How The Busiest Heart Transplant Center In The World Got Its Start – An Inside Story Of The First Decade

The Vanderbilt Transplant Center is currently the busiest heart transplant center in the world. This is the story of building the foundation for what the Center has become today — a narrative of the initial decade of the 34 years since the founding of this first-of-its-kind, multidisciplinary, multi-organ transplant center. Over 12,300 adult and pediatric transplants have been performed at Vanderbilt. Not only does Vanderbilt perform more heart transplants annually than any other center, but it is where the longest surviving lung transplant patient was transplanted over three decades ago.

It started with a phone call.

In 1985 I was a Fellow in transplant surgery at Stanford University Medical School, operating under the tutelage of Dr. Norman Shumway. Shumway is considered the “Father of Heart Transplantation,” a title fitting for my mentor who was a research-grounded, scientist-surgeon. For more than two decades prior to my arrival at Stanford, Shumway had systematically conducted basic science and pre-clinical transplant research that culminated in his performing the first human heart transplant in the United States on January 6, 1968 (Dr. Christiaan Barnard, using techniques and knowledge that Shumway had developed over decades, performed the first human-to-human heart transplant in South Africa a month before.).

It was while completing my fellowship program under Shumway that late one evening my phone rang. On the other end of line was Dr. Harvey Bender, Chief of Cardiac Surgery at Vanderbilt: “Bill,” he said, “Ike Robinson (then Vanderbilt’s Vice-Chancellor) and I would like for you to come back home to Nashville to join Walter (Merrill, MD) to start and build a heart transplant program.”

At the time, heart transplantation was in its infancy. Shumway’s promising early clinical results, solidly grounded in more than two decades of painstaking basic and pre-clinical research, suggested that heart transplantation would someday become routine. At that moment, however, not a single heart transplantation had been performed back in Tennessee. The field was still considered experimental.

I was intrigued by Bender’s offer, but I had envisioned a much grander dream than he had proposed. That dream was to create a new concept — a multi-organ and multidisciplinary transplant center under one roof. No one had done it. The grand vision would include more holistic, patient-focused transplant care – for hearts, but also for a multitude of organs. Such scale would lead to better patient care and synergies other programs could never achieve.

Bender’s call inspired me to further research and refine what had been percolating in my mind. It was an audacious goal, but it was one that I knew at the right place, with the right resources, and with an unwavering commitment to ongoing scientific discovery, would become a reality.

Expanding the Stanford Single-Organ Model to a Multi-Organ Center: Collaboration

At Stanford, Dr. Shumway had focused on breaking down silos; he championed the power of the collaborative team, expressly respecting the vital roles of nurses (very unusual for cardiac surgeons of those early days!) and all members of the transplant team. Under his guidance in the early 1980s, he taught me the power of organizing into closely-knit teams professionals from a variety of backgrounds. Excellent transplant care, he practiced, was best achieved by bringing together research, clinical care, and education professionals. I knew this had to be applied to the newly envisioned multi-organ Vanderbilt Transplant model, with the distinctly unique dimension of this being carried out across a whole range of organs, not just the heart.

At Vanderbilt’s newly conceived transplant center, the anesthesiologists, surgeons, psychiatrists, nurses, social workers, rehabilitation and physical therapy specialists, clinical scientists, ethicists, and infectious disease experts would all engage each other at one site, side-by-side, all laser-focused on the patient. The natural, free-flowing exchange within a single Center among the many medical, surgical, and research disciplines would bring forth new ideas to be explored. Perhaps, we mused in the 1980s, we would even succeed one day at single-lung transplants, notoriously unsuccessful in those years.

Only one institution, the University of Pittsburgh, had attempted anything similar, then under the leadership of renowned liver transplant surgeon Dr. Thomas Starzl. But there, transplantation was isolated by organ type into separate programs, without geographic colocation. At other existing programs around the country, transplantation was built around a single organ, with most stove-piped around a single, high-profile surgeon. Such emphasis on a single surgeon – or a single organ – typically led to a program that could not be sustained over decades. Our goal was the build the foundation for a program that would thrive for generations.

The Move to Vanderbilt: Making the Dream Real

Back at Stanford while still completing my Fellowship, I formalized the plan. I put together a 45-page business, research, and clinical proposal that outlined in detail how the new Center would succeed, even at a time when third party reimbursement for heart transplantation did not exist. Financial barriers were formidable.

I accepted the position and arrived at Vanderbilt in 1985.

We assembled the envisioned multi-disciplinary transplant team and together we formulated a single-minded mission, around which we all aligned culturally: “To advance the medical and scientific aspects of transplantation through innovative, multi-specialty programs in education, research, and clinical practice.”

The team we assembled collectively committed to establishing Vanderbilt as the national leader in transplantation – and we would do so by including and mastering the entire spectrum of care, from chronic care before transplantation, through the surgical procedure, to the long-term care of patient and family post-transplant. This was decades before today’s realization of the importance of “episodes of care” to value-based care. It was about much more than “surgical outcomes.” It was about the best for our patients and their families before, during, and long after the transplant procedure.

Fortunately, Vanderbilt had some strong transplant experience. The previous decade, Drs. Keith Johnson and Bob Richie had together established a very successful kidney transplant program in Nashville at Vanderbilt. But the grand dream extended well beyond kidney: we would add heart, then liver, pancreas, bone marrow, lung, and combined heart and lung transplants. We would recruit a dedicated infectious disease expert with specialized transplant knowledge to be shared across all organs. We would bring on a full-time transplant ethicist, unheard of at the time, to help us sort through the tough decisions of life and death in this new world of high demand for transplantation but scarce donor organ supply. Who would receive the scarce organs and who would die waiting? The rapidly advancing scientific procedures never possible before introduced new health equity issues society had never had to consider. So, we built the framework for consideration of these ethical issues into the Center at the outset.

For transplantation, accurate and readily accessible data was more important to success than for any other medical field. We needed the clinical and financial data in real time so that we could smartly and safely advance the new and ever-changing field, not just let it evolve. From day one we at the Center measured everything: costs, processes, quality measures, outcomes, and functional results.

Transplantation became the most regulated field of medicine. The federal government for the first time wisely demanded these data, not just for government-funded procedures but for all transplants. The sector of transplantation was regarded as a public good. We in the transplant world were years ahead of other medical specialties in reporting and measuring clinical outcomes.

A Lesson From the Past: The Critical Role of Innovation

When we embarked on our journey in the mid-1980s, heart transplantation was in its infancy. Every successful step forward would introduce new problems, new challenges, that would require new solutions. Innovation with ongoing re-invention, we knew, had to be embedded in our culture. Thus, we built a team passionate about continuous problem-solving for what would unfold.

I had an earlier experience while in surgical training in Boston that taught me the high cost of walling off innovation. In 1980 as a cardiac surgical resident at Massachusetts General Hospital (MGH), the Board of Trustees of the hospital dramatically placed an indefinite moratorium on heart transplantation. This surprising announcement, the rationale of which was laid out in the prestigious New England Journal of Medicine, cited cost and a utilitarian philosophy – the crucial question, they wrote, being “what choice would reap the greatest good for the greatest number.”

I was stunned — and deeply disappointed. I strongly felt the trustees’ policy decision, however well-intentioned, was shortsighted and misguided based on the science at the time. How could the very hospitals that had pioneered kidney transplantation three decades earlier ban a promising heart procedure that could eventually save thousands of lives? Instead of working with their many resources to pioneer this rapidly advancing albeit new procedure, the hospital leadership abruptly shut the door to clinical innovation and research that would improve patient care. The ban on clinical innovation expanded to the other Harvard hospitals in Boston.

Admittedly with a touch of bitterness because of my own conviction around the future of heart and lung transplants, I left the MGH and Boston to join Shumway at Stanford, who had committed to strong clinical research and innovation. And it took years after the moratorium was finally lifted for Boston to catch up to other centers. There is a cost to saying “no” to innovation.

Institutional Commitment to Innovation and Equity

From the outset, at Vanderbilt we made health equity a priority. We believed these life-saving innovations should be available not just to the tiny minority who could pay six-figures out-of-pocket for a new heart. Vanderbilt’s leadership, specifically the Board of Trustees, endorsed us opening our doors to the patients in greatest need, not just those who could afford to pay. Eventually, of course, our Center would need to pay our own way. But during those early years in the 1980s when insurers had not yet begun to cover transplantation, Vanderbilt absorbed the initial patient costs. This wise, initial investment allowed us to build early on the patient volume, accumulate the data, and develop the expertise to demonstrate through comprehensively measured outcomes the immense value of heart transplantation to the patient, to the community, and ultimately to the nation.

Earning designation a few years after our start as a national “center of excellence” for companies such as Honeywell and Blue Cross, and then for Medicare, allowed us to mount the compelling, evidence-based case for more extensive commercial insurance and Medicaid reimbursement, and thus increased access for all patients. The investment in innovation and health equity established a strong foundation for the future, becoming cornerstones to our culture and mission.

Actively Engaging in Public Policy

Heart transplantation is dependent on a limited supply of donor organs, which is heavily regulated to ensure safety and fairness. Thus, from the outset we knew that much of our progress would depend on public policy developed and implemented at the state and national level. Though we were trained as a medical team, we understood that it was imperative for us to actively engage in public policy.

Our Center leadership supported and participated in the early evolution of the government-mandated United Network for Organ Sharing (UNOS) to ensure all Americans could gain equitable and just access to these new life-saving procedures. Of interesting historical note, the original model of UNOS in the mid-1980s grew out of the pre-existing Southeast Organ Procurement Foundation, where Vanderbilt’s Keith Johnson and others had actively engaged and played leadership roles.

At the state level, when in 1990 Tennessee dropped the organ donor card from the back of the state driver’s license, we at the Center launched and led the statewide, grassroots campaign called “Give Life to Your License”. Two years later, the donor card was returned to the licenses where it has remained over the past 30 years.

Today: The Busiest Heart Transplant Center in the World

The Vanderbilt Transplant Center has performed more than 12,300 total adult and pediatric transplants. It is currently performing more heart transplants than any in the world. For all transplants, it is fifth in the country. It is one of a few transplant programs designated by the U.S. Department of Veterans Affairs to provide heart and liver transplants to our nation's veterans.

The strong foundation of the Center was laid in its first decade of existence. It was built on a dream — and a culture and commitment to science, data, innovation, and patient-centeredness. The two subsequent decades, whose story will be told by others, witnessed tremendous growth:

· Heart: In 1989 the first year of the multi-organ Center (five years after the first heart transplant at Vanderbilt), we performed 28 heart transplants, among the highest in the country. Thirty-two years later in 2022, the Center performed a record 141 heart transplants, more than any other center in the world (Asia does not report data.). This milestone was reached under the leadership of Dr. Ashish Shah and Dr. Kelly Schlendorf. More than 1,749 heart transplants have been performed at Vanderbilt.

· Kidney: Over 7,100 kidney, simultaneous pancreas-kidney, and pancreas transplants have been performed at Vanderbilt. In 1989 the Center performed 89 kidney transplant procedures; that number more than tripled to 315 by 2021.

· Lung: In 1990 we launched our single-lung transplant program, performing five transplants in the first year, under the leadership of the author and pulmonologist Dr. Jim Loyd. In 2021 the Center performed 54 lung transplants. Over the lifetime of the program over 700 lung and combined heart-lung transplants have been conducted.

Pamela Everett-Smith, our Center’s fourth lung transplant patient back in 1990, is the longest-surviving single-lung transplant patient known in the United States. Dr. Walter Merrill and the author (Frist) performed her transplant 32 years ago. In a 2021 article in the VUMC Reporter, Pamela shared, “I’m 56 now and I didn’t think I’d see 30, let alone 56. I just thank God for every day that he gives me.”

· Liver: In 1990 Dr. Wright Pinson, today Deputy CEO and Chief Health System Officer at Vanderbilt University Medical Center, was recruited to start the liver transplant program. In 2021 the Center performed 123 liver transplants. Over 2,700 liver transplants have been performed since Dr. Pinson initiated the program. Dr. Pinson succeeded the author as Director of the Transplant Center in 1993 and served in that capacity until 2011.

Vanderbilt also leads the nation in expanding donors, pioneering both the use of Hepatitis C-exposed donors in transplantation of non-infected recipients (which are then treated after transplant) and the ex vivo perfusion system, which improves organ quality and extends the operating window of time by using a machine to continuously pump blood through the organ rather than store it on ice before transplantation.

This is the story of the first decade, which laid the sturdy foundation upon which a remarkable trajectory of growth has persisted. Now more than 30 years after its founding, the Vanderbilt Transplant Center continues to transform countless lives and exceed our earliest dreams. We thank the many physicians and staff who have worked to make this dream a reality. And a special acknowledgment to the patients and families who entrusted us with their care.