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Joel D. Cooper, MD, the Physician
Who Launched Lung Transplantation on Its Path to Successful
Outcomes
 You
might say that every patient with pulmonary hypertension
whose life has been extended by a lung transplant continues
to live and thrive in the long shadow cast by Joel D.
Cooper, MD, the physician who performed the first successful
lung transplant surgery in 1983. Not that Dr Cooper would
seriously consider this metaphor, but there is no doubting
the everlasting impact of his research in lung transplantation.
Dr Cooper no longer performs lung transplantation in
PH, yet he remains a towering figure not only in this
setting but in his other areas of clinical interest, including
general thoracic surgery, lung volume reduction surgery
for emphysema, myasthenia gravis, gastroesophageal reflux,
and esophageal cancer. Although lung transplantation in
PH has evolved significantly since the time when Dr Cooper
pioneered the operation, the principles and precepts governing
the technique when it was first performed offer insights
into how far its evolution has progressed.
Currently Chief of the Division of Cardiothoracic Surgery,
Washington University at Barnes-Jewish Hospital, St. Louis,
Missouri, Dr Cooper recalls his years in residency at
Massachusetts General Hospital where he served under the
well-known thoracic surgeon Hermes Grillo, MD, whom he
credits as the inspiration for later research on lung
transplantation. Moving to the University of Toronto after
completing his residency in Boston, Dr Cooper was further
encouraged by his colleagues to pursue his interest, particularly
by William Nelems, MD, who had studied with surgeons in
Europe. By 1978, 38 lung transplant operations had been
attempted worldwide, but with no success. “Most
of them were deathbed rescue attempts, maybe one attempted
every other year around the world,” said Dr
Cooper.
“We went back to the lab and we saw that most of
these patients had died within 2 weeks and those who lived
longer all had complications of the airway connection.
We studied these issues in a dog model and came up with
a better understanding.” A combination of factors,
including poor blood supply, posed obstacles to a successful
outcome.“During surgery the bronchial arteries are
severed and cannot be reconstructed. High doses of prednisone
were also required to prevent rejection. We recognized
that it was also sort of a wound-healing problem. Cyclosporin
helped and finally we were able to improve the technique
in a dog model.” Not long afterward, in 1983, Dr
Cooper and his associates performed the first successful
lung transplant.
This first successful transplant occurred several years
before additional attempts were made in patients with
PH. “It was thought at the time that you needed
to replace both the heart and the lung. We went back to
the lab and working with a dog model we produced a model
of right heart strain. We did it by gradually constricting
the pulmonary artery with a band, tightening it every
week or two until the right heart failed just as it does
in the clinical situation. Then we released the band,
dropping the pressure to more normal in these dogs and
we studied how quickly the right ventricle recovers if
you take the load off of it. This was a prelude to considering
lung transplant rather than heart-lung transplant and
we found that in these dogs there could be very rapid
recovery of function in the right ventricle.”
This led Dr Cooper and colleagues to rethink their strategy,
namely, that they did not need to perform both a heart
and a lung transplant. This meant that many more organs
would be available for additional patients. “You
could do a lung transplant
and the heart would recover. We found that the heart undergoes
remodeling, the thickened right ventricle returns to a
more normal shape and thickness.” Dr Cooper recalls
that a single lung transplant for PH was performed on
November 21, 1989, in a woman who survived and lived for
a number of years.“ We do have good results for
single lung transplant for PH even though a bilateral
is done most of the time now. Fortunately, medical management
of these patients has greatly improved, so the number
of patients coming to transplant has diminished somewhat,”
he added.
“I’ve always felt that lung transplantation
for PH is the most critical, most demanding surgery—not
so much from a technical standpoint, although it does
involve the use of cardiopulmonary bypass, but in terms
of postoperative care of the patient. Therefore, the best
results will be obtained by centers that are very experienced.
The problem is, if you have too few centers of excellence,
you are not accessible to the patient.”
The program at Barnes Hospital, however, is exceptional
in that the hospital assumes the responsibility for the
patient while he or she is on the waiting list. “In
the long term, successful outcomes for lung transplantation,
particularly for PH, require an experienced team,”
said Dr Cooper.
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