History of Cardiac Surgery

	INTRODUCTION

	HEART WOUNDS

 
On July 10, 1893, Dr. Daniel Hale Williams (Fig. 1-1), a surgeon from Chicago, successfully operated on a 24-year-old man who had been stabbed in the heart during a fight. The patient was admitted to Chicago's Provident Hospital on July 9 at 7:30 P.M. The stab wound was slightly to the left of the sternum and dead center over the heart. Initially, the wound was thought to be superficial, but during the night the patient experience persistent bleeding, pain, and pronounced symptoms of shock. Williams opened the patient's chest and tied off an artery and vein that had been injured inside the chest wall, likely causing the blood loss. Then he noticed a tear in the pericardium and a puncture wound to the heart, "about one-tenth of an inch in length."¹

View larger version (133K): [in this window] [in a new window]   FIGURE 1-1 Dr. Daniel Hale Williams, a surgeon from Chicago who successfully operated on a patient with a wound to the chest involving the pericardium and the heart. (Reproduced with permission from Organ CH Jr, Kosiba MM: The Century of the Black Surgeons: A USA Experience. Norman, OK, Transcript Press, 1987; p 312.)

A few years after Williams' case, a couple of other surgeons actually sutured heart wounds, but the patients did not survive. Dr. Ludwig Rehn (Fig. 1-2), a surgeon in Frankfurt, Germany, performed what many consider the first successful heart operation.² On September 7, 1896, a 22-year-old man was stabbed in the heart and collapsed. The police found him pale, covered with cold sweat, and extremely short of breath. His pulse was irregular and his clothes were soaked with blood. By September 9, his condition was worsening, as shown in Dr. Rehn's case notes:

Pulse weaker, increasing cardiac dullness on percussion, respiration 76, further deterioration during the day, diagnostic tap reveals dark blood. Patient appears moribund. Diagnosis: increasing hemothorax. I decided to operate entering the chest through the left fourth intercostal space, there is massive blood in the pleural cavity. The mammary artery is not injured. There is continuous bleeding from a hole in the pericardium. This opening is enlarged. The heart is exposed. Old blood and clots are emptied. There is a 1.5 cm gaping right ventricular wound. Bleeding is controlled with finger pressure....

View larger version (127K): [in this window] [in a new window]   FIGURE 1-2 Dr. Ludwig Rehn, a surgeon from Frankfurt, Germany, who performed the first successful suture of a human heart wound. (Reproduced with permission from Mead R: A History of Thoracic Surgery. Springfield, IL, Charles C Thomas, 1961; p 887.)

 
I decided to suture the heart wound. I used a small intestinal needle and silk suture. The suture was tied in diastole. Bleeding diminished remarkably with the third suture, all bleeding was controlled. The pulse improved. The pleural cavity was irrigated. Pleura and pericardium were drained with iodoform gauze. The incision was approximated, heart rate and respiratory rate decreased and pulse improved postoperatively.

... Today the patient is cured. He looks very good. His heart action is regular. I have not allowed him to work physically hard. This proves the feasibility of cardiac suture repair without a doubt! I hope this will lead to more investigation regarding surgery of the heart. This may save many lives.

Ten years after Rehn's initial repair, he had accumulated a series of 124 cases with a mortality of only 60%, quite a feat at that time.³

Dr. Luther Hill was the first American to report the successful repair of a cardiac wound, in a 13-year-old boy who was a victim of multiple stab wounds.⁴ When the first doctor arrived, the boy was in profound shock. The doctor remembered that Dr. Luther Hill had spoken on the subject of repair of cardiac wounds at a local medical society meeting in Montgomery, Alabama. With the consent of the boy's parents, Dr. Hill was sent for. He arrived sometime after midnight with six other physicians. One was his brother. The surgery took place on the patient's kitchen table in a rundown shack. Lighting was provided by two kerosene lamps borrowed from neighbors. One physician administered chloroform anesthesia. The boy was suffering from cardiac tamponade as a result of a stab wound to the left ventricle. The stab wound to the ventricle was repaired with two catgut sutures. Although the early postoperative course was stormy, the boy made a complete recovery. That patient, Henry Myrick, eventually moved to Chicago, where, in 1942, at the age of 53, he got into a heated argument and was stabbed in the heart again, very close to the original stab wound. This time, Henry was not as lucky and died from the wound.

Another milestone in cardiac surgery for trauma occurred during World War II when Dwight Harken, then a U.S. Army surgeon, removed 134 missiles from the mediastinum, including 55 from the pericardium and 13 from cardiac chambers, without a death.⁵ It is hard to imagine this type of elective (and semielective) surgery taking place without sophisticated indwelling pulmonary artery catheters, blood banks, and electronic monitoring equipment. Rapid blood infusion consisted of pumping air into glass bottles of blood.

	OPERATIVE MANAGEMENT OF PULMONARY EMBOLI

 
Frederic Trendelenburg was the first to attempt a pulmonary embolectomy. In his classic paper that appeared in 1908,⁶ he stated that the clinical picture is characteristic: rapid collapse, frequently accompanied by substernal pain that often causes the patient to suddenly scream wildly. He reported on animal studies in 1907; following rapid exposure of the heart, he quickly incised the conus pulmonalis, inserted a cannula, advanced it into the pulmonary artery, and removed emboli using suction. Further experimentation revealed that a direct incision in the artery with removal of the emboli using forceps (those designed for removal of polyps) was much easier. He describes his first unsuccessful pulmonary embolectomy in a human. That operation became famous and is known as the Trendelenburg operation.

Trendelenburg subsequently reported two more cases, both fatal.⁷ The first of those two patients died 15 hours postoperatively of cardiac failure, the second 37 hours postoperatively. Kirschner, Trendelenburg's student, reported the first patient who fully recovered after undergoing pulmonary embolectomy in 1924.⁸ In 1937, John Gibbon estimated that 9 of 142 patients who had undergone the Trendelenburg procedure worldwide left the hospital alive.⁹ These dismal results were a stimulus for Gibbon to start work on a pump oxygenator that could maintain the circulation during pulmonary embolectomy. Sharp was first to perform pulmonary embolectomy using cardiopulmonary bypass, in 1962.¹⁰

	SURGERY OF THE PERICARDIUM

 
Morgagni reported seven cases of constrictive pericarditis in 1761 and described the dangers of cardiac compression by stating that the heart was "so constricted and confined that it could not receive a proper quantity of blood to pass through it."¹¹ Pick presented a paper in 1896 in which he described the course of chronic pericarditis under the guise of cirrhosis of the liver.¹² Weill in 1895 and Delorme in 1898 proposed excision of the thickened fibrous pericardium in constrictive pericarditis.^13,14 Pericardial resection was introduced independently by Rehn¹⁵ and Sauerbruch.¹⁶ Since Rehn's report, there have been few advances in the surgical treatment of constrictive pericarditis. Some operations are now performed with the aid of cardiopulmonary bypass. In certain situations, radical pericardiectomy that removes most of the pericardium posterior to the phrenic nerves is done.

	CATHETERIZATION OF THE RIGHT SIDE OF THE HEART

 
Although cardiac catheterization is not considered heart surgery, it is an invasive procedure and some catheter procedures have replaced heart operations. Warner Forssmann is credited with the first heart catheterization. He performed the procedure on himself and reported it in Kleinische Wochenschrift.¹⁷ In 1956, Forssmann shared the Nobel Prize in Physiology or Medicine with Andre F. Cournand and Dickenson W. Richards, Jr. His 1929 paper states, "These are reasons why one often hesitates to use intercardiac injections. Often, time is wasted with other measures. This is why I kept looking for different, safer access to the cardiac chambers: the catheterization of the right heart via the venous system." He goes on to say,

I confirmed these facts by studies on a cadaver, catheterizing any vein near the elbow, the catheter would pass easily into the right ventricle....

After these successful preliminary studies, I attempted the first experiment on a living human, performing the experiment on myself. In a preliminary experiment, I had asked a colleague to puncture my right brachial vein with a large-bore needle. Then I advanced a well-lubricated No. 4 ureteral catheter through the cannula into the vein.... One week later I tried it again without assistance this time. I proceeded with vena puncture in my left antebrachial vein and introduced the catheter to its full length of 65 cm....

I checked the catheter position radiologically, after having climbed stairs from the OR to the radiology department. A nurse was holding a mirror in front of the x-ray screen for me to observe the catheter advance in position. The length of the catheter did not allow further advancement than into the right atrium. I paid particular attention to the possible effects on the cardiac conduction system, but I could not detect any effect.

In this report by Forssmann, a photograph of the x-ray taken of Forssmann with the catheter in his heart is presented. Forssmann, in that same report, goes on to present the first clinical application of the central venous catheter for a patient in shock with generalized peritonitis. Forssmann concludes his paper by stating, "I also want to mention that this method allows new options for metabolic studies and studies about cardiac physiology."

In a 1951 lecture, Forssmann discussed the tremendous resistance he faced during his initial experiments.¹⁸ "Such methods are good for a circus, but not for a respected hospital," was the answer to his request to pursue physiological studies using cardiac catheterization. His progressive ideas pushed him into the position of an outsider with ideas too crazy to give him a clinical position. Klein applied cardiac catheterization for cardiac output determinations using the Fick method a half year after Forssmann's first report.¹⁹ In 1930 Forssmann described his experiments with catheter cardiac angiography.²⁰ Further use of this new methodology had to wait until Cournand's work in the 1940s.

	HEART VALVE SURGERY BEFORE THE ERA OF CARDIOPULMONARY BYPASS

 
The first clinical attempt to open a stenotic valve was carried out by Theodore Tuffier on July 13, 1912.²¹ Alexis Carrel was present at the operation.²² Tuffier used his finger to reach the stenotic aortic valve. He was able to dilate the valve by supposedly pushing the invaginated aortic wall through the stenotic valve. The 26-year-old patient recovered and returned to his home in Belgium. One must be skeptical as to what was accomplished. Russell Brock attempted to dilate calcified aortic valves in humans in the late 1940s by passing an instrument through the valve from the innominate or another artery.²³ His results were poor, and he abandoned the approach. During the next several years, Brock²⁴ and Bailey et al²⁵ used different dilators and various approaches to dilate stenotic aortic valves in patients. Mortality for these procedures that were often done in conjunction with mitral commissurotomy was high.

Harvey Cushing attempted to create mitral stenosis in dogs but was not successful.²⁶ He encouraged Elliott Cutler, a young surgeon working with him, to continue. In collaboration with a Boston cardiologist, Samuel Levine, Cutler worked 2 years on a mitral valvulotomy procedure in the laboratory.²⁷ Their first patient was a desperately ill 12-year-old girl who was confined to bed for 6 months before operation. She underwent successful valvulotomy on May 20, 1923, using a teratomy knife. Unfortunately, most of Cutler's subsequent patients died because he created too much regurgitation with his valvulotome, and he soon gave up the operation. In 1925 Mr. Souttar, an English surgeon, successfully performed a mitral valvulotomy using his finger to fracture the commissures in a young female who had been bedridden for 6 months.²⁸ His case was successful, but he did not do more operations.

In 1961 Dr. Dwight Harken wrote Henry Suttar a letter and asked him why he did not continue with his mitral valvuloplasty. He replied: "Thank you so much for your very kind letter. I did not repeat the operation because I could not get another case. Although my patient made an uninterrupted recovery, the physicians declared that it was all nonsense and in fact the operation was unjustifiable. In fact, it is of no use to be ahead of one's time...."²⁹ Two decades passed before there was a resurgence of interest in valvular surgery.

In Charles Bailey's 1949 paper titled "The Surgical Treatment of Mitral Stenosis," he states, "After 1929 no more surgical attempts [on mitral stenosis] were made until 1945. Dr. Dwight Harken, Dr. Horace Smithy, and the author recently made operative attempts to improve mitral stenosis. Our clinical experience with the surgery of the mitral valves has been 5 cases to date. During the past 8 years, the author and his associates have performed operations on the mitral valves of 60 mongrel dogs."³⁰ Bailey goes on to state several conclusions from their animal research. He then describes his five cases, four of whom died and only one of whom lived a long life.

Bailey's home base, Hahnemann Hospital, refused to allow him to attempt any more mitral commissurotomies after two deaths. He became known as the "butcher of Hahnemann Hospital."²⁹ However, his cardiologist, Dr. Durant, continued to support him. On June 10, 1948, Bailey scheduled cases 4 and 5. The patient operated on at Philadelphia General Hospital in the morning died (case 4). The surgical team regrouped and rushed to Episcopal Hospital, where the second operation was started promptly before the bad morning news was known and before the hospital administration forbade the procedure. The surgery was completed, and 1 week later Bailey brought the patient by train 1000 miles to Chicago, where he presented the woman to the American College of Chest Physicians.³¹ A few days after Bailey's success, on June 16 in Boston, Dr. Dwight Harken successfully performed his first valvulotomy for mitral stenosis. Three months later, Russell Brock in England did his first successful clinical case. He did not report this, however, until 1950, when he described success with six patients.³²

The first successful pulmonary valvulotomy was performed by Thomas Holmes Sellers on December 4, 1947. A systemic pulmonary artery shunt was planned on the left side, but the attempt was abandoned in this patient with severe tetralogy of Fallot and advanced bilateral pulmonary tuberculosis.³³ The pericardium was opened. Dr. Sellers could feel the stenotic valve each time it pushed through the pulmonary trunk during ventricular systole. Sellers used a tenotomy knife, which he passed through the right ventricle to perform the valvulotomy. The patient made a good recovery and was markedly improved.

Russell Brock also attempted pulmonary valvulotomies in a number of patients during the same period using various techniques. Brock's first three patients died, but he eventually developed a successful procedure similar to Sellers'.³⁴

In the early 1950s, Charles Hufnagel, in Washington, DC, and J. M. Campbell, in Oklahoma, independently developed and implanted artificial valves in the descending aorta of dogs. The valves consisted of a mobile ball inside a Lucite case.^35,36 After presenting this first model of a mechanical prosthesis at the American College of Surgeons meeting in 1949, Hufnagel applied this concept clinically for the treatment of aortic valvular insufficiency. In his first clinical paper published in Surgery in 1954,³⁷ Hufnagel reported a series of 23 patients starting September 1952 who had this operation for aortic insufficiency. There were 4 deaths among the first 10 patients and 2 deaths among the next 13. Hufnagel's caged ball valve, which used multiple-point fixation rings to secure the apparatus to the aorta, was the only surgical treatment for aortic valvular incompetence until the advent of cardiopulmonary bypass and the development of heart valves that could be sewn into the aortic annulus position.

The first surgical treatment of multiple valvular disease was by Trace et al.³⁸ After closed mitral commissurotomy on May 2, 1952, in a 24-year-old woman, the surgeon noted that the right auricular appendage was gravely distended and pointed directly toward the left. Its pulsation was noticed and it was quite blue-purple in color. The purse-string was being placed around the appendage in order to explore it when the patient's heart became arrhythmic. It was deemed advisable to terminate the surgical procedure at this point. The patient did poorly postoperatively. In the 2 weeks after the first operation, a tricuspid commissurotomy was performed. The patient made a good recovery and at 1-year follow-up remained improved.

Combined mitral and tricuspid commissurotomy was performed by Brofman in 1953.³⁹ Likoff et al⁴⁰ reported a series of 74 patients who had combined aortic and mitral valve commissurotomies in 1955 with up to a 2-year follow-up. C. Walton Lillehei was the first to report repair of multiple valvular lesions using cardiopulmonary bypass. On May 23, 1956, he successfully performed an open mitral commissurotomy and aortic valvuloplasty in a 52-year-old man with mitral stenosis and combined aortic stenosis and incompetence.⁴¹ Borman performed a quadruple valve commissurotomy in October 1973 in a 12-year-old Israeli girl with stenosis of all four valves.⁴²

	CONGENITAL CARDIAC SURGERY BEFORE THE HEART-LUNG MACHINE ERA

 
Congenital cardiac surgery began when John Streider at the Massachusetts General Hospital first successfully interrupted a ductus on March 6, 1937. The patient was septic and died on the fourth postoperative day. At autopsy, vegetations filled the pulmonary artery down to the valve.⁴³ On August 16, 1938, Robert Gross, at Boston Children's Hospital, operated on a 7-year-old girl with dyspnea after moderate exercise.⁴⁴ Dr. Gross described the ductus as 7 to 8 mm in diameter and 5 to 6 mm in length. A no. 8 braided silk tie was placed around the ductus with an aneurysm needle, and the vessel was occluded temporarily for a 3-minute observation. During this time, blood pressure rose from 100/35 to 125/90. According to Dr. Gross, "Since there was no embarrassment of the circulation, it was decided to ligate the ductus permanently." The patient made an uneventful recovery (Fig. 1-3).

View larger version (72K): [in this window] [in a new window]   FIGURE 1-3 Ligation of patent ductus arteriosus. Daily blood pressure readings of the patient with a patent ductus arteriosus before and after operation (arrow). (Reproduced with permission from Gross RE, Hubbard JH: Surgical ligation of a patent ductus arteriosus: report of first successful case. JAMA 1939; 112:729.)

View larger version (34K): [in this window] [in a new window]   FIGURE 1-4 Resection of aortic coarctation. (A) Section of aorta mobilized by freeing it from its bed and dividing regional intercostal arteries (I.A.), bronchial artery (B.A.), and ligamentum arteriosum (L.A.). Clamps applied to aorta. (B) Segment of aorta excised. (C) Aorta reconstructed by end-to-end anastomosis, with continuous, everting, mattress-type silk suture. (Reproduced with permission from Gross RE: Surgical correction for coarctation of the aorta. Surgery 1945; 18:673.)

The famous Blalock-Taussig operation also was first reported in 1945. The first patient was a 15-month-old girl with a clinical diagnosis of tetralogy of Fallot with a severe pulmonary stenosis.⁴⁹ At age 8 months the baby had her first cyanotic spell, which occurred after eating. Dr. Helen Taussig, the cardiologist, followed the child for 3 months, and during that time cyanosis increased and she failed to gain weight. She was readmitted and during the next 6 weeks refused most of her feedings, lost weight, and weighed only 4 kg at operation. The operation was performed by Dr. Alfred Blalock at Johns Hopkins University on November 29, 1944. The left subclavian artery was anastomosed to the left pulmonary artery in an end-to-side fashion (Fig. 1-5). The postoperative course was described as stormy; she was discharged 2 months postoperatively. Two additional successful cases were done within 3 months of their first patient.

View larger version (33K): [in this window] [in a new window]   FIGURE 1-5 Diagram of the first Blalock-Taussig anastomosis. (Reproduced with permission from Blalock A, Taussig HB: The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA 1945; 128:189.)

Anomalous coronary artery in which the left coronary artery communicates with the pulmonary artery was the next surgical conquest. The surgery was performed on July 22, 1946, and was reported by Gunnar Biorck and Clarence Crafoord.⁵⁰ The patient was a 15-year-old boy who was unable to do gymnastics or play football because of dyspnea shortly after beginning exercise. At operation, the ductus arteriosus was found to be a cord, but there was a thrill over the pericardium. When the pericardium was opened, the anomalous coronary artery was identified and doubly ligated. The patient made an uneventful recovery.

Muller⁵¹ reported successful surgical treatment of transposition of the pulmonary veins in 1951, but the operation addressed a partial form of the anomaly. Later in the 1950s, Gott, Varco, Lillehei, and Cooley reported successful operative variations for anomalous pulmonary veins.

Another of Gross's pioneering surgical procedures was the surgical closure of an aortopulmonary window in a 4-year-old girl who had dyspnea with slight exertion and a cardiac murmur that was consistent with a patent ductus.⁵² The operation was carried out on May 22, 1948. After dissecting the posterior aspect of the great vessels, a similar plane was developed between the vessels above the shunt, and an aneurysm needle was passed completely around the shunt.⁵² A piece of linen tape 1 cm wide was drawn around the vessel so that it encircled the shunt. At this point, arterial blood began to escape from the depths of the wound so that it was evident that the thin posterior wall of the shunt had been slightly torn. Believing that the one hope of controlling the situation might be to quickly tie the tape that had been placed previously, this was now rapidly and tightly drawn down. Fortunately, all bleeding stopped. All the thrill in the pulmonary artery disappeared. The chest was closed, and the patient made a satisfactory convalescence.

Gross stated, "After successfully treating the child, it is felt that the fortunate outcome had been attended by a high degree of luck and that simple ligature might lead to disaster if attempted in all cases of aortopulmonary artery fenestration. As far as is known, this is the first instance of successful surgical correction of this congenital abnormality." Others were soon to follow using various techniques to interrupt the aortopulmonary window. Cooley et al⁵³ were the first to report on the use of cardiopulmonary bypass to repair this defect and converted a difficult and hazardous procedure into a relatively straightforward one.

The cavopulmonary anastomosis has had several variations by different designers. Carlon et al⁵⁴ are credited with first proposing the anastomosis in 1951. Glenn⁵⁵ reported the first successful clinical application in the United States in 1958 for what has been termed the Glenn shunt. Similar work was done in Russia during the 1950s by several investigators. On January 3, 1957, Galankin,⁵⁶ a Russian surgeon, performed a cavopulmonary anastomosis in a 16-year-old patient with tetralogy of Fallot. The patient made a good recovery with significant improvement in exercise tolerance and cyanosis.

	THE DEVELOPMENT OF CARDIOPULMONARY BYPASS

 
The development of the heart-lung machine made repair of intracardiac lesions possible. To bypass the heart, one needs a basic understanding of physiology of the circulation, a method of preventing the blood from clotting, a mechanism to pump blood, and finally, a method to ventilate the blood.⁵⁷

Before 1900, physiologists were already interested in isolated organ perfusion and therefore needed a method to oxygenate blood. Von Frey and Gruber⁵⁸ described a blood pump in 1885 in which gas exchange occurred as blood flowed into a thin film over the inner surface of a slanted rotating cylinder. In 1895 Jacobi passed blood through an excised animal's lung that was aerated by artificial respiration.⁵⁹ In 1926, Professors S. S. Brukhonenko and S. Terebinsky⁶⁰ in Russia designed a machine that used an excised lung from a donor animal as an oxygenator and two mechanically actuated blood pumps. Their machine was used initially to perfuse isolated organs but later was used to perfuse entire animals.

Alexis Carrel, a Nobel laureate, and Charles Lindbergh, the famous aviator, developed a device that successfully perfused the thyroid gland of a cat for 18 days, beginning April 5, 1935.⁶¹ A picture of the two investigators with their perfusion apparatus appeared on the July 1, 1935, cover of Time magazine.⁶² At the end of that time, much of the tissue was partially preserved, and pieces grew epithelial cells in tissue culture. According to Edwards and Edwards,⁶¹ many other organs were perfused over the next few years by Carrel and Lindbergh. Hearts were kept beating for several days. Although perfused organs survived surprisingly well, all showed progressive degenerative changes in a few days. Edema fluid filled tissue spaces, arteries became calcified, and connective tissue cells outgrew the more specialized cells.

One of the key requirements of the heart-lung machine was anticoagulation. Heparin was discovered by a medical student, Jay McLean, working in the laboratory of Dr. William Howell, a physiologist at Johns Hopkins.⁶³ In 1915 Howell gave McLean the task of studying a crude brain extract known to be a powerful thromboplastin. Howell believed that the thromboplastic activity was caused by cephalin contained in the extract. McLean's job was to fractionate the extract and purify the cephalin. McLean also studied extracts prepared from heart and liver. McLean discovered that a substance in the extract was retarding coagulation. McLean wrote⁶⁴:

I went one morning to the door of Dr. Howell's office, and standing there (he was seated at his desk), I said, Dr. Howell, I have discovered antithrombin. He smiled and said, "Antithrombin is a protein and you are working with phospholipids. Are you sure that salt is not contaminating your substance?"... I told him that I was not sure of that, but it was a powerful anticoagulant. He was most skeptical, so I had the diener, John Schweinhand, bleed a cat. Into a small beaker full of its blood, I stirred all of the proven batch of heparphosphotides, and placed this on Dr. Howell's laboratory table and asked him to tell when it clotted. It never did.

McLean described his finding in February 1916 at a medical society meeting in Philadelphia and later reported it in an article entitled, "The Thromboplastic Action of Cephalin."^64,65 Howell and Holt⁶⁶ reported their work on heparin in 1918. In the 1920s, animal experiments confirmed that heparin was an effective anticoagulant.⁶⁷

John Gibbon contributed more to the success of the development of the heart-lung machine than anyone else. His interest began as a young doctor one night in 1930 in Boston "during an all-night vigil by the side of a patient with a massive embolus..."⁶⁸

My job that night was to take the patient's blood pressure and pulse every 15 minutes and plot it on a chart. During the 17 hours by the patient's side, the thought constantly recurred that the patient's hazardous condition could be improved if some of the blue blood in the patient's distended veins could be continuously withdrawn into an apparatus where the blood could pick up oxygen and discharge carbon dioxide and then pump this blood into the patient's arteries. At 8 A.M. the patient's blood pressure could not be measured. Dr. Edward Churchill, the chief of surgery, immediately opened the chest through an anterior left thoracotomy, then occluded both the pulmonary artery and the aorta as they exited from the heart. He opened the pulmonary artery and removed massive blood clots. The patient did not survive.

Gibbon's work on the heart-lung machine took place over the next 20 years, in laboratories at the Massachusetts General Hospital, the University of Pennsylvania, and Thomas Jefferson University. In 1937, Gibbon reported the first successful demonstration that life could be maintained by an artificial heart and lung and that the native heart and lungs could resume function. Unfortunately, only three animals recovered adequate cardiorespiratory function after total pulmonary artery occlusion and bypass, and even they died a few hours later.⁶⁹ Gibbon's work was interrupted by World War II; afterwards, he resumed his work at the Thomas Jefferson Medical College in Philadelphia. Meanwhile, other groups, including Clarence Crafoord in Stockholm, Sweden, J. Jongbloed at the University of Utrecht in Holland, Clarence Dennis at the University of Minnesota, Mario Digliotti and coworkers at the University of Turino in Italy, and ForestDodrill at Harper Hospital in Detroit, also worked on a heart-lung machine.⁷⁰

Clarence Dennis's first clinical attempt at open heart surgery was in a 6-year-old girl with end-stage cardiac disease.⁷¹ Her heart was already massive, and her only hope was surgical closure of an atrial septal defect. At operation on April 5, 1951, her circulation was supported by a heart-lung machine that Dennis and his coworkers had developed.⁷² The atrial septal defect was very difficult to close. Although the heart-lung machine functioned well, the patient did not survive, probably because of a combination of blood loss and surgically induced tricuspid stenosis.

In August of 1951, Mario Digliotti used his heart-lung machine to partially support the circulation at the flow of 1 L/min in a 49-year-old patient during resection of a large mediastinal tumor.⁷³ During the operation, the patient developed hypotension and cyanosis. He was therefore placed on partial bypass at 1 L/min for 20 minutes. Although the mass was resected successfully, the Italian machine was never used for open heart surgery in humans.

Forest Dodrill and colleagues used the mechanical blood pump they developed with General Motors on a 41-year-old man.⁷⁴ The machine was used to substitute for the left ventricle for 50 minutes while a surgical procedure was carried out to repair the mitral valve; the patient's own lungs were used to oxygenate the blood. This, the first clinically successful total left-sided heart bypass in a human, was performed on July 3, 1952, and followed from Dodrill's experimental work with a mechanical pump for univentricular, biventricular, or cardiopulmonary bypass. Although Dodrill et al had used their pump with an oxygenator for total heart bypass in animals,⁷⁵ they felt that left-sided heart bypass was the most practical method for their first clinical case. When their patient was interviewed at age 68, he recalled seeing dogs romping on the roof of a nearby building from his hospital room in 1952. Later he learned that they had been used in the final test of the Dodrill-General Motors mechanical heart machine (Fig. 1-6).

View larger version (125K): [in this window] [in a new window]   FIGURE 1-6 Blueprints by General Motors engineers of the Dodrill-GMR Mechanical Heart. (Courtesy of Calvin Hughes, M.D.)

Hypothermia was another method to stop the heart and allow it to be opened. In 1950, Bigelow et al⁷⁸ reported on 20 dogs that had been cooled to 20°C, with 15 minutes of circulatory arrest; 11 animals also had a cardiotomy. Only 6 animals survived after rewarming. Bigelow and colleagues continued to study hypothermia.^79–81

John Lewis closed an atrial septal defect in a 5-year-old girl on September 2, 1952, using a hypothermic technique⁸²:

She was wrapped in refrigerated blankets until after a period of two hours and ten minutes her rectal temperature had fallen to 28°C. At this point the chest was entered through the bed of the right fifth rib. The cardiac inflow was occluded for a total of five and one-half minutes and during this time the septal defect was closed under direct vision. The patient was rewarmed by placing her in hot water kept at 45°C, and after 35 minutes her rectal temperature had risen to 36°C, at which time she was removed from the bath. Recovery from the anesthesia was prompt and her subsequent postoperative convalescence was uneventful.

Shortly thereafter, Swan et al⁸³ reported successful results in 13 clinical cases using a similar technique. But the use of systemic hypothermia for open intracardiac surgery was relatively short-lived; after the heart-lung machine was introduced clinically, it appeared that deep hypothermia was obsolete. However, during the 1960s it became apparent that operative results in infants under 1 year of age using cardiopulmonary bypass were poor. In 1967, Hikasa et al,⁸⁴ from Kyoto, Japan, published an article that reintroduced profound hypothermia for cardiac surgery in infants and used the heart-lung machine for rewarming. Their technique involved surface cooling to 20°C, cardiac surgery during circulatory arrest for 15 to 75 minutes, and rewarming with cardiopulmonary bypass. At the same time, other groups reported using profound hypothermia with circulatory arrest in infants with the heart-lung machine for cooling and rewarming.^85–88 Results were much improved, and subsequently the technique also was applied for resection of aortic arch aneurysms.

After World War II, John Gibbon resumed his research. He eventually met Thomas Watson, chairman of the board of the International Business Machines (IBM) Corporation. Watson was fascinated by Gibbon's research and promised help. Soon afterward, six IBM engineers arrived and built a machine that was similar to Gibbon's earlier machine, which contained a rotating vertical cylinder oxygenator and a modified DeBakey rotary pump (Fig. 1-7). Gibbon successfully used this new machine for intercardiac surgery on small dogs and had several long-term survivors, but the blood oxygenator was too small for human patients. Eventually, the team developed a larger oxygenator that the IBM engineers incorporated into a new machine.⁸⁹

View larger version (126K): [in this window] [in a new window]   FIGURE 1-7 A schematic drawing by IBM engineers of the pump oxygenator they designed and constructed under Gibbon's direction. (Courtesy of Thomas Jefferson University Archives, Scott Memorial Library, Philadelphia, PA.)

During this period, C. Walton Lillehei and colleagues at the University of Minnesota studied a technique called controlled cross-circulation.⁵⁷ With this technique the circulation of one dog was temporarily used to support that of a second dog while the second dog's heart was temporarily stopped and opened. After a simulated repair in the second dog, the animals were disconnected and allowed to recover.

Lillehei et al⁹¹ used their technique at the University of Minnesota to correct a ventricular septal defect in a 12-month-old infant on March 26, 1954 (Fig. 1-8). Either a parent or a close relative with the same blood type was connected to the child's circulation. In Lillehei's first clinical case, it was the child's father. The patient had been hospitalized 10 months for uncontrollable heart failure and pneumonitis. The patient made an uneventful recovery until death on the 11th postoperative day from a rapidly progressing tracheal bronchitis. At autopsy, the VSD was closed, and the respiratory infection was confirmed as the cause of death. Two weeks later the second and third patients had VSDs closed by the same technique 3 days apart. Both remained long-term survivors with normal hemodynamics confirmed by cardiac catheterization.

View larger version (59K): [in this window] [in a new window]   FIGURE 1-8 A depiction of the method of direct vision intracardiac surgery utilizing extracorporeal circulation by means of controlled cross-circulation. (A) The patient, showing sites of arterial and venous cannulations. (B) The donor, showing sites of arterial and venous (superficial femoral and great saphenous) cannulations. (C) The Sigma motor pump controlling precisely the reciprocal exchange of blood between the patient and donor. (D) Close-up of the patient's heart, showing the vena caval catheter positioned to draw venous blood from both the superior and inferior venae cavae during the cardiac bypass interval. The arterial blood from the donor circulated to the patient's body through the catheter that was inserted into the left subclavian artery. (Reproduced with permission from Lillehei CW, Cohen M, Warden HE, et al: The results of direct vision closure of ventricular septal defects in eight patients by means of controlled cross circulation. Surg Gynecol Obstet 1955; 101:446. Copyright American College of Surgeons.)

Meanwhile, at the Mayo Clinic only 90 miles away, John W. Kirklin and colleagues launched their open heart program on March 5, 1955.⁹³ They used a heart-lung machine based on the Gibbon-IBM machine, but with their own modifications. Dr. Kirklin wrote⁹⁴:

We investigated and visited the groups working intensively with the mechanical pump oxygenators. We visited Dr. Gibbon in his laboratories in Philadelphia, and Dr. Forest Dodrill in Detroit, among others. The Gibbon pump oxygenator had been developed and made by the International Business Machine Corporation and looked quite a bit like a computer. Dr. Dodrill's heart-lung machine had been developed and built for him by General Motors and it looked a great deal like a car engine. We came home, reflected and decided to try to persuade the Mayo Clinic to let us build a pump oxygenator similar to the Gibbon machine, but somewhat different. We already had had about a year's experience in the animal laboratory with David Donald using a simple pump and bubble oxygenator when we set about very early in 1953, the laborious task of building a Mayo-Gibbon pump oxygenator and continuing the laboratory research.

Most people were very discouraged with the laboratory progress. The American Heart Association and the National Institutes of Health had stopped funding any projects for the study of heart-lung machines, because it was felt that the problem was physiologically insurmountable. David Donald and I undertook a series of laboratory experiments lasting about a year and a half during which time the engineering shops at the Mayo Clinic constructed a pump oxygenator based on the Gibbon model.⁹⁵

...The electrifying day came in the spring of 1954 when the newspapers carried an account of Walt Lillehei's successful open heart operation on a small child. Of course, I was terribly envious and yet I was terribly admiring at the same moment. That admiration increased exponentially when a short time later, a few of my colleagues and I visited Minneapolis and observed one of what was now a series of successful open heart operations with control cross-circulation.

...[I]n the winter of 1954 and 1955 we had 9 surviving dogs out of 10 cardiopulmonary bypass runs. With my wonderful colleague and pediatric cardiologist, Jim DuShane, we had earlier selected 8 patients for intracardiac repair. Two had to be put off because two babies with very serious congenital heart disease came along and we decided to fit them into the schedule. We had determined to do all 8 patients even if the first 7 died. All of this was planned with the knowledge and approval of the governance of the Mayo Clinic. Our plan was then to return to the laboratory and spend the next 6 to 12 months solving the problems that had arisen in the first planned clinical trial of a pump oxygenator.... We did our first open heart operation on a Tuesday in March 1955.

Kirklin continued⁹⁴:

Four of our first 8 patients survived, but the press of the clinical work prevented our ever being able to return to the laboratory with the force that we had planned. By now, Walt Lillehei and I were on parallel, but intertwined paths. I am extremely grateful to Walt Lillehei and am very proud for the two of us, that during that 12 to 18 months when we were the only surgeons in the world performing open intracardiac operations with cardiopulmonary bypass and surely in intense competition with each other, we shared our gains and losses with each other. We continued to communicate and we argued privately in nightclubs and on airplanes rather than publicly over our differences. Walt was more cheerful and more optimistic than I when we discussed problems. I remember saying to him one day, "Walt, I am so discouraged with complete atrial ventricular canal." "Oh, sure," he said, "that is a tough lesion, but we will learn to do well with it."

By the end of 1956, many university groups around the world had launched into open heart programs. Currently, it is estimated that more than one million cardiac operations are performed each year worldwide with the use of the heart-lung machine. In most cases, the operative mortality is quite low, approaching 1% for some operations. Little thought is given to the courageous pioneers in the 1950s whose monumental contributions made all this possible.

	EXTRACORPOREAL LIFE SUPPORT

 
Extracorporeal life support is an extension of cardiopulmonary bypass. Cardiopulmonary bypass initially was limited to no more than 6 hours. The development of membrane oxygenators in the 1960s permitted longer support. Donald Hill and colleagues, in 1972, treated a 24-year-old man who developed shock lung after blunt trauma.⁹⁶ The patient was supported for 75 hours using a heart-lung machine with a membrane oxygenator, cannulated via the femoral vein and artery. The patient was weaned and recovered. Hill's second patient was supported for 5 days and recovered. This led to a randomized trial supported by the National Institutes of Health to determine the efficacy of this therapy for adults with respiratory failure. The study was conducted from 1972 to 1975 and showed no significant difference in survival between patients managed by extracorporeal life support (9.5%) and those who received conventional ventilatory therapy (8.3%).⁹⁷ Because of these results, most U.S. centers abandoned efforts to support adult patients using extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO).

One participant in the adult trial decided to study neonates. The usual causes of neonatal respiratory failure have in common abnormal postnatal blood shunts known as persistent fetal circulation (PFC).^98–101 This is a temporary, reversible phenomenon. In 1976, Bartlett and colleagues, at the University of Michigan, were the first to successfully treat a neonate using extracorporeal life support. Since that time, two prospective studies have shown the efficacy of ECLS for management of neonatal respiratory failure.^102,103 More than 8000 neonatal patients have been treated using ECLS worldwide with a survival rate of 82% (ELSO registry data).

	MYOCARDIAL PROTECTION

 
Alexis Carrel reported in 1914 that "The arresting of the circulation of the heart has already been performed in many ways by various experimenters. We ourselves have used all known methods of stopping the circulation through the heart."¹⁰⁴ He also referred to work of Borrel and others, who had experimented with different forms of myocardial preservation. Carrel goes on to state, "When the above-mentioned precautions were taken, it was possible to clamp the pedicle of the heart (aorta and pulmonary artery) for two and a half or three minutes without any subsequent trouble. As soon as the clamp was removed, the heart resumed its pulsations, and after a very short time, the pulsations were again normal."

Melrose et al¹⁰⁵ in 1955 presented the first experimental study describing induced arrest by potassium-based cardioplegia. Blood cardioplegia was used "to preserve myocardial energy stores at the onset of cardiac ischemia." These authors state, "Ringer drew attention in 1883 to the effect of the differentiations on the heartbeat and Hooker in 1929 suggested that potassium inhibition induced by an excess of potassium chloride could be used to stop the heart when its beat was disorganized by ventricular fibrillation." Melrose goes on to state that "... they have succeeded in evolving a reliable method of stopping and restarting the heart at both normal and reduced body temperatures." Unfortunately, the Melrose solution proved to be toxic to the myocardium, and as a result, cardioplegia was not used widely for several years.

Gay and Ebert¹⁰⁶ and Tyres et al¹⁰⁷ demonstrated that cardioplegia with lower potassium concentrations was safe. Studies by Kirsch et al,¹⁰⁸ Bretschneider et al,¹⁰⁹ and Hearse et al¹¹⁰ demonstrated the effectiveness of cardioplegia with other constituents and renewed interest in this technique. Gay and Ebert in 1973 demonstrated a significant reduction in myocardial oxygen consumption during potassium-induced arrest when compared with that of the fibrillating heart.¹⁰⁶ They also showed that the problems in the use of the Melrose solution in the early days of cardiac surgery probably were due to its hyperosmolar properties and perhaps not to the high potassium concentration.

In a 1978 publication by Follette et al,¹¹¹ the technique of blood cardioplegia was reintroduced. In experimental and clinical studies, these authors demonstrated that hypothermic, intermittent blood cardioplegia provided better myocardial protection than normothermic, continuous coronary perfusion and/or hypothermic, intermittent blood perfusion without cardioplegia solution. The composition of the best cardioplegia solution remains controversial, and new formulations, methods of delivery, and recommended temperature continue to evolve.

	EVOLUTION OF CONGENITAL CARDIAC SURGERY DURING THE ERA OF CARDIOPULMONARY BYPASS

 
With the advent of cardiopulmonary bypass using either the cross-circulation technique of Lillehei et al or the version of the mechanical heart-lung machine used by Kirklin et al, the two groups led the way for intracardiac repairs for many of the commonly occurring congenital heart defects. Because of the morbidity associated with the heart-lung machine, palliative operations also were developed to improve circulatory physiology without directly addressing the anatomic pathology. These palliative operations included the Blalock-Taussig subclavian-pulmonary arterial shunt⁴⁹ with modifications by Potts et al¹¹² and Waterston et al,¹¹³ the Blalock-Hanlon operation to create an atrial septal defect,¹¹⁴ and the Galankin-Glenn superior vena cava–right pulmonary arterial shunt.⁵⁵

As the safety of cardiopulmonary bypass steadily improved, surgeons addressed more and more complex abnormalities of the heart in younger and younger patients. Some of the milestones in the development of operations to correct congenital heart defects using cardiopulmonary bypass appear in Table 1-1. These advances coincided with simultaneous advances in the surgery of adult heart disease, and the same surgeons operated on both children and adults. In the 1970s, although dependent on the same technology and basic knowledge, pediatric and adult cardiac surgery began to separate. Operations for more complex congenital lesions in younger and younger patients required new techniques, and likewise the advent of direct operations for ischemic heart disease required new technology and methods to deal with damaged ventricles and acute complications of ischemia. With the exception of sporadic patients who reached adult life with uncorrected or partially corrected congenital heart defects, cardiac surgery in the adult represents the surgery of acquired heart disease. Nevertheless, a close connection continues because the advances in one subspecialty usually are applicable in the other, and this kinship and interdependence probably will remain for the foreseeable future.

	VALVULAR SURGERY: CARDIOPULMONARY BYPASS ERA

That same year, Starr and Edwards¹¹⁶ successfully replaced the mitral valve using a caged ball valve of their own design. Starr later wrote¹¹⁷:

In 1958, Lowell Edwards presented himself in my office with a proposal to develop an implantable artificial heart. I learned that he was a retired engineer with considerable financial resources. His visit was fortuitous, because just about that time, I had become interested in valvular prostheses.... Edwards agreed to begin the project by working on one valve at a time.... The obvious direction then was towards the ball valve prosthesis. I drew out for Edwards the general configuration of the Hufnagel valve. He then drew out for me how he thought that particular valve could be adapted for intracardiac use using an open cage. The first animal to have this implant survived for more than a year, but all other subsequent animals died of thrombosis.... The big breakthrough came at the end of 1958 when we developed the Silastic shield for the ball valve, which allowed an 80 percent long-term survival.... A Silastic shield over the area where thrombus formed on the valve would give us a chance to have long-term survivors.

The first successful operation was done in September of 1960 on a young girl in her mid-twenties. The patient was in pulmonary edema on oxygen prior to operation, and in excellent condition and wide awake on the evening of the day of the surgery.

By 1967, nearly 2000 Starr-Edwards valves had been implanted, and the caged ball valve prosthesis was established as the standard against which all other mechanical prostheses would be compared.

In 1964, Starr et al reported 13 patients who had undergone multiple valve replacement.¹¹⁸ One patient had the aortic, mitral, and tricuspid valves replaced on February 21, 1963. Cartwright et al, however, on November 1, 1961, were first to successfully replace both the aortic and mitral valves with ball valve prostheses that they had developed.¹¹⁹ Knott-Craig et al,¹²⁰ from the Mayo Clinic, successfully replaced all four heart valves in a patient with carcinoid involvement.

In 1961, Andrew Morrow and Edwin Brockenbrough¹²¹ reported the treatment for idiopathic hypertrophic subaortic stenosis by resecting a portion of the thickened ventricular septum. They referred to this as subaortic ventriculomyotomy. They gave credit to William Cleland and H. H. Bentall in London, who had encountered this condition unexpectedly at operation and resected a small portion of the ventricular mass. The patient improved, but no postoperative hemodynamic studies had been reported. The subaortic ventriculomyotomy became the standard surgical treatment for this cardiac anomaly, although in some patients systolic anterior motion (SAM) of the anterior leaflet of the mitral valve necessitates mitral valve replacement with a low-profile mechanical valve.

An aortic homograft valve was used clinically for the first time by Heimbecker et al in Toronto for replacement of the mitral valve in one patient and an aortic valve in another.¹²² Survival was short, 1 day in one patient and 1 month in the other. Donald Ross reported on the first successful aortic valve placement with an aortic valve homograft.¹²³ He used a technique of subcoronary implantation developed in the laboratory by Carlos Duran and Alfred Gunning in Oxford.

The technique of aortic valve replacement with a pulmonary autograft initially described by Ross in 1967 is advocated by some groups for younger patients who require aortic valve replacement.^124,125 An aortic or pulmonary valve homograft is used to replace the pulmonary valve that has been transferred to the aortic position.

Other autogenous materials that have been used to manufacture valve prostheses include pericardium, fasciae latae, and dura mater. In the 1960s, Binet et al¹²⁶ began to develop and test tissue valves. In 1964, Duran and Gunning in England replaced an aortic valve in a patient using a xenograft porcine aortic valve. Early results with formaldehyde-fixed xenografts were good,¹²⁶ but in a few years these valves began to fail because of tissue degeneration and calcification.¹²⁷ Carpentier et al revitalized interest in xenograft valves by fixating porcine valves with gluteraldehyde. Carpentier also mounted his valves on a stent, to produce a bioprosthesis. Carpentier-Edwards porcine valves and Hancock and Angell-Shiley bioprostheses became popular and were implanted in large numbers of patients.^128,129

Carpentier later wrote, "In 1964 as a young resident in thoracic surgery, I was asked by J. P. Binet, chief of the service, to collect homograft valves from cadavers. Studies of the anatomy of the valves in various animal species showed that the valves from the pigs were the closest to those of humans."¹³⁰ Carpentier described the first successful xenograft valve replacement in 1965, followed by 12 other operations, but within 5 years all the heterograft valves had to be replaced. Carpentier goes on to state:

The use of formalin proposed by O'Brien did not significantly improve the results. I began mounting the valves on a stent in 1966, which permitted the use of heterograft valves in the mitral position. It became obvious that the future of tissue valves would depend upon the development of methods of preparation capable of preventing inflammatory cell reaction, and penetration into the tissue. My background in chemistry is obviously insufficient. I decided to abandon surgery for two days a week to follow the teaching program in chemistry at the Faculty of Sciences and prepare a Ph.D. It is certainly not easy to become a student in chemistry when you are 35 and an associate professor of surgery.

I began to investigate numerous cross-linking inducing factors and found that gluteraldehyde was able to almost eliminate inflammatory reaction....

With the development of cardiopulmonary bypass, valves could be approached under direct vision, and for the first time mitral insufficiency could be attacked by reparative techniques. Techniques for mitral annuloplasty were described by Wooler et al,¹³¹ Reed et al,¹³² and Kaye et al.¹³³ The next step forward was development of annuloplasty rings by Carpentier and Duran. In the 1970s, few groups were involved in valve repairs. Slowly, techniques evolved, were tested clinically, and were followed over the years. Carpentier led the field by establishing the importance of careful analysis of valve pathology, described in detail several techniques of valve repair, and reported good results after early and late follow-up, especially with concomitant use of annuloplasty rings.¹³⁴

From 1966 to 1968, a small epidemic of infective endocarditis in Detroit among heroin addicts broke out. Patients were dying of intractable gram-negative tricuspid valve endocarditis, often due to Pseudomonas aeruginosa. Long-term antibiotic administration in combination with tricuspid valve replacement was 100% fatal. These results prompted Agustin Arbulu and colleagues to remove the tricuspid valve entirely without replacing it in seven dogs in 1969. Six survived with satisfactory hemodynamic performance. Starting in 1970, Arbulu operated on 55 patients; in 53, the tricuspid valve was removed without replacing it.^135,136 At 25 years, the actuarial survival is 61%.

	CORONARY ARTERY SURGERY

 
Alexis Carrel remarked in 1910¹³⁷:

I attempted to perform an indirect anastomosis between descending aorta and the left coronary artery. It was for many reasons a difficult operation. On account of the continuous motion of the heart, it was not easy to dissect and to suture the artery. In one case, I implanted one end of a long carotid artery, preserved in a cold storage, on the descending aorta. The other end was passed through the pericardium and anastomosed to the pericardial end of the coronary near the pulmonary artery. Unfortunately, the operation was too slow. Three minutes after the interruption of the circulation fibrillary contractions appeared, but the anastomosis took five minutes. By massage of the heart, the dog was kept alive, but he died less than two hours afterwards. It shows that the anastomosis must be done in less than three minutes.

In 1930, Claude Beck, a Cleveland surgeon, developed methods to indirectly revascularize the hearts of animals by attaching adjacent tissues in hopes of forming collateral blood flow to ischemic myocardium.¹³⁸ These tissues included pericardium, pericardial fat, pectoralis muscle, and omentum. Postmortem examination showed that anastomotic vessels did develop between these tissues and the myocardium. In the first patient, Beck roughened the outer surface of the heart with a burr and then sutured a pedicle graft of pectoralis muscle to the left ventricular wall.¹³⁹ The patient made an uneventful recovery and was angina-free after the operation. Beck subsequently performed this operation with modifications on 16 patients.¹⁴⁰

Arthur Vineberg, a Canadian surgeon, in 1946 reported implanting the internal mammary artery through a tunnel in the myocardium, but he did not actually anastomose the left internal mammary artery to a coronary artery.¹⁴¹ He showed in animals that communications developed between the internal mammary and the coronary arteries. Contemporary surgeons, however, remained skeptical, but Mason Sones validated Vineberg's concept by demonstrating communications between the graft in the myocardium and the coronary system by angiography in two patients operated on 5 and 6 years earlier. In the middle 1960s the Vineberg operation with many variations was performed at many institutions in the United States and Canada.¹⁴²

At the same time, other surgeons performed coronary arterial endarterectomies. Longmire et al¹⁴³ were the first to report endarterectomy of the coronary arteries for the treatment of ischemic coronary disease. In 1958 they reported five patients, with four hospital survivors. Although the operation was used subsequently by other groups, mortality was high, and the procedure was abandoned as an isolated operation.

Selective coronary angiography was developed by Sones and Shirey, at the Cleveland Clinic, and reported in their 1962 classic paper, "Cine Coronary Arteriography."¹⁴⁴ They used a catheter to directly inject contrast material into the coronary artery ostia. This technique gave a major impetus to direct revascularization of obstructed coronary arteries.

From 1960 to 1967, several sporadic instances of coronary grafting were reported. All were isolated cases and, for uncertain reasons, were not reproduced. None had an impact on the development of coronary surgery. Dr. Robert H. Goetz performed what appears to be the first clearly documented coronary artery bypass operation in a human, which was successful. The surgery took place at Van Etten Hospital in New York City on May 2, 1960.¹⁴⁵ He operated on a 38-year-old male who was severely symptomatic and used a nonsuture technique to connect the right internal mammary artery to a right coronary artery. It took him 17 seconds to join the two arteries using a hollow metal tube. The right internal mammary artery–coronary artery connection was confirmed patent by angiography performed on the 14th postoperative day. The patient remained asymptomatic for about a year, then developed recurrent angina and died of a myocardial infarction on June 23, 1961. Goetz was severely criticized by his medical and surgical colleagues for this procedure, although he had performed it successfully many times in the animal laboratory. He never attempted another coronary bypass operation in a human.

Another example involved a case of autogenous saphenous vein bypass grafting performed on November 23, 1964, in a 42-year-old man who was scheduled to have endarterectomy of his left coronary artery.¹⁴⁶ Since the lesion involved the entire bifurcation, endarterectomy with venous patch graft was abandoned as too hazardous. The anterior descending coronary artery was softer distal to the bifurcation. An autogenous saphenous vein graft was therefore placed from the aorta to the left anterior descending. This was probably the first clinical case of successful coronary artery bypass surgery using saphenous vein. The authors, Garrett, Dennis, and DeBakey, however, did not report this case until 1973. The patient was alive at that time, and angiograms showed the vein graft to be patent.

Shumaker¹⁴⁷ credits Longmire with the first internal mammary to coronary artery anastomosis. It was almost surely Longmire, long-time chairman at UCLA, and his associate, Jack Cannon, who first performed an anastomosis between the internal mammary artery and a coronary branch, probably in early 1958. Longmire wrote:

At that time we were doing the coronary thromboendarterectomy procedure, we also, I think, performed a couple of the earliest internal mammary–coronary anastomoses.... We were forced into it when the coronary artery we were endarterectomizing disintegrated, and in desperation we anastomosed the internal mammary artery to the distal end of the right coronary artery—and later decided it was a good operation.

The reference that Shumaker gives for this quotation from Longmire is a personal communication to Shumaker in 1990, which is 32 years after the fact!

As early as 1952, Vladimir Demikhov, the renowned Soviet surgeon, was anastomosing the internal mammary artery to the left coronary artery in dogs.¹⁴⁸ In 1967, at the height of the Cold War, a Soviet surgeon from Leningrad, V. I. Kolessov, reported his experience with mammary artery–coronary artery anastomoses for treatment of angina pectoris in six patients, in an American surgical journal.¹⁴⁹ The first patient in that series was done in 1964. Operations were performed through a left thoracotomy without extracorporeal circulation or preoperative coronary angiography. The following year, Green et al¹⁵⁰ and Bailey and Hirose¹⁵¹ separately published reports in which the internal mammary artery was used for coronary artery bypass in patients. Bailey and Hirose carried out the anastomosis on the beating heart and advocated using loupes for magnification. Green et al advocated using cardiopulmonary bypass, fibrillating the vented heart, cross-clamping the aorta, and washing all blood from the coronary system while performing the anastomosis.

Rene Favalaro from the Cleveland Clinic used saphenous vein for bypassing coronary obstructions.¹⁵² Favalaro's 1968 article focused on 15 patients, who were part of a larger series of 180 patients who had undergone the Vineberg procedure. In these 15 patients with occlusion of the proximal right coronary artery, an interpositional graft of saphenous vein also was placed between the ascending aorta and the right coronary artery distal to the blockage. The right coronary was divided, and the vein graft was anastomosed end-to-end. Favalaro states that this procedure was done because of the unfavorable results with pericardial patch reconstruction of the coronary artery. In an addendum to that paper, 55 cases were added, 52 for segmental occlusion of the right coronary and 3 others for circumflex disease.

The contributions by Favalaro, Kolessov, Green et al, and Bailey and Hirose were all important, but arguably the official start of coronary bypass surgery as we know it today happened in 1969 when W. Dudley Johnson and coworkers from Milwaukee reported their series of 301 patients who had undergone various operations for coronary disease since February of 1967.¹⁵³ In that report, the authors presented their results with direct coronary surgery during a 19-month period (Fig. 1-9). They state:

After two initial and successful patch grafts, the vein bypass technique has been used exclusively. Early results were so encouraging that last summer the vein graft technique was expanded and used to all major branches. Vein grafts to the left side of the arteries run from the aorta over the pulmonary artery and down to the appropriate coronary vessel. Right-sided grafts run along the atrio-ventricular groove and also attach directly to the aorta. There is almost no limit of potential (coronary) arteries to use. Veins can be sutured to the distal anterior descending or even to posterior marginal branches. Double vein grafts are now used in over 40 percent of patients and can be used to any combination of arteries.

View larger version (21K): [in this window] [in a new window]   FIGURE 1-9 W. Dudley Johnson method of myocardial revascularization. Veins are usually inserted into an area of normal artery; however, if a second area of atherosclerosis occurs (commonly in the mid-anterior descending artery), the arteriotomy extends across the plaque into normal artery on each end. The vein is sutured as a patch graft always extending the anastomosis to normal artery proximally and distally. With progressive atherosclerosis this maneuver preserves bidirectional flow. (Reproduced with permission from Johnson WD, Flemma RJ, Lepley D Jr, Ellison EH: Extended treatment of severe coronary artery disease: a total surgical approach. Ann Surg 1969; 171:460.)

 

Johnson goes on to say:

Our experience indicates that five factors are important to direct surgery. One: Do not limit grafts to proximal portions of large arteries.... Two: Do not work with diseased arteries. Vein grafts can be made as long as necessary and should be inserted into distal normal arteries. Three: Always do end-to-side anastomosis.... Four: Always work on dry, quiet field. Consistently successful fine vessel anastomoses cannot be done on a moving, bloody target.... Five: Do not allow the hematocrit to fall below 35.

In discussing Dr. Johnson's presentation, Dr. Frank Spencer commented, "I would like to congratulate Dr. Johnson very heartily. We may have heard a milestone in cardiac surgery today. Because for years, pathologists, cardiologists, and many surgeons have repeatedly stated that the pattern of coronary artery disease is so extensive that direct anastomosis can be done in only 5 to 7 percent of patients. If the exciting data by Dr. Johnson remain valid and the grafts remain patent over a long period of time, a total revision of thinking will be required regarding the feasibility of direct arterial surgery for coronary artery disease."¹⁵³

The direct anastomosis between the internal mammary artery and the coronary artery was not initially as popular as the vein graft technique; however, due to the persistence of Drs. Green, Loop, Grondin, and others, internal mammary artery grafts eventually became the conduit of choice when their superior long-term patency became known.¹⁵⁴

Denton Cooley and colleagues made two important contributions to the surgery for ischemic heart disease.¹⁵⁵ In 1956, with the use of cardiopulmonary bypass, they were the first to repair a ruptured interventricular septum following acute myocardial infarction. The patient initially did well but died 6 weeks after operation of complications. Cooley et al also were the first to report the resection of a left ventricular aneurysm with the use of cardiopulmonary bypass.¹⁵⁶

Beck¹⁵⁷ in 1944 was the first to successfully excise a left ventricular aneurysm, and Bailey et al¹⁵⁸ in 1951 had five survivors of six attempts with a clamp and oversew technique.

	ARRHYTHMIC SURGERY

 
Sealy et al at Duke University developed the first successful surgical treatment for cardiac arrhythmias.^159,160 A 32-year-old fisherman was referred for symptomatic episodes of atrial tachycardia that caused congestive heart failure. On May 2, 1968, after epicardial mapping, a 5- to 6-cm cut was made extending from the base of the right atrial appendage to the right border of the right atrium during cardiopulmonary bypass. The incision transsected the conduction pathway between the atrium and ventricle. Subsequent epicardial mapping indicated eradication of the pathway. Six weeks after operation heart size had decreased and lung fields had cleared. The patient eventually returned to work.

A year earlier, Dr. Dwight McGoon at the Mayo Clinic closed an atrial septal defect in a patient who also had the Wolf-Parkinson-White syndrome (WPW).¹⁶⁰ At operation, Dr. Birchell mapped the epicardium of the heart and localized the accessory pathway to the right atrioventricular groove. Lidocaine was injected into the site, and the delta wave immediately disappeared. Unfortunately, conduction across the pathway reappeared a few hours later. This was probably the first attempt to treat the WPW syndrome surgically. As a result of knowledge gained from the surgical treatment for WPW syndrome, over 95% of all refractory clinical cases are now treated successfully by nonsurgical means.¹⁶⁰

Guiraudon et al,¹⁶¹ from Paris, France, reported their results with an encircling endomyocardial ventriculotomy for the treatment of malignant ventricular arrhythmias. The following year, in 1979, Josephson et al¹⁶² described a more specific procedure for treatment of malignant ventricular arrhythmias. After endocardial mapping, the endocardial source of the arrhythmia was excised. Although the Guiraudon technique usually isolated the source of the arrhythmia, the incision also devascularized healthy myocardium and was associated with high mortality. Endocardial resection was safer and more efficacious, and became the basis of all approaches for the treatment of ischemic ventricular tachycardia.¹⁶⁰

Ross et al,¹⁶³ in Sydney, Australia, and Cox et al,¹⁶⁴ in St. Louis, Missouri, used cryosurgical treatment of atrial ventricular node reentry tachycardia. Subsequently, Cox, after years of laboratory research, developed the Maze operation for atrial fibrillation.¹⁶⁵

Stimulated by the death of a close personal friend from ventricular arrhythmias, Dr. Mirowski developed a prototype defibrillator over a 3-month period in 1969. In 1980, Mirowski et al described three successful cases using their implantable myocardial stimulator at Johns Hopkins.¹⁶⁶

	PACEMAKERS

 
Lidwill and Booth in Australia supposedly revived a stillborn infant with electrical pacing in the 1920s.¹⁶⁷ Hyman temporarily paced the heart using two needle electrodes that were passed through the ribs and an electrical device of his own design. In the early 1950s, Bigelow and colleagues reported controlling the heart rate in dogs using external pacemakers.⁷⁸

Paul Zoll is given credit for ushering in the clinical era of pacemaking. In 1952, he reported on two patients suffering from recurring prolonged ventricular standstill whom he treated with an external pacemaker.¹⁶⁸ The first patient was a 75-year-old man with complete heart block who had been revived with 34 intracardiac injections of epinephrine over a 4-hour period. Zoll applied electric shocks 2 milliseconds in duration that were transmitted through the chest wall at frequencies from 25 to 60 per minute and increased the intensity of the shock until ventricular responses were observed. After 25 minutes of intermittent stimulation, however, the patient died. Many subsequent patients, however, recovered.

The next step came when Lillehei et al reported a series of patients who had external pacing after open heart surgery during the 1950s.¹⁶⁹ The field of open heart surgery gave a major impetus to the development of pacemakers, because there was a high incidence of heart block following many intracardiac repairs. The major difference between Zoll's pacing and that of Lillehei et al was that Zoll used external electrodes placed on the chest wall, whereas Lillehei et al attached electrodes directly to the heart at operation. Lillehei et al used a relatively small external pacemaker to stimulate the heart and much less electric current. This form of heart pacing was better tolerated by the patient and was a more efficient way to stimulate the heart. The survival rate of Lillehei's patients with surgically induced heart block was significantly improved.

During this period, progress was made toward a totally implantable pacemaker. Elmquist and Senning¹⁷⁰ developed a pacer battery that was small enough for an epigastric pocket with electrodes connected to the heart. They implanted the unit in a patient with atrioventricular block in 1958. Just before implantation, the patient had 20 to 30 cardiac arrests a day. To avoid publicity, the implantation was done in the evening when the operating rooms were empty. The first pacemaker that was implanted functioned only 8 hours; the second pacemaker implanted in the same patient had better success. The patient survived until January 2002 and had many additional pacemakers. Chardack, Gage, and Greatbatch are perhaps better known for their development of the totally implantable pacemaker.¹⁷¹ In 1961 they reported a series of 15 patients who had pacemakers implanted that they had developed. The technique for inserting permanent transvenous bipolar pacemaker electrodes was developed in 1962 by Parsonnet et al¹⁷² in the United States and Ekestrom et al¹⁷³ in Sweden.

Early implantable pacemakers were fixed-rate, asynchronous devices that delivered an impulse independent of the underlying cardiac rhythm. During the past 35 years, enormous progress has been made in the field of pacing technology. The number of individuals with artificial pacemakers is unknown; however, estimates indicate that approximately 500,000 Americans are living with a pacemaker and that each year another 100,000 or more patients require permanent pacemakers in the United States.

	HEART, HEART-LUNG, AND LUNG TRANSPLANTATION

 
Alexis Carrel and Charles Guthrie reported transplantation of the heart and lungs while at the University of Chicago in 1905.¹⁷⁴ The heart of a small dog was transplanted into the neck of a larger one by anastomosing the caudad ends of the jugular vein and carotid artery to the aorta and pulmonary artery. The animal was not anticoagulated, and the experiment ended about 2 hours after circulation was established because of blood clot in the cavities of the transplanted heart. Carrel also reported in 1906 that he had transplanted the heart and lungs of a 1-week-old cat into the neck of a larger cat.¹⁷⁵ The coronary circulation was immediately reestablished, and the "auricles began to beat. The lungs became red and after a few minutes effective pulsation of the ventricles appeared." Carrel stated that a phlegmon of the neck terminated this observation 2 days later.

Vladimir Demikhov, the great Soviet investigator, described more than 20 different techniques for heart transplantation in 1950.¹⁷⁶ He also published various techniques for heart and lung transplantation. He was even able to perform an orthotopic heart transplant in a dog before the heart-lung machine was developed. This was accomplished by placing the donor heart above the dog's own heart, and then with a series of tubes and connections, he rerouted the blood from one heart to the other until he had the donor heart functioning in the appropriate position and the native heart removed. One of his dogs climbed the steps of the Kremlin on the sixth postoperative day but died shortly afterwards of rejection.

Richard Lower and Norman Shumway established the technique for heart transplantation as it is performed today.¹⁷⁷ Preservation of the cuff of recipient left and right atria with part of the atrial septum was described earlier by Brock¹⁷⁸ in England and Demikhov¹⁴⁸ in the Soviet Union, but it became popular only after Shumway and Lower reported it in their 1960 paper. Shumway stated¹⁷⁹:

In 1958 when I started work at Stanford, the idea [cardiac transplantation] grew out of our local cooling experiments, since we had one hour of aortic cross-clamping during cardiopulmonary bypass. Accordingly we decided to remove the heart at the atrial level and then to suture it back into position. After several of these experiments, we found it would be easier to remove the heart of another dog and to do the actual allotransplant. Something like 20 to 30 experiments were performed before we had a survivor. All of this was done before chemical immune suppression was available.

The first attempt at a human heart transplantation was made by Hardy et al¹⁸⁰ at the University of Mississippi. Since no human donor organ was available at the time, a large chimpanzee's heart was used; however, it was unable to support the circulation because of hyperacute rejection.

The first human-to-human heart transplant occurred December 3, 1967, at the Groote Schuur Hospital in Capetown, South Africa.¹⁸¹ The surgical team, headed by Christiaan Barnard, transplanted the heart of a donor who had been certified dead after the electrocardiogram showed no activity for 5 minutes into a 54-year-old man whose heart was irreparably damaged by repeated myocardial infarctions. The second human heart transplant using a human donor was performed on a child 3 days after the first on December 6, 1967, by Adrian Kantrowitz in Brooklyn, New York. Dr. Kantrowitz's patient died of a bleeding complication within the first 24 hours.¹⁸² Barnard's patient, Lewis Washkansky, died on the 18th postoperative day. At autopsy, the heart appeared normal, and there was no evidence of chronic liver congestion, but bilateral pneumonia, possibly due to severe myloid depression from immunosuppression, was present.¹⁸³

On January 2, 1968, Barnard performed a second heart transplant on Phillip Blaiberg, 12 days after Washkansky's death.¹⁸⁴ Blaiberg was discharged from the hospital and became a celebrity during the several months he lived after the transplant. Blaiberg's procedure indicated that a heart transplant was an option for humans suffering from end-stage heart disease. Within a year of Barnard's first heart transplant, 99 heart transplants had been performed by cardiac surgeons around the world. However, by the end of 1968, most groups abandoned heart transplantation because of the extremely high mortality related to rejection. Shumway and Lower, Barnard, and a few others persevered both clinically and in the laboratory. Their efforts in discovering better drugs for immunosuppression eventually established heart transplantation as we know it today.

A clinical trial of heart-lung transplantation was commenced at Stanford University in 1981 by Reitz et al.¹⁸⁵ Their first patient was treated with a combination of cyclosporine and azothioprine. The patient was discharged from the hospital in good condition and was well more than 5 years after the transplant. Reitz's clinical success was based on earlier experiments with primates using allografts.^186,187 These primate recipients survived for more than 140 days when cyclosporine A was used for immune suppression. Several of these animals lived for more than 5 years after allotransplantation.¹⁸⁸

The current success with heart, heart-lung, and lung transplantation is in part related to the discovery of cyclosporine by workers at the Sandoz Laboratory in Basel, Switzerland, in 1970. In December of 1980, cyclosporine was introduced at Stanford for cardiac transplantation. The incidence of rejection was not reduced, nor was the incidence of infection. However, these two major complications of cardiac transplantation were less severe when cyclosporine was used. Availability of cyclosporine stimulated many new programs across the United States in the mid-1980s.

Andre Juvenelle showed that animals could survive autologous lung transplantation for many years.¹⁸⁹ Lung transplantation from dog to dog was fatal when attempted in the early 1950s.¹⁹⁰ Some animals, however, survived with an autotransplant up to 29 days before succumbing to rejection.¹⁹¹ The first human lung transplant was performed by Hardy et al¹⁹² at the University of Mississippi on June 11, 1964. A pneumonectomy for carcinoma with pleural adhesions had to be performed first. The patient died on the 17th postoperative day. In 1971, a Belgian surgeon, Fritz Derom, achieved a 10-month survival in a patient with pulmonary silicosis.¹⁹³

Much of the credit, however, for the success of lung transplantation belongs to the Toronto group whose efforts were headed by Joel Cooper. Their successes were based on laboratory experimentation and the discovery of cyclosporine. After losing an early patient to bronchial anastomotic dehiscence in 1978, the group substituted cyclosporine for cortisone and wrapped the bronchial suture line with a pedicle of omentum. They also developed a comprehensive preoperative preparation program that increased the strength and nutritional status of the recipients. In 1986, Cooper and associates presented their first two successful patients, who had returned to normal activities and were alive 14 and 26 months after operation.¹⁹⁴ This success was the culmination of more than 40 previous attempts throughout the world made after Derom's case.

	HEART ASSIST AND ARTIFICIAL HEARTS

 
The concept of intraaortic counterpulsation was first described by Harken¹⁹⁵ in 1958 and reported by Clauss et al¹⁹⁶ in 1961. This idea proposed removal of blood via the femoral artery during systole and rapid reinfusion of the same blood during diastole to increase coronary perfusion. Technical difficulties and complications secondary to hemolysis delayed clinical use until 1962, when Moulopoulos et al introduced a balloon catheter placed in the thoracic aorta.¹⁹⁷ In 1963, Kantrowitz et al reported the first use of the intraaortic balloon pump in three patients.¹⁹⁸ All were in cardiogenic shock but improved during balloon pumping. One survived to leave the hospital.

Akutsu and Kolff reported the development and first application of a totally artificial heart in an animal model at the Cleveland Clinic in 1957.¹⁹⁹ The authors implanted a totally artificial heart in a living dog that survived for 90 minutes with the mechanical heart.

In 1963, Liotta et al reported a 42-year-old man who had a stenotic aortic valve replaced but suffered a cardiac arrest the following morning.²⁰⁰ The patient was resuscitated but developed severe ventricular failure. An artificial intrathoracic circulatory pump was implanted. The patient's pulmonary edema cleared, but he died 4 days later with the pump working continuously. In 1966, the same group used a newer intrathoracic pump to support another patient who could not be weaned from cardiopulmonary bypass. This pump maintained the circulation. The patient eventually died before the pump could be removed.²⁰¹ Later that year, the same group used a left ventricular assist device in a woman who could not be weaned from cardiopulmonary bypass after double valve replacement.²⁰² After 10 days of circulatory assistance, the patient was weaned successfully from the device and recovered. This woman was probably the first patient to be weaned from an assist device and to leave the hospital.

The first human application of a totally artificial heart was by Denton Cooley and colleagues as a "bridge" to transplantation.²⁰³ They implanted a totally artificial heart in a patient who could not be weaned from cardiopulmonary bypass. After 64 hours of artificial heart support, heart transplantation was performed, but the patient died of Pseudomonas pneumonia 32 hours after transplantation. The first two patients successfully bridged to transplantation were reported at almost the same time and in the same location by different groups. On September 5, 1984, in San Francisco,²⁰⁴ Donald Hill implanted a Pierce-Donachy left ventricular assist device in a patient in cardiogenic shock. The patient received a successful transplant 2 days later and was later discharged. The assist device used by Hill was developed at Pennsylvania State University by Pierce and Donachy. Phillip Oyer and associates at Stanford University placed an electrically driven Novacor left ventricular assist device in a patient in cardiogenic shock on September 7, 1984.²⁰⁵ The patient was transplanted successfully and survived beyond 3 years. The device used by the Stanford group was developed by Peer Portner.

The first implantation of a permanent totally artificial heart (Jarvik-7) was performed by DeVries et al at the University of Utah in 1982.²⁰⁶ By 1985, they had implanted the Jarvik in four patients, and one survived for 620 days after implantation. This initial clinical experience was heavily based on the work of Kolff and associates.

The effort to use autologous skeletal muscle to assist the failing circulation began in 1959 when Adrian Kantrowitz wrapped diaphragm around the canine aorta to produce diastolic counterpulsation.²⁰⁷ The problem of muscle fatigue was solved in 1969 when Salmons and Vrbova²⁰⁸ discovered that fast-twitch fibers found in skeletal muscle could be transformed into slow-twitch fatigue-resistant fibers by chronic electrical stimulation of the motor nerve. That observation led Macoviak et al and Mannion et al to develop electrical conditioning protocols for fiber transformation of large canine muscles^209,210 and Dewar et al²¹¹ to develop the concept of burst stimulation to increase the force of muscle contraction. These advances prompted several surgeons to wrap latissimus dorsi muscle around ventricles of failing hearts and stimulate the muscle to contract during systole. Alain Carpentier first performed this procedure in a patient in 1985.²¹² Subsequently, more than 600 patients worldwide have had this procedure, known as cardiomyoplasty. Carpentier's group was also first to wrap latissimus dorsi muscle around the human aorta and then stimulate the muscle during cardiac diastole and use this as an aortic diastolic counterpulsator somewhat like the intra-aortic balloon pump. To date, at least 25 of these clinical procedures have been done worldwide.²¹³ An alternative method to harness skeletal muscle power to the circulation is to wrap a muscle around a pericardial or endothelial cell-lined pouch attached to the thoracic aorta.²¹⁴ Canine studies have demonstrated that these skeletal muscle ventricles continue to function for over four years.²¹⁵

	THORACIC AORTA SURGERY

 
Alexis Carrel was responsible for one of the great surgical advances of the 20th century: techniques for suturing and transplanting blood vessels.²¹⁶ Although Carrel initially developed his methods of blood vessel anastomosis in Lyon, France, his work with Charles Guthrie in Chicago led to many major advances in vascular, cardiac, and transplantation surgery. In a short period of time, these investigators perfected techniques for blood vessel anastomoses and transposition of arterial and venous segments using both fresh and frozen grafts. After leaving Chicago, Carrel continued to expand his work on blood vessels and organ transplantation and in 1912 received the Nobel Prize. Interestingly, Carrel's work did not receive immediate clinical application.

Rudolph Matas pioneered clinical vascular surgery. Matas's work took place before drugs were available to prevent blood clotting, before antibiotics, and without reliable blood vessel substitutes.²¹⁷ Matas performed 620 vascular operations between 1888 and 1940. Only 101 of these were attempts to repair arteries; most involved ligation. Matas developed three variations of his well-known endoaneurys-morrhaphy procedure. The most advanced was to reconstruct the wall of the blood vessel from within while using a rubber tube as a stent.

Vascular surgery advanced tentatively during World War II as traumatic injuries to major blood vessels were repaired in some soldiers with results significantly better than with the standard treatment of ligation.²¹⁸ The successful treatment of coarctation of the aorta by Crafoord and Gross added a major boost to the reconstructive surgery of arteries.

Shumaker reported the excision of a small descending thoracic aortic aneurysm with reanastomosis of the aorta in 1948.²¹⁹ Swan et al²²⁰ repaired a complex aneurysmal coarctation and used aortic homograft for reconstruction in 1950. Gross²²¹ reported a series of similar cases using homograft replacement. In 1951, DuBost et al,²²² from Paris, resected an intra-abdominal aortic aneurysm with homograft replacement.

In 1953, Henry Bahnson,²²³ from Johns Hopkins, successfully resected six saccular aneurysms of the aorta in eight patients. In the same year, DeBakey and Cooley²²⁴ reported a 46-year-old man who had resection of a huge aneurysm of the descending thoracic aorta that measured approximately 20 cm in length and in greatest diameter. The aneurysm was resected and replaced with an aortic homograft approximately 15 cm in length.

During the Korean War, the arterial homograft and autogenous vein graft were used to reconstruct battlefield arterial injuries and reduce the overall amputation rate to 11.1%,²²⁵ compared to the rate of 49.6 % reported in World War II. Although the vein autograft remains the first-choice peripheral vascular conduit today, the arterial homograft was superseded by the development of synthetic vascular grafts by Arthur Voorhees at Columbia University in 1952. Voorhees et al developed Vinyon-N cloth tubes to substitute for diseased arterial segments,²²⁶ but because of kinking, these smooth-lined tubes could not be used across joints. Development of the crimped graft by Edwards and Tapp²²⁷ and the introduction of Dacron by DeBakey²²⁸ were important milestones. DeBakey's account of his discovery of Dacron reflects the resourcefulness and innovation of these pioneering surgeons²²⁸:

We were greatly impressed with the report of Voorhees on the use of a fabric woven of Vinyon-N. On my first trip to obtain some of these fabrics from a department store here, I found that they only had some sheets of Dacron. I purchased several yards and cut them in different sizes to make tubes by sewing on my wife's sewing machine. I had been taught by my mother as a boy to sew and I became an expert not only in the use of the sewing machine, but also on the other aspects of sewing. These tubes proved highly successful in animals, and although we later obtained sheets of Orlon, Teflon, nylon and Ivalon, none of these were as good as the original Dacron fabric. It was rather interesting and an example of serendipity that the first material we obtained (Dacron), the only one available at the store at the time, proved later to be the best. One of these Dacron grafts that I had fabricated as a bifurcation graft was used to replace an aneurysm of the abdominal aorta in September, 1954.

Another advance in aortic surgery appeared in 1955 when DeBakey et al²²⁹ reported six cases of aortic dissection treated by aggressive surgery. This paper included a description of pathologic and hemodynamic factors associated with the dissections and led to a more logical approach to treatment of these lesions. Because mortality of operation for acute dissections remained high, Myron Wheat, Jr., introduced medical therapy for the disease.²³⁰

During the late 1950s the Houston group, Michael DeBakey, Denton Cooley, Stanley Crawford, and their other associates, systematically developed operations for resection and graft replacement of the ascending aorta,²³¹ descending aorta, and the thoracoabdominal aorta.²³² Cardiopulmonary bypass was used for the ascending aortic resections. The high risk of paraplegia highlighted a major complication of thoracoabdominal aortic resections. The Houston group was the first to resect an aortic arch with the use of cardiopulmonary bypass in 1957²³³ and replace the arch with a reconstituted aortic arch homograph (Fig. 1-10). More interesting is that Cooley et al, using great ingenuity, resected a large aortic arch aneurysm that also involved a portion of the descending aorta in a 49-year-old patient on June 24, 1955. The surgery was done, without the use of cardiopulmonary bypass, by first sewing in a temporary graft from the ascending aorta to the distal descending aorta and sewing in two more temporary limbs off that graft, which were anastomosed to the left and right carotid arteries while the aneurysm was resected and a permanent graft was placed.²³⁴

View larger version (157K): [in this window] [in a new window]   FIGURE 1-10 Homograft replacement of the ascending aorta. Drawings showing final anastomosis of homograft to base of ascending aorta (inset) and appearance after completion of all anastomoses to homograft. (Reproduced with permission from DeBakey ME, Crawford ES, Cooley DA, Morris GC Jr: Successful resection of fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet 1957; 105:657. Copyright American College of Surgeons.)

	SUMMARY

 
The history of adult cardiac surgery continues to be written and will continue to evolve as long as acquired heart disease shortens lives. In the early days after the introduction of cardiopulmonary bypass, the pace of advance was torrid but, in a way, narrowly focused. Now hundreds of thousands of clinicians, scientists, and engineers are involved in a broad and deep effort to develop new and safer operations and procedures, new valves, new revascularization techniques, new biomaterials, new heart substitutes, new life-support systems, and new methods to control cardiac arrhythmias and ventricular remodeling after injury. This research and development are supported by a vigorous infrastructure of basic science in biology and medicine, chemistry and pharmacology, and engineering and computer technology. The history of cardiac surgery is only a prelude; the moving finger writes and having writ moves on to a bright, exciting future.