20 Jun The Slow Disappearance of Iconic Cardiac Pioneers
Cardiac surgery is a relatively young specialty having evolved for the most part in the second half of the twentieth century, when the use of pacemakers, postoperative antibiotics, postoperative ventilators, and various cardiac and antiarrhythmic drugs gradually became common. Most of these new techniques evolved in the early years of cardiac surgery between 1955 and 1965 and brought about a profound drop in the risk of cardiac operations from a 30 to 40 percent risk of death in 1955 to less than a 5 to 10 percent risk by 1965.
Since the time of Hippocrates, there has been a difference between those who practice medicine and those who practice surgery. Internists practice the “art” of medicine, while surgeons lean more to the “craft.” These two divisions have taken different paths over time. Medicine has slowly, but steadily, progressed as new information has been published, scientific discoveries have been made, and pharmacology has advanced. Surgical progress, on the other hand, has been held in slow motion by the long absence of anesthesia and the problem of postoperative infections. Although there have been many inventive and gifted surgeons in the past, operations in the 1880’s and early 1900’s remained relatively rare because of the horror of pain and the risk of infection. When an operation was necessary before the discovery of anesthetic agents, all efforts were concentrated on speed and speed alone. Of the surgical subspecialties, cardiac surgery has been the most dependent on evolving technology; hence its development did not really begin until one hundred years after the introduction of anesthesia.
Many physicians and surgeons invented and developed new approaches in the medical and surgical treatment of pediatric and adult cardiac disease. These people are known as iconic pioneers. By the Oxford and the Merriam Webster dictionaries, a pioneer is “one who is first or among the earliest in a field, a person who helps create or develop new ideas, a person who is among the first to research an area of knowledge, a person widely known and acknowledged especially for distinctive work”. As cardiac surgical procedures became safer in the mid-1960s, numerous medical centers acquired a catheterization laboratory and a heart-lung machine and developed a cardiac surgical service. In pediatric and adult cardiology and cardiac surgery we are still using, refining and developing from these inventive and innovative pioneers. I will review a few of these iconic pioneers, some I had the privilege to meet.
An important medical turning point came in 1941 when include first name Cournand demonstrated that cardiac catheterization was a safe method in man. In the technical field major progress came from Scandinavia were rapid filming angiography was born. The Seldinger technique, also known as Seldinger wire technique, is a medical procedure to obtain safe access to blood vessels. Dr. Svan Seldinger, a Swedish radiologist, introduced the procedure in 1953. Dr. Kurt Amplatz, an Austrian radiologist, performed one of the first percutaneous cardiac catheterization in 1958, in fact using the Seldinger technique. Further progress was initiated in 1977 by Gruentzig who invented the balloon angioplasty. Gruentzig’s first successful coronary angioplasty treatment on an awake human was performed in September 1977,in Zurich, Switzerland. He expanded a short, about 3 mm, stenosis of the left coronary artery. His work is widely recognized in leading the development of all subsequent catheter interventions.
The natural history of untreated Transposition of the Great Artery (TGA) in the neonate is poor. The medical treatment of TGA was greatly enhanced by the role of Balloon Atrial Septostomy, a non-surgical procedure to create an atrial septal defect, described for the first time by Rashkind and Miller from Philadelphia in 1966.4 Early palliation by creation of an intra-atrial communication was possible, remaining since then, an integral part of cardiac catheterization in neonates.
The common standard of closing an atrial septal defect, a common congenital heart defect found in infants, is surgery. There was an impetus to find a non-surgical approach, using a device inserted by percutaneous catheter placement, thus avoiding open-heart surgery. A 17 year-old girl underwent an atrial septal defect closure with the King-Mills umbrella on April 8, 1975, at the Ochsner Clinic in New Orleans, Louisiana. In 1983, Rashkind reported using a single foam-covered device with hooks, a modification of the first umbrella. This device was abandoned because of embolization. Drs. Lock, Hellenbrand, Latson, and Benson modified the Rashkind ASD device in 1985 and initial human use was begun in 1987 by Dr. Hellenbrand at Yale. Lock’s experience and observations lead him to a conceptual variation of the spring-loaded Rashkind Patent Ductus Arteriosus (PDA) device. Between 1987 and 1991, the Lock Clamshell was used successfully in approximately 1,000 patients; however, a significant number of early and late arm fractures lead to elective withdrawal of the device. The Lock Clamshell device further proved the feasibility of transvenous closure of ASDs. The Atrial Septal Defect Occluder System (ASDOS) was reported by Babic in 1990. His device used a long venoarterial wire track and a pair of self-opening umbrellas made of stainless steel and covered with preserved pericardium. The CardioSeal device (NMT Medical, Boston, MA) was reported by Latson in 1996 and evolved from the Lock Clamshell. The Amplatzer Septal Occluder, developed by Dr. Kurt Amplatz, is a self-centering device with two circular retaining discs that are made of nitinol wire mesh connected by a short connecting waist. The first clinical trial was reported in 1997, and the device has since been used extensively worldwide.
Medical pioneers are not only inventors of new technologies, devices or pharmaceutical discovery, but have brought an unparalleled understanding of pediatric and adult congenital heart disease. Heart disease in children was mainly diagnosed as rheumatic in origin and relatively little was known. What decade? Dr. Taussig had earlier established a cardiac clinic at the Johns Hopkins Hospital in Baltimore, Maryland, and Dr. Abbott of Montreal had compiled 1,000 cases of congenital heart disease, published in atlas form in 1936. During the mid- and late 1950s Drs. Keith, Rowe, and Vlad published extensively on many forms of congenital heart disease, focusing attention on clinical and angiocardiographic diagnoses and surgical outcomes. The first edition of the now classic textbook Heart Disease in Infancy and Childhood written by Drs. Keith, Rowe and Vlad was published in 1958 and the 3rd and final edition in 1978. Dr. first name? Van Praagh, a native Torontonian, trained in paediatrics and cardiology at The Hospital for Sick Children in Toronto. who was a …? most re-known morphology anatomist and pathologist from Boston has made some of the most important contributions on the segmental approach to congenital heart disease including those papers on the anatomy and diagnosis of single ventricle and dextrocardia. His british counter part and colleague, Dr. Robert Anderson, was responsible for demonstrating the location of “Invisible” conduction tissues within the heart and clarifying the morphology of the congenitally malformed heart and other complex congenital heart disease. Dr. Robert Freedom, from the Hospital for Sick Children, Toronto, has published extensively in the 80’s and the 90’s on a wide range of insight and knowledge on congenital heart disease. He has centrally participated in the enormous advances in the science, diagnosis and treatment of pediatric cardiology. Dr. Jane Sommerville, from London, UK, has been the pioneer in the 80’s and 90’s,of the, then, new field of adult congenital heart disease, bringing a force and awareness of the complexity of adult congenital heart disease. She lead the development of international specific training in this new discipline.
The surgical field is populated by an amazing number of pioneers. In the 1950s, Bill Bigelow developed the idea of making heart operations safer. Bigelow trained in surgery at Toronto General Hospital in the Gallie program until he enlisted in the Canadian Army Medical Corps as a military surgeon in 1941, returning to Toronto to further pursue surgery in 1945. Bigelow conducted the first closed mitral valvotomy in Toronto in the early 1950’s and pursued his research using hypothermia as a medical procedure. This involves reducing a patient’s body temperature prior to an operation in order to reduce the amount of oxygen needed, making the body’s oxygen requirements less while lowering the body’s core temperature to a point at which safe open heart surgery was possible. The first successful human application of Bigelow’s hypothermia research for open-heart surgery occurred in 1953. Meanwhile, he had pioneered another major advance in the management of heart disease, the pacemaker, which evolved, quite unexpectedly, out of his hypothermia research in 1951.
On October 19, 1944, Crafoord and Nylinin from Sweden reported the first successful end-to-end anastomosis of the aorta after resection of an aortic coarctation. Robert Gross, of Boston, performed his first successful coarctation resection and anastomosis on July 6, 1945. Shortly thereafter, on May 24, 1948, Gross successfully replaced a longer segment of a resected coarctation with a preserved arterial homograft with methods devised by Charles Hufnagel for the preservation of human homografts. The stage was set for the rapid developments that were to follow. On June 28, 1949, Henry Swan, apparently, was the first to resect an aneurysm associated with a coarctation and to replace the resected area with a homograft. In 1951, Robert Gross reported five cases of aneurysm associated with coarctation treated by resection and graft. DeBakey and Cooley reported the first case of a successful resection and graft of a fusiform thoracic aneurysm that was performed January 5, 1953.In 1954, DeBakey and his group began working on various materials for grafts. DeBakey collaborated with Professor Thomas Edman, a Philadelphia textile engineer, to build a new knitting machine that would make seamless Dacron grafts of all sizes, shapes, and configurations with a satisfactory material: the principle was established. In 1955 Sterling Edwards reported the development of nylon prostheses and also devised a technique of crimping prosthetic grafts. Nylon did not hold, but Teflon and Dacron grafts followed in short order.
Along the way, children were dying of congestive heart failure and/or cyanosis. A major break-through was in the development of a novel operation for cyanotic children. This was first done in 1944 by the surgeon, Alfred Blalock, and Helen Taussig, a pediatric cardiologist. The Blalock Hanlon procedure was later developed for cyanotic children with transposition of the great arteries by Vivien Thomas (a research fellow of Blalock) at the Hunterian Laboratory (“the dog house”), more commonly known as the, “Dog House” at Johns Hopkins Universtiy and described by Alfred Blalock and C. Rollins Hanlon in 1950. It was one of the most important surgical developments in the treatment of cyanotic babies. Both procedures are still used today.
While progress was being made, one major obstacle remained. How to master and bypass the circulation to perform cardiac surgery?. The first successful open heart procedure on a human utilizing the heart lung machine was performed by John Gibbon on May 6, 1953 at Thomas Jefferson University Hospital in Philadelphia. He repaired an atrial septal defect in an 18-year-old woman. Unfortunately, it was a very complex technique and 4 patients died. The technique was stopped. The situation changed in March 1954 when Walton Lillehei and his associates—Morley Cohen, Herb Warden, and Richard Varco—used controlled cross-circulation to correct a ventricular septal defect in an 11-year-old boy. The boy’s anesthetized father served as the oxygenator. Blood flow was routed from the patient’s caval system to the father’s femoral vein, and then returned to the patient’s carotid artery. The cardiac defect was repaired with a total pump time of 19 minutes. Over the ensuing 15 months, Walton Lillehei operated on 45 patients with otherwise irreparable complex interventricular defects.
In 1952, John Kirklin, from Rochester, decided to pursue research on the development of a heart-lung machine. He modified the Gibbon machine, improving the original pumping and oxygenator system. The Gibbon’s machine was further developed into a reliable instrument by Kirklin’s surgical team, performing the world’s first series of open-heart operations using this new heart-lung machine. 9 out of 10 cardiopulmonary bypass runs were successful and his team decided that they were ready to proceed with intracardiac repairs in humans. Beginning in 1955, a clinical trial on eight children was approved by the governance of the Mayo Clinic. That same year, Richard A. DeWall and Walton Lillehei introduced the first clinically successful bubble oxygenator, which remained the standard for extracorporeal circulation for many years before the membrane oxygenator arrived in the late 60’s.
This article is not a complete historical review of adult and pediatric cardiac surgery. Instead, it is a review of the major innovative techniques and discoveries by the people who pioneered them. I do not take into account the surgical skills, teaching, and other aspects of practicing medicine for these pioneers. It is exclusively addressing the innovative prowess, capabilities, and the consummate desire to advance the field. As I said, I had the privilege to meet some of these pioneers who were at the core of my learning and practice.
So, why am I questioning “The Slow Disappearance of Iconic Cardiac Pioneers?” My thoughts have come full circle in relation to how the field of cardiac sciences is developing. I do not question the current advancements, developments and innovative approaches within the current practices, but I am not seeing this progress related to one or a few iconic pioneers. I do not see the name of a cardiac “pioneer” attached to the current cardiac innovations. May be it is my mistake to attach innovation to specific pioneers. Cardiac sciences has progressed leaps and bounds since the discoveries of these “larger than life” innovators, but it seems to me that we are mainly building, developing and innovating on science that already exists in principle. Perhaps I am still attached to the historical development of cardiac sciences and it’s pioneers as I was somewhat a part of it. I would argue however, that the complexity of our medical and pharmaceutical industries, the rules from the FDA and other controlling agencies and the quality assurance requirements at all levels, have contributed to the multiple bureaucratic steps in developing new technologies, treatments and medicine such that the process of innovating is burdened with bureaucracy. Don’t get me wrong, there is an explosion of research at all levels of the medical and surgical fields and lead by capable, knowledgeable, interested and innovative leaders. Leaders who must conform to a system that drives what is “revolutionary” and no longer allows the individual to drive progress. What advancements might be missed in our current approach to innovating? As the iconic pioneers slowly disappear, are we loosing the approach that creates the next major leap forward in cardiac care? Or perhaps we are at a period in time where new break through are just around the corner and there will be a new generation of iconic cardiac pioneers. I wonder who they will be?