The Night of 3 December 1967

Professor Barnard’s personal account of the world’s first successful heart transplant

12:45 AM
The donor was transferred to the operating theatre and placed in one of the operating rooms prepared for the transplant. Artificial ventilation and EKG monitoring were continued. Blood pressure at this stage was 95-100 mm Hg and she was prepared for a thoracotomy and total cardiopulmonary bypass.

A disposable oxygenator primed with Ringer’s lactate solution was kept in readiness in this theatre. My brother Marius and Dr Terry O’Donovan were put in charge of the removal of the donor heart.

12:50 AM
The recipient was brought to the anaesthetic induction room: blood pressure was 130 mm Hg and pulse rate 90/minute. Atropine (0.6 mg) was given intravenously, resulting in the pulse rate increase to 100/minute.

12:55 AM
Anaesthesia was induced, an oral endotracheal tube was passed into the trachea, and the patient moved to the operating room next to the donor. He was prepared for open heart surgery like any other patient.

I decided not to scrub at this stage so that I could coordinate the events in both rooms. Doctors Hewitson and Hitchcock were in charge of starting the operation on the recipient.

01:30 AM
The operation commenced with the right groin incision to expose the femoral artery and the saphenous vein. The vein was cannulated to monitor various pressures and used to inject any intravenous drugs.

01:40 AM
The thoracotomy commenced and the patient’s heart exposed through a median sternotomy incision and the heart prepared for cardiopulmonary bypass. Heparin was given and the femoral artery cannulated.

02:20 AM
I walked across to the donor and disconnected the respirator. The donor was heparinized.

02:32 AM
The donor heart went into cardiac arrest, and only at this stage did Dr O’Donovan and my brother start to open her chest. They were instructed to connect the donor’s heart to the oxygenator as soon as possible. This was done by placing a catheter in the ascending aorta for the arterial return and a single venous catheter in the right atrium through the appendage for venous return.

Bypass and cooling were started. A vent was placed in the left ventricle. General body cooling was continued until the mid-esophageal temperature had dropped to 26oC, as the kidneys were also to be protected for use in a transplantation procedure in another hospital.

When the mid-esophageal temperature had reached 26oC, the aortic cannula was adjusted so that it pointed toward the aortic valve. The flow was then cross clamped so that only the myocardium of the donor’s heart was perfused. The heart was cooled down to 16oC and, leaving the catheters in the aorta and left ventricle, it was removed and placed in a bowl containing Ringer’s lactate solution at 10oC.

02:32 AM
Cardiopulmonary bypass and cooling of the recipient were begun by connecting the patient to a bubble oxygenator primed with citrated blood diluted with plasmolyte-B solution. This was done by placing a catheter in the femoral artery and two catheters for venous return introduced via the atrial appendage into the venae cavae.

During the insertion of the cannula into the right common femoral artery, we noticed that this vessel was atherosclerotic. After seven minutes of bypass it was noted that the arterial line pressure had risen to 33 mm Hg. Accordingly, a cannula was inserted into the ascending aorta and the bypass was discontinued momentarily while the arterial line was disconnected and reconnected to the cannula in the ascending aorta. Bypass was recommenced after three minutes.

03:01 AM
The donor heart arrived in the patient’s operating room. Perfusion of the heart was recommended immediately (0.4 l/minute) by connecting the arterial cannula to a coronary perfusion line, and as soon as the aorta had filled to displace the air, it was clamped distal to the perfusion cannula so that the coronary arteries would be perfused. The heart was vented continuously during this procedure, and a period of four minutes had elapsed between cessation of the perfusion in the second operating theatre.

The patient’s heart was now excised and the donor heart connected in exactly the same way as we had done in the animal laboratory.

05:43 AM
The transplant was completed and re-warming started.

05:52 AM
With esophageal and rectal temperatures of 35.4oC and 28.1oC, respectively, the heart was defibrillated by a single shock.

06:06 AM – 06:13 AM
Three trials of unassisted circulation were made. After the third attempt, the patient maintained an adequate blood pressure. The transplanted heart was carefully inspected for bleeding from suture lines.

The heparin was neutralised with protamine. Drains were placed in the pericardial sac and mediastinum and the pericardium closed. I left the closure of the chest to Doctors Hewitson and Hitchcock.

While my brother Marius and I were sitting in the tearoom, we realised that we had not yet informed the head of the hospital about the operation, so I phoned Dr Burger, the Chief Medical Superintendent, and told him that we had done a transplant. He was not impressed that I woke him so early to give him the news as he thought that I was referring to the animal research. However, when I told him that this operation was done on a patient, he wished me the best of luck.

08:30 AM
Anaesthetic was discontinued, and the patient was returned to a specially prepared ward and placed on a ventilator. The concentrated postoperative care was directed towards maintaining a satisfactory cardiac output, suppressing the immunological reaction, and preventing infection.

I left the hospital at about 9 o’clock that morning, and it may surprise you to learn that there was not a single member of the media waiting for me – no photographers, no reporters, and no television cameras. This was probably because we did not announce our intentions of doing the operation or that the operation was being performed that night. In fact, not a single photograph was taken during surgery.

When I drove back to my home, I turned on the car radio, and a short report in the news bulletin stated that the first human-to-human heart transplant was performed by a team of doctors at Groote Schuur Hospital that night. Soon after I arrived home, I received a phone call from a friend stating that he heard the news bulletin and that if the media did not recognise my contribution during the next week, he would write a letter to inform them! As previously stated, we were quite surprised and not prepared for the massive media interest in this event.