now for someone who receives a transplant what advances have we seen in these fifty years. Well. There have been great advances i mean to transplant a heart the technicalities of that and not difficult at all its a very straightforward operation the big issue was to keep that hot safe within the chest afterwards because the recipient was always going to try and reject the organ the immune response to the organ was the big problem there had been years and years of work with dog heart transplants and booboo heart. Transplants in the United States before barnard first operation. Whats more there was a heart transplant in the United States intended to be a human heart transplant way back in one nine hundred sixty four three years before the capetown operation on that occasion the big issue was the definition of brain death james hardie in mississippi had a recipient lined up a young man with a bad brain injury but they just could not time the transfer of the heart from the donor into the patient so that patient ended up getting a champ chimpanzees heart which rejected very very rapidly and the patient died on the operating table what has happened in the past fifty years is that the immunosuppression has become much better but how long to patients live. Sixty percent of the patients actually do not survive for ten years. For those that do and you can spot the characteristics of the ones that are likely to do well they may live for twenty and in one case even thirty years but for those that dont get a particularly good donor heart and dont get to ten years the average survival is actually much more than for not much more than four years. Ok dont they have a do do you expect those odds to improve more than sixty percent surviving ten years oh certainly i think that there are a lot of exciting technologies for us to be able to understand different mo dalat ease of rejection and to understand how to deal with them even from a gene transcription perspective and there are thoughts too to modular peoples and new responses on a much closer an individualized basis that will be able to understand their particular mechanisms for rejection and be able to respond appropriately theres also been conjectures about modulation of gut microbial and perhaps playing a role in our ability to modulation the immune system so there are certainly exciting technologies and thoughts on the horizon for perfecting this process ok james does some south africa remain a pioneer in this field i think that. We have we have a number of challenges in our healthcare system. So a lot of the for example was diverted towards hiv aids very successfully to combat that program over a number of years given the scourge that it aids was wreaking in so that. And that we its been a very its a six six a successful story was that african government aids but it came addict at some cost and i think one of the costs was the impact it had on Something Like transplant surgery and to kill a cardiac surgery sadly but but they still some groundbreaking work in the area of cardiac surgery and one area a pretty skewed hospital and you see two university of cape town it currently developing and i think. I believe that in the final phases is a hard pill which can be which can be put into a human hearts that was out opening up the chest so many many invasive and that makes surgery a lot cheaper and a lot quicker and we do believe i think really the sentiment that. Metric fever is causing a lot of trouble in developing countries especially south africas well and and valves like that will be very important Going Forward to provide hope to thousands of desperately but desperately ill people so even what are your thoughts on involved like that especially if they do come with a much reduced price tag on the form much more widely available. Well weve been putting in heart valves on the end of catheters for almost ten years now and indeed my very good colleagues in south africa have been doing that a long time i was a great had mire of many of the surgeons in south africa and i knew crisp on our very well but at the end of the day you have to ask yourself what what was the legacy of that first heart transplant in the u. K. There are around fifteen thousand patients under the age of sixty five who died from severe Heart Failure each year for those patients there are less than one hundred fifty dont arts so a cardiac transplant operation applies to less than one percent of the people that need it even if were very ages sed Heart Failure is a disease of older people and quite frankly we have to do better we will never generate more dont arts in my view weve tried giving animal hearts a go but not got very far but we do now have an alternative and that is the miniature rotary blood pumps that are used quite extensively in the United States and are now all coming up with outcomes that rival heart transplantation the first implant of one of these miniature artificial hearts that i did it was the First Permanent one in the world was in two thousand and the patient lived for almost eight years and he had been deemed totally unsuitable for a heart transplant because of his kidney failure. I said we want to look at the issues of donors so surrounding donors and just a moment first well just run with the instruction that you gave us of the mechanical hospital tonnage of the transplants. Do you believe that mechanical hearts can rival transplants there are certainly limitations to both heart transplantation and to mechanical circulatory support at this point the survival outcomes are more favorable for transplantation but to the point the resource is so limited and the need is so great that both technologies i should say both operations are needed to to meet the needs of the growing Heart Failure population so i think that the technology is greatly improving with mechanical circulatory support at this moment the survival outcomes are superior but i think that in conjunction with both technologies and in fact the transition from the use of mechanical circulatory support even for short term reasons to be able to get a heart transplant its hard to speak of these technologies without each other theyre very much needed to meet the need so in answer to your question at the moment no i believe that heart transplant is superior if possible but because of limited resources we must focus to do all that we can to optimize mechanical circulatory support ok why do we have limited resources why is stephen a we never going to generate enough bona hots. Well if we think about the supply of hearts we have to be very particular about the Selection Process it would do very little good for patients receiving hearts to receive organs that were not optimally functioning and so to be able to find hearts that come from recipients with with hearts that are acceptable for donating can be a very challenging process and as has been alluded to there have been previous attempts at even looking at other animal species at this point there are also investigations into the use of deceased donors and high risk donors such as those with hepatitis c. As alternative donor sources but its really the idea of finding those hearts and those donors that will provide an optimal organ for the recipients james whats the do you know supply like in south africa. Terrible. For various reasons i think its the same across as across the world but responded also always said you know that thats going to be a major problem and that in his career he said that but lead in his career confirmed that was the case but you blame bureaucracy to a large extent as well later. And possibly one way of looking at it would have to it would take some bold steps from politicians for example i believe this some countries in europe i think spain and austria comes to mind where once you die your body goes to the states perhaps thats one way that one should look at oak and only nation in future we the state says that once you die your body or your organs become the property of the state to take away that theres almost the problem with families who might be very lax to say well you can have my partner on march so childrens organs i mean its a very difficult thing for you to do but if its mandated perhaps by state by law it might give you a much easier way to late in life you can say you know what it was the right decision even though the u. K. Is taking one of those bold steps doesnt it i mean theyre moving towards assuming that everyone is an organ donor unless they expressly object otherwise hows that going down in the well its not started in wales and the response has been minimal. It has been tried in other countries in france and brazil spain have the largest Organ Donation rates and they certainly do not go for this presumed consent approach its its more about talking to the relatives of potential donors much earlier and giving them an understanding of the benefits of transplantation but whatever you do you are simply not going to improve. The pool of donors its been talked about for thirty forty and now almost fifty years and it simply is not making a significant difference now what we have to do is is find other methods of making that difference and one way of going about this is is with the use of stem cells in conjunction with the road through blood pumps and weve gone that way certainly not in potions in the National Health service here but ive been doing that with colleagues in greece. And we have now a stem cell that will remove scar from adult heart muscle after the patient is out a heart attack so if you have now have patients that dying from end stage coronary Artery Disease and what we call this scheme it cardiomyopathy they would probably be just as well having a pump to save their lives and stem cells injected at the same time to regenerate their own heart muscle. And i think thats going to be the way to go for the future i mean its very important to carry on with heart transplantation particularly for children with severely deformed Hearts Content a little Heart Disease but for the vast majority of patients with coronary Artery Disease that have heart attacks we need to find a different solution and were well on the way to doing that ok ill of you on board with this finding of a different solution absolutely absolutely i just would emphasize that i think transplantation will continue to play a role but to the point that alternative sources of mechanical circulatory support are absolutely needed to meet their needs. James there was a lot of ethical controversy wasnt there when the first transplant happened all those years ago people believed that they were taking someone saw all out and replacing it with Something Else and we now look what were talking about were talking about putting in cells were talking about putting in a foreign material entirely a mechanical heart do you think theres still a large ethical debate to be had around this procedure. I think if thinks is great but if youre somebody dying. In stage Heart Disease. You know youve got to do it youre going to different. Things i think theres always going to be ethical debates you know the progress is prolife versus abortion debate i mean its never going to go away. And so if x. Is certainly important but at the end of the day youre going to look at trying and trying to treat patients that are dying and the World Health Organization two years ago i think said that seventeen Million People around the world died of Heart Disease i think it was the biggest killer globally kartik disease so weve got to do something and weve got to do something about what people in developing countries in Subsaharan Africa people are dying in the hundreds of thousands and increasing annually because of lifestyle change overnight zation diet you know the bad lifestyle habits so its increasing in these areas where we need to spread to some interventions that are not costly and where we need to look at making a real change which is what barnett was i think trying to do back in one thousand nine hundred seven trying to say you know yeah weve got to do something for somebody who has no other no other option and ethics while they are important and i think they were important to him to some extent i think for him it was finally about finding a clinical treatment to help the dying patients and i think that should be the focus as an Extraordinary Technology back then and it remains say today thank you very much to all our guests for joining us here today on inside story stephen west to be the trial of a gal that and james. 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