When Juan Francisco Delgado woke up after the operation, he asked the surgeons what state the heart they had just removed from him had been in. “It would have lasted six months,” they told him. That was 32 years ago. He is the second longest-living heart transplant patient in Spain - the first, who received a transplant one year earlier, is not very well at present.
Delgado was one of the pioneers on a list which now includes 8,000 people in Spain, 427 of them children. It is 50 years since South Afrcian doctor Christiaan Barnard carried out the first heart transplant ever, giving Louis Washkansky, a 56-year-old grocery store owner, the heart of Denise Darvall, a 25-year-old office worker who was killed when she was hit by a car. He survived for 18 days, and the world went crazy.
Delgado was only seven years old when that story hit the news headlines, and obviously had no idea that he would be affected one day. When he was 14 he was diagnosed with a cardiomyopathy, and he spent a decade in and out of Emergency Departments until the doctors suggested a transplant.
“They hadn't got much further with the rejection problem in those days, but there was no alternative. I was horrified. I thought they might have been wrong, but they said I might not have another chance, so I decided I would just have to do it. One day they phoned and said they had a heart, but there was another compatible patient whose condition was worse than mine, so he got it and I waited another two months. During the first year I hardly left the hospital because of the rejections, but here I am today, alive and well.”
He works as caretaker, eats a healthy diet and takes his medication. He discovered the identity of his donor by accident, although by law they are anonymous; the only information recipients are given is the weight and height, cause of death and, sometimes, the age and sex. But curiosity and obituary notices can often help.
Shortly after Barnard's success, in 1968, Dr Cristóbal Martínez Bordiú, Franco's son-in-law, tried to carry out a heart transplant in Spain; for many, this was seen an attempt by the regime to make a name for itself. However the patient, a plumber from Galicia, died within a few hours, so fame evaded them. Spain had to wait another 15 years for it, because this long story has two phases: before and after the milestone in 1983 when approval was given to a drug which is an effective immunosuppressant, to stop rejection.
It was on the night of 8 May 1984, at the Santa Creu i Sant Pau hospital in Barcelona, that Dr José María Caralps carried out the first successful heart transplant in Spain: the recipient, Juan Alarcón, who was 29, survived for nine months.
“The operation had been scheduled earlier but there was a delay,” recalls Caralps. We played cards, we played ludo, we even slept a little, and then at four or five o'clock in the morning they told us the organ had arrived, by which time we had used up all our adrenaline. Anyway, everything went as planned and when we saw that the new heart was functioning we were really happy. I had mentally carried out that operation millions of times.”
He didn't, however, receive the recognition he expected. “Not one surgical team rang to congratulate us. People didn't like the fact that we were daring to do something that nobody else had dared to do,” he says. He has now relocated 200 hearts.
Barnard also faced criticism. Caralps was in the Maimonides hospital in New York doing three transplants on dogs every day when the news of his successful transplant came through.
“There was a huge cheer, because there were a lot of people preparing for this at the Maimonides. I remember hugging a Japanese colleague, because it confirmed that what we were doing was viable and would save thousands of lives,” he says.
Many people, however, were suspicious of Christiaan Barnard. Norman Shumway, from whom he had learned the technique, was in the USA at the time, trying to resolve the problem of rejection. “Many people believed he had really carried out the transplant. Also, at that time South Africa was a controversial place because of apartheid, and when Barnard came to give a talk, not one black doctor attended the cocktail party,” says Dr Caralps.
With Grace of Monaco
Barnard almost became a Hollywood 'star'; he was seen driving around in a convertible car, and dancing with Princess Grace of Monaco, as Lorenzo Silva, the head of the Acute Cardiac Care Unit at the Puerta de Hierro hospital, which holds the record for heart transplants in Spain (about 900), recalls. He was nine years old when Barnard made history.
“My father was a rural doctor and was excited about the news. I also remember that Barnard had arthritis in his hands; I remember his wife, and when he got married again....”
This cardiologist was present when the first transplants were carried out in Spain. “In 1984, we did a re-transplant on an 11-year-old girl. It was very exciting to go into the operating theatre with Dr Figueras and also Dr Alonso-Pulpón - he is one of the people who is responsible for heart transplants in Spain being where they are today,” he explains.
Silva says the therapy for rejection and quality of life has improved a great deal. “The hospital mortality rate is about 13 per cent, but survival is 80 per cent in the first year and 70 per cent after five years. After 11 years, half are still living.”
Sometimes, however, things don't go well; he recalls one young man with a congenital heart condition. “He looked like a child. I remember him phoning his mother when a donor was found. He was sobbing. He was terrified. And he died on the operating table. It was really awful.”
Juan Miguel Gil-Jaurena, the head of the children's cardiac surgery unit at the Gregorio Marañón hospital, has had similar experiences. He was even threatened by a couple who lost their teenage son. “You are so sorry about what has happened; you feel so bad. You ask yourself whether if you had done anything differently it would still have happened. You end up in an insane loop of self-reproach. We do the very best that we can,” he says.
Most of the time, results are positive: he operates on about ten children a year (under-18s, and young people with congenital heart conditions), which accounts for about 10 per cent of all heart transplants in Spain. The survival rate is between 85 and 90 per cent.
A child needs a heart which is a bit bigger than his or her own, and as there are so few donors there are sometimes 'size discrepancies'. “Don't let this frighten you,” says Dr Gil-Jaurena, “but two years ago we had a donor who weighed ten kilos and a recipient who only weighed three; we had to leave his chest open for several days while it settled. He's doing well now. We are lucky because the smaller the patient is, the better they adapt.” With children, it is difficult to give an idea of the waiting list. Once a two-month-old baby needed a transplant, and a heart arrived the same night. On the other hand, a three-year-old had to wait six months with an artificial heart.
Does he still find his work emotional? “That moment in the operating theatre when you see the heart starting to beat again is just... magical,” he says.