To secure an hour with Dr Willie Koen, you must compete with a clock running out of time for someone else.
Our first interview was called off abruptly as an emergency rolled into the operating theatres at Netcare Christiaan Barnard Memorial Hospital.
Koen was needed to pull a failing heart back from the brink - a fitting introduction to the high-stakes realm of South African cardiac surgery, where minutes determine whether a patient survives.
Decades after Dr Chris Barnard performed the world’s first human heart transplant here in 1967, South Africa remains at the forefront of cardiac innovation.
Today, surgical teams across private and public sectors use cutting-edge mechanical support, from Left Ventricular Assist Devices (LVADs) to full artificial hearts, to bridge the critical gap between terminal heart failure and a second chance at life.
South Africa’s heart-failure burden
Every September, during Heart Awareness Month, South Africa confronts a serious health challenge.
A 2018 study at Groote Schuur Hospital in Cape Town looked at 119 patients with acute heart failure and found the top five causes: cardiomyopathy (20.2%), ischaemic heart disease (19.3%), rheumatic valvular heart disease (18.5%), cor pulmonale (11.8%), and hypertension (10.1%).
These results show what causes heart failure in this hospital, but they do not represent the whole country.
This crisis attacks the human body from multiple fronts. As a result, South Africans are trapped in a healthcare system defined by massive diagnostic gaps, extreme organ scarcity, and cutting-edge mechanical innovation.
The anatomy of a failing heart
“When the heart muscle begins to collapse, ravaged by silent culprits like unmonitored blood pressure or chronic diabetes, the body undergoes a catastrophic physical transformation," explains world-renowned cardiac and transplant surgeon Koen.
“The heart loses its capacity to pump blood effectively," he says.
"Without normal circulation, the body's fluid dynamics reverse. Fluid pools where it shouldn’t. The feet begin to balloon with severe swelling. Slowly, inevitably, the lungs begin to fill with fluid. Clinicians call it 'getting wet'.
"The patient experiences it as a constant, waking drowning.
"And that's when we call it heart failure," he says.
"You can put them on very good medication, and it can help people. But if you look at that group of patients, there is a percentage who will only benefit if you do a heart transplant."
When medication is no longer enough
"When standard medications stop working, survival becomes a race against time. Patients must go through evaluations to get onto a national transplant waiting list. But in South Africa, being on this list is emotionally agonising.
"Patients are left completely weak and helpless. They cannot work or live a normal life, spending their days trapped in a painful loop between a quiet home and an intensive care unit (ICU) bed," explains Koen.
“The survival math is brutal.
"South Africa needs over 5,000 heart transplants a year to meet demand. Yet, the entire country produces fewer than 50 usable donor hearts annually. This massive shortage leaves thousands of patients to waste away in hospital beds, their organs starving for oxygen while they pray for a miracle.
"We wait and wait and wait," Koen says.
"But then the patient deteriorates, and it gets to a point where we can see that if we don't do something now, this patient's not going to make it. That's the point where we say, 'Look, we have an alternative'."
How the HeartMate 3 works
Turning to mechanical engineering is the ultimate response to decades of severe organ shortages, says Koen
In the early days of cardiac surgery, desperate scientists looked to nature for a solution, experimenting with xenotransplantation, using animal organs, like pig hearts, to save human lives, says Koen.
In 2001, Koen led the team that performed South Africa’s first reported total artificial heart implantation at City Park Hospital in Cape Town, using a Berlin Heart.
The device was intended to support the patient until a donor heart became available.
Today, devices such as the HeartMate 3 serve a different purpose. Unlike a total artificial heart, the HeartMate 3 is a left ventricular assist device (LVAD): an implantable mechanical pump that supports the heart’s left ventricle rather than replacing the entire heart.
In 2021, Koen and Dr Loven Moodley implanted a HeartMate 3 LVAD at Netcare Christiaan Barnard Memorial Hospital in Cape Town.
“Today the modern HeartMate 3 pump is small enough to be hidden inside the chest,” explains Koen. “It does not beat like a human heart. Instead, it uses a spinning magnetic field to silently push a steady stream of oxygen-rich blood through the body.
"The only sign on the outside is a small wire coming out of the stomach. This wire connects the internal pump to a pocket-sized controller and a wearable battery pack.”
The physical recovery is instant.
Patients who were dying in the ICU, too weak to even lift a fork, get their independence back.
Koen recalls a patient from just five months ago: "This patient was lying in the ICU. And this patient now can do everything; he's even cycling every day to the shop and back on his bicycle.
"It restores the ability, again, from taking them out of hospital to a fully functional person."
The donor heart gap
Despite the power of this technology, Koen is clear: a mechanical pump is either a temporary safety net or a final resort when no other options exist. “A human donor heart is still the absolute best choice for long-term survival.”
This brings South Africans face-to-face with one of the most sensitive areas in medicine: confirming brain death.
“A heart transplant cannot happen through living donation, the way a kidney can. It relies entirely on sudden tragedy. When an individual suffers an irreversible brain injury, frequently from a catastrophic vehicle accident or trauma, their brain dies, but their vital organs are temporarily preserved via a ventilator.”
"It's so sad that the patient must die, but at least one can get something out of it to help somebody else," Koen notes.
In the past, these conversations stopped because of strict cultural and religious beliefs. Older traditions required a person to be buried completely whole.
However, Koen shares that modern South African society is changing, led by a younger and deeply empathetic generation.
Communities now see organ donation as a profound act of kindness. They are embracing the well-known saying: “You don't need your organs in heaven, leave them on earth for the people who do.”
Cutting-edge cardiac care on South Africa’s doorstep
For Heart Health Month, Koen wants to share a two-part message: "We need to focus heavily on prevention, but we should also take immense pride in what our medical teams can do.
"It is true that South Africa has a younger, health-conscious population that protects us from some of the higher heart disease rates seen in places like Europe.
"But the threat is still very real. This crisis can destroy the lives of people between the ages of 25 and 50 just as easily as it affects the elderly.
“Eighty per cent of this risk can be entirely mitigated by routinely checking and treating what you cannot feel: blood pressure, blood sugar, and cholesterol, while completely eradicating cigarette smoke.
"If we don't have these articles to educate our population, people won't know that there is this problem. Once it happens in your community or in your family, then you realise it's a very real problem."
When prevention fails, South Africans do not need to look across the ocean for salvation.
"There are so many issues here in our country," Koen concludes. But in spite of that, we are still at the forefront of a lot of technology and things happening in the world.
"We don't have to stand back for other countries. We have it here on our own doorstep where we can still do this cutting-edge technology, helping our patients with the latest techniques."
vuyile.madwantsi@nationalmg.co.za