August/september 1983 | Volume 34, Issue 5
“A wound in the heart is mortal,” Hippocrates said two thousand years ago. Until very recently he was right.
IN MAY OF 1975, when I was fortyseven, I developed angina (heart pain due to an insufficient supply of blood to the heart muscle), and about two months later, after a stress test, a coronary angiogram, and various blood tests, I underwent an operation. The operation was a coronary artery bypass in which veins from my leg were used to bypass the obstructed arteries of my heart. For about one hour, while this was being done, my heart was stopped and a heart-lung machine did the work of pumping and oxygenating my blood, work ordinarily performed by rny heart and lungs.
In the eight years that have passed since my operation, I have lived a full life, practicing surgery, writing, playing tennis and racquetball, and, in general, enjoying myself. I have not once had an attack of angina.
I am a very lucky man. If I had been born twenty-five years earlier, if I had been forty-seven in 1950 and developed angina then, I would probably not have lived more than a couple of years; and if I had, I could have done so only by greatly restricting my activity. In 1950 there were no stress tests, no angiograms, no heart-lung machines, and, of course, no open-heart surgery, which has existed for barely thirty years. When we realize that in 1983 there will be about eighty thousand coronary by-passes performed, and that thousands of other hearts will be opened so that congenital anomalies can be repaired and new valves inserted to replace worn-out or diseased valves, we begin to appreciate how rapidly heart surgery has progressed in a very short time.
Hippocrates, who was born in 460 B.C. and is regarded as the father of medicine, wrote, “A wound in the heart is mortal”; with few exceptions the heart remained sacred territory, outside the bounds of surgery, for centuries. Theodor Billroth, the famous Viennese surgeon who first successfully removed a stomach cancer and who devised the operation still in general use for partial stomach removal for ulcer or cancer, wrote in the 1880s, “Any surgeon who wishes to preserve the respect of his colleagues would never attempt to suture the heart.” When a man of Billroth’s eminence spoke, surgeons listened; in fact, it’s probably safe to say that Billroth’s writings delayed the development of heart surgery for many years.
But not, as we know, indefinitely. Surgeons are generally adventurous people, and when confronted by acute problems, insoluble by medical means, they will at least consider a surgical approach. Knife and bullet wounds of the heart fall into that category, and by 1909, despite Billroth’s edict, 109 cases of suturing of wounds of the heart had appeared in the surgical literature. True, 60 percent of these patients died, most of them because of infection, but without suturing the mortality would have approached 100 percent. Still, the British surgeon Stephen Paget, who knew of some of these successful cases, wrote in 1895, “Surgery of the heart has reached the limits set by Nature to all surgery; no new method and no new discovery, can overcome the natural difficulties that attend a wound of the heart.”
As is true of most advances in surgery, progress in heart operations was related to developments in other fields. For example, it was 1846 when William Morton, a medical student and one-time dentist, first demonstrated the use of ether as an anesthetic (in the famous “ether dome” of Massachusetts General Hospital); in 1895 Wilhelm Roentgen discovered the X ray; and in 1901 Karl Landsteiner discovered blood typing, which eventually made transfusions safe and practical. These three advances, once they had been refined and accepted, all contributed significantly to the advance of heart surgery—as, of course, did Alexander Fleming’s discovery of penicillin in 1928.
From 1912 on, sporadic attempts were made at elective surgical repair of heart problems. On May 20, 1923, for example, Elliott Cutler, professor of surgery at Harvard, operated on an eleven-year-old girl who was totally bedridden, constantly coughing up blood, all because the mitral valve of her heart, the valve that separates the left atrium (the chamber that collects blood from the lungs) from the left ventricle (the chamber that pumps blood out to all the organs of the body except the lungs), had been damaged by rheumatic fever. The girl had mitral stenosis, a condition usually caused by rheumatic fever and one that was extremely common until the advent of penicillin (which enabled doctors to prevent rheumatic fever by promptly treating streptococcal infections).
Cutler operated on her beating heart by inserting a sharp instrument through the wall of her heart until it had, in his estimation, reached the mitral valve, which he then cut, blindly of course.
His little patient lived, in improved health, for four and a half more years. But the next six patients on whom Cutler operated died, and, discouraged, he gave up on the operation.
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.
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.
“Dr. Wangensteen was really an imaginative man. On one wall of his office he kept a list of all the staff surgeons and what their special interests were. For example, next to his name was written ‘stomach cancer and duodenal ulcer.’ Whatever his special interest was, that surgeon was supposed to keep up to date on all the literature and sort of specialize in those operations.
“I finished my residency in 1951 and went on the staff. I was in his office one day and he asked me what I wanted to list as my special interest. I said, “Open-heart surgery,” and without batting an eye that’s what he wrote down next to my name, even though at that time no one had ever done an open-heart operation. That’s the kind of man he was.”
In 1954 Dr. Lillehei and his coworkers tried a new approach to open-heart surgery, a technique they had worked out on dogs. Their patients were almost invariably children with congenital heart defects, usually holes between the walls that were supposed to separate one chamber of the heart from another. They would attach the patient’s circulatory system to that of one of the parents—using plastic tubes inserted into blood vessels in the groin—and the parent would, in effect, act as the heart-lung machine for the patient. “When we proposed doing this, there was a lot of opposition, of course, as there always is to anything new. At a surgical meeting where we explained what we planned to do, one surgeon said, ‘You’ve got a chance to get in the record books; you may perform the first operation with 200 percent mortality.’
“It didn’t work out that way. In fact, of the forty-five cases we did between 1954 and 1955, not one donor died. We lost sixteen patients, but we saved twenty-nine; and you have to remember that, without surgical repair, all fortyfive would almost certainly have died.
“In retrospect, it was actually an excellent way to repair heart defects in very sick children, because during the cross-circulation the healthy parent’s body corrected any metabolic problems that the child might have. Remember, in 1954 we didn’t know the importance of potassium and blood acidity and all the other things we know now.”
Late in 1955 Lillehei and his team gave up the cross-circulation technique because Lillehei and Richard DeWall, a former general practitioner who had decided he wanted to get into research, developed a heart-lung machine that was not only simple but reliable. “We had always known we could get oxygen into the blood,” Lillehei said. “All we had to do was bubble oxygen into it. The problem was getting the bubbles out. Once we solved that, using a helixshaped series of coils to return blood to the patient, we were home free. Sure, there were surgeons who said we’d wind up pumping air into the patients and they’d get air emboli and have strokes and other problems, but that never happened. The bubble oxygenator worked beautifully.”
As a matter of fact, the heart-lung machines that are now used routinely all over the world are almost exclusively of the bubble oxygenator type developed by Lillehei, DeWall, and their coworkers in 1955. It is for this invention, as well as for his pioneering work in hypothermie total-inflow occlusion and cross-circulation surgery, that C. Walton Lillehei is often referred to as the father of open-heart surgery.
F ROM 1955 ON , progress in heart surgery was rapid. In 1941 cardiac catheterization had been developed, enabling physicians to take blood samples from and measure pressures in all the chambers of the heart. In 1962 Dr. Mason Sones, at the Cleveland Clinic, developed a technique for taking X rays of the blood vessels of the heart. With catheterization and accurate X-ray methods, diagnosis of heart disorders became specific and reliable; and with reliable heart-lung machines available so that the heart could be safely stopped, at least temporarily, all sorts of heart repairs became practicable.
On January 23, 1964, Dr. James Hardy did the first heart transplant in a human; unfortunately he had to use a chimpanzee heart as a replacement, there being no human donor available, and it was too small to sustain the patient. In 1967 Dr. Christiaan Barnard, who had been trained by Lillehei, did the first successful human-to-human heart transplant. (It was followed by a worldwide and premature explosion of heart transplants, few of which were successful.) By 1982, however, due primarily to the work of Dr. Norman Shumway at Stanford, and to the development of new antirejection drugs, the one-year survival rate after heart transplantation was near 75 percent, and the projected five-year survival rate was at least 50 percent.
In 1968 the first coronary bypass graft was done, and since that time heart surgeons have never looked back. Last December surgeons at the University of Utah implanted the first total, plastic artificial heart in Barney Clark, a sixty-one-year-old retired dentist from Seattle. This heart was planned as a permanent replacement; that is, it was not intended to be replaced by a donor heart. It was powered by an outside source, about the size of a vacuum cleaner, and Clark’s mobility was severely limited. This plastic heart beat in Barney Clark’s body for 112 days; he died on March 23, brought down at last by “circulatory collapse and secondary multiorgan system failure,” as the hospital report put it. The 112 days of life that were given to Clark by the procedure make it almost inevitable that within the next few years an artificial heart, probably run by an implantable power source, will become a realistic option for those afflicted with otherwise terminal heart disease. Once that is accomplished, I can’t foresee any other new worlds for cardiac surgeons to conquer. They will finally have done it all.