Part XXII- Episode 5- Poking the Sleeping Giant The Advent of Myocardial Protection Standing on Tall Shoulders- The History of Cardiac Surgery by Thomas N Muziani PA-C, CP

“Often a healing takes place in ourselves as we pray for the healing of others” – Michael E. DeBakey (1908-2008)

Prologue:

With the reanimation of potassium based cardioplegia in the United States during early 1970… a true renaissance emerged for both cardiac innovation and the pioneers effectuating the new procedures.

René Gerόnimo Favaloro’s revolutionary surgical proposal in 1968- “Aorto-coronary artery implantation with saphenous vein bypass grafting utilizing heart-lung machine” provided patients with atherosclerotic coronaries for the first time in surgical history… with a do-over. However, this initial nomenclature of “aorto-coronary artery…” was too long and confusing to constantly write down for scheduling, administration…and patients. Hence, the universal adoption for the acronym “CABG” (pronounced cabbage) – Coronary Artery Bypass Grafting. The revolution in cardiac repair metamorphosed from embryonic to newborn rather quickly.

Cardiac surgeons were anointed Primus inter pares by 1970- first among equals. This operation, coupled with cardiac reparative procedures, insured a daily full schedule of surgeries which kept the heart rooms bustling. “Open-heart” surgery (a technical misnomer) suddenly became the media darling, supplanting craniotomies as the “Golden Child”…or Golden Egg-depending upon what floor you worked- operating room or finance. The donations began to pour into our institution. Every new piece of equipment displayed a gold plaque glued to it with someone’s name etched that donated the funds to purchase it. The donors and media were ecstatic with the visual and the hospital featured the plaques prominently with any solicitation for funds. To quote author Tom Wolfe from his novel The Right Stuff: “No bucks…no Buck Rogers.” These were the halcyon days for cardiac surgery, innovation and those wonderful gadgets.

Concurrently- the Cardiac Catheterization Laboratory was transforming its somewhat dated image. Many institutions remodeled their Cath Labs to accommodate new equipment- from analyzing, recording, monitoring to the latest diagnostic catheters. The physiologic monitors now incorporated color matched alpha numerics (digital readouts) synchronized with their respective waveforms. The information was analyzed, updated and displayed every three seconds. This three second calculation interval was intentional and partially derived after laborious studies based upon the rapidity that an average human eye blinks. This was by no means a small feat. This author was invited to participate at General Electric Monitoring Division in Kenosha, Wisconsin in assisting with developing an electronic language so the alpha numerics would comprehend, speak and instantly update what the waveforms were conveying. This coding had to be written in machine language-MoS DOS during these years. I have the utmost respect for programmers. They have the patience of Job. Diagnosis became immediate and course of treatment with consensus would occur within minutes- not days.

Another serendipitous benefactor bestowed upon cardiac surgery and medicine as a whole that is never discussed but created its own technical revolution during the early 1970’s…was the glorious gift of innovation provided to medicine and mankind by NASA.

When the National Advisory Committee for Aeronautics (NACA) which evolved into National Aeronautics and Space Administration (NASA) proposed its vision of space exploration to Dr. Wernher von Braun on 20 June 1945, they made two issues readily apparent: 1) It had to be accomplished quickly 2) It had to be within a workable budget. President Harry S. Truman, who had just assumed office after President Roosevelt’s death on 12 April 1945 was an extremely frugal individual. He proudly maintained a plaque on his desk that read: “The Buck Stops Here”.

Dr. Wernher von Braun, a brilliant visionary albeit pure Aryan Nazi, had worked on the development of the V1 rocket for Adolf Hitler and Nazi Germany during World War Two. Through a rather surreptitious and somewhat dubious authorization, Dr. von Braun was covertly brought to America along with 1,600 other German scientists, engineers and technicians during the end of the war. Together they were sequestered in Huntsville Alabama with the task of developing the first intermediate-range ballistic missile program for the United States. A missile does not discriminate between a nuclear bomb or humans hitching a ride.

With pressure to produce a viable rocket capable of carrying humans into space within a relatively short time frame and within tight budget constraints, the only workable option available to them was to adopt the “use and discard” concept. When a rocket takes off, once the first stage expends its fuel and no longer serves a purpose, it is tossed away to burn up in the atmosphere. The same procedure was applied to the second stage. This same philosophy applied to the Lunar Lander and the Lunar Base Module during Apollo and worked exceedingly well. If it no longer serves a purpose there really is no valid reason to haul it back to Earth.

Unfortunately, this corporate mindset of “use and discard” which proved exceedingly efficient and successful in application, now metastasized to how NASA treated their personnel. NASA hierarchy, some of whom had worked for General Motors, incorporated the GM mantra of “design obsolescence.” Alfred P. Sloan, who became President of General Motors in 1924, realized the American automobile market was reaching saturation. He gave his engineers and designers the task of tweaking the cars just enough that consumers would feel compelled they needed the latest model in their garage every year. The concept worked beautifully and GM made a fortune.

Out of necessity, NASA’s growth exploded so quickly due to the myriad of details that demanded instant resolution…it quickly became a managerial nightmare. NASA’s logical answer; design obsolescence.  Once a program achieved its goals, the scientists, engineers and technicians were let go. The Mercury, Gemini and Apollo programs maintained their own distinct group of specialists. The big difference; upon termination, all of them placed all those wonderful inventions and toys in their figurative brief cases as they walked out the door. And the world has collectively benefited beyond Tang, whatever that drink developed for space travel pretends to be, ever since. The inventions are too numerous to mention in this article- but just a small sample; transducer technology, non-invasive self-inflating blood pressure cuffs, finger clip-on oxygen saturation monitors and synchronizing portable lightweight heart defibrillators.

Out of necessity, most Intensive Care Units at major and minor hospitals were forced out of their collective torpor with a mandate to re-invent themselves. Up until this time “recovery” rooms really had not evolved since the turn-of-the-century (1900’s). It was still rather profound to imagine that only fifty years earlier, the average patient would only consent to go to hospital when they were going to die. “ICU” was still one large recovery room with beds separated by pull sheets suspended from the ceiling. If, by some chance a patient went into cardiac arrest… all the other patients became unwilling spectators to the drama, with the inevitable question of: “is that what they’ll do to me if my heart stops?”

Interestingly, this is also about the same time that nurses decided to shed their nursing caps which, at the time, were nursing dress de rigueur since Florence Nightingale. The caps were as diverse as nursing schools and as small as “pill box” variants all the way up to Sister Bertrille flying wings. Some nurses actually wore heavily starched flying wings…albeit, they were mostly nuns. The obvious fortunately won out; head cover can be a detriment and downright dangerous when someone is in cardiac arrest or spewing fluids from every orifice. Plus the times were changing rapidly. Men no longer wore top hats or spats and women’s dress length went from ankle to knee length or higher.

As nursing became savvy to the latest techniques gleaned from exposure with very active cardiac programs around the country… that acquired knowledge became self-evident to be very marketable when negotiating salary with any new or existing hospital. Therefore, this empirical expertise transformed moribund cardiac programs in America rather quickly during the early 1970’s. New techniques, new equipment and new procedures…it was very exciting to be a participant in changing outcomes forever.

With cardiac surgery becoming routine at most institutions, mortality rates dropped appreciably. Perfusion, perfusion products and perfusion equipment expanded at light speed. Perfusion meetings became a must-attend affair. Myocardial protection, re-invigorated by the re-emergence of potassium based cardioplegia became a much discussed topic again. Patients, that only a few years earlier would have been sent home to settle up their affairs and say good-byes, were now treated as routine cases with outcomes improving dramatically across the country.

A four hour cross clamp no longer routinely prompted cold sweats and rapid pulse with the ever present mantra repeatedly ringing in your ears: “All Bleeding Stops…Eventually”

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Perfusion Theory is an educational platform for the Oxygen Pressure Field Theory (OPFT). August Krogh’s theoretical concept of the oxygen pressure field is explained and then applied to clinical applications in perfusion practice.