A Short History Of Heart Surgery

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I THINK MOST surgeons would agree that a landmark case in modern heart surgery took place on August 26, 1938, when Dr. Robert Gross successfully operated on a seven-and-a-half-year-old girl with a condition known as a patent ductus arteriosus. The ductus is an artery that connects the aorta with the pulmonary artery and is part of the embryological development of the heart. Ordinarily it closes before the baby is born. When the ductus remains open, it weakens the heart and makes it susceptible to infection. It is now considered a relatively simple operation for a cardiac surgeon to divide a ductus—the mortality rate is less than one percent—but that first successful case triggered an explosion of interest in heart surgery.

For roughly the next fifteen years heart surgery was done on the beating heart. As late as 1959, when I was chief resident on the Cornell Surgical Division at Bellevue Hospital, I remember assisting Dr. Cranston Holman, our director of surgery, as he operated on a mitral valve. With the heart exposed he put a purse-string suture in the tip of the atrium, and as I held the purse-string suture snug, he snipped off the tip of the atrium, known as the auricular (earlike) appendage. He then took off his glove and, as I loosened the purse-string suture, he worked his finger into the heart until he could feel, and fracture, the calcified, narrow valve. As he removed his finger, I tightened the purse-string suture.

I remember that moment as if it were yesterday because, as I tightened the silk suture, Dr. Holman said, “Tighter, Bill,” and I pulled it tighter. Again, he said, “Tighter,” and, though I had a feeling I was making a mistake, I followed his instructions—and the suture broke. There was, of course, an immediate copious gush of blood from the now open and pumping heart. In less than a second Dr. Holman, never even momentarily losing his poise, pinched the hole shut between his thumb and index finger. “Bill,” he said, his voice remarkably calm, “do you think you could put in another pursestring suture while I hold the heart shut?” I did, and this time the suture held. Our patient, by the way, recovered nicely.

We were, as was often the case at Bellevue, just a little behind the rest of the surgical world. John Gibbon of Philadelphia, who had been trying to devise a heart-lung machine since the 1930s, had finally produced one that worked, at least occasionally. In 1953, after his first three patients died, he successfully repaired a heart defect in an eighteen-year-old girl who was dependent on Gibbon’s pump for twenty-six minutes. Further success with the Gibbon pump was, unfortunately, extremely limited.

“Sometimes you’d open the heart only to find that you had the wrong diagnosis; all you could do was close it up.”
 

Meanwhile, at the University of Minnesota, C. Walton Lillehei had discovered that, if you lowered the temperature of a patient to about eighty-two degrees Fahrenheit, you could occlude all the inflow to the heart, open the heart, and make repairs under direct visualization, without using a pump. Others, notably Henry Swan of Denver, were also successfully using the new technique called hypothermia. Unfortunately you needed a relatively healthy heart to withstand this total inflow occlusion; the hypothermia technique was only applicable to patients with specific life-threatening but relatively uncomplicated defects. “One of the most discouraging things about those early days of open-heart surgery,” Dr. Lillehei said to me recently as we sat in the backyard of his home in St. Paul, “was that the diagnostic methods weren’t as accurate as we would have liked. Sometimes you’d open the heart, only to find that you had the wrong diagnosis and the condition was one you couldn’t help. All you could do then was close it up. But in 1952 John Lewis, with whom I was working, often did two or three cases successfully in a week. The trick was to make certain you had the right diagnosis.”

Dr. Lillehei, one of the many pioneers of heart surgery, retired from practice in 1975, at the age of fiftyseven. “I decided to take a year off, in 1975, to write a book about congenital heart surgery, and I got caught up in other things and never went back. I keep telling myself I still might but I probably won’t. To tell you the truth, I think coronary artery bypass operations must be kind of tedious and boring.” Dr. Lillehei had been Professor of Surgery at Cornell Medical School from 1968 until 1975, but it was about his years at Minnesota, from 1945 until 1968, that I wanted to talk.

“They were exciting times,” he said. “Minnesota was really the center of world activity in heart surgery, due largely to Dr. Wangensteen’s influence. [Dr. Owen Wangensteen, one of the giants of modern surgery, was Professor of Surgery at Minnesota from 1931 until 1967; he died in 1980.] He didn’t have much personal interest in heart surgery—he was always caught up in stomach and colon surgery—but he supported those of us who were interested. He believed that if you could work problems out on dogs in the laboratory, then you were justified in applying the answers to humans.