Part IV – Closing Atrial “Loop Holes” – Standing on Tall Shoulders – The History of Cardiac Surgery by Thomas N Muziani PA-C, CP
“A successful surgeon should be a man who, when asked to name the three best surgeons in the world, would have difficulty deciding on the other two” -Denton Cooley
1952-1954: The Dawn of Open Heart Surgery
True open heart surgery had yet to be successfully accomplished at the beginning of 1952. However, on 15 April of that year, Robert E. Gross at Boston Children’s Hospital successfully utilized his “atrial well” technique to close an atrial septal defect (ASD). This ingenious technique involved creating a “well”. A soft, plastic material was sewn to the pericardium and right atrium, thereby creating a “well” which would flood the area with blood thus preventing air from entering the atrium. The surgeon was then able to place his index finger into the atrium and explore the atrial structures and, hopefully, perform the necessary repair working beneath the layer of blood in the pocket of his creation.
I had the good fortune to work with a very creative surgeon that insisted in order to “accurately palpate” the mitral structures, he must remove the portion of his glove on his right index finger. It really was quite a visual, watching this surgeon with his eyes closed in a trance, bare index finger, digitally penetrate under the well of blood the open atrium…and then occasionally utilizing a scimitar blade, perform his magic on a malfunctioning mitral valve. He used a glove to create his “well”.
This method precluded direct vision. However, as I mentioned, in clever hands this permitted remarkable results. Using this technique in 1954, Dr. John Kirklin at the Mayo Clinic successfully corrected a partial common atrialventricular (AV) canal (combined atrial and ventricular defects).
On 2 September 1952, John F Lewis and colleagues at University of Minnesota successfully closed an ASD under direct vision during 5.5 minutes of circulatory arrest (caval inflow occlusion) permitted by moderate surfaced-induced hypothermia (26° C). Dr. Wilfred E. Bigelow, from Toronto Canada, as a combat surgeon during World War II, was very frustrated and depressed that he could not provide extra corrective time to young vibrant soldiers that suffered massive chest wounds. The rampant, unabated bleeding allowed only a very short window between repair and death.
One night, recalling his youth and falling through the ice during freezing winters in Canada…he remembered the hibernating groundhog. He recalled how it controlled it’s furnace during times of stress and hibernation. Hypothermia could be the solution he was looking for to provide time to perform the necessary repair. In 1949 he perform the first open heart surgery utilizing hypothermia on a dog. When he returned to Canada after the war, his techniques for surfaced-cooled hypothermia using a rubber sheet and ice became widely adapted. Dr. Bigelow also developed the world’s first pacemaker.
By February 1954, Dr. Lewis had utilized his surface-induced hypothermia technique 11 more times with only two deaths; one was a patient with primum ASD who developed surgical complete heart block for which no therapy was then available.
Henry Swan and colleagues at University of Colorado also started using hypothermia and brief periods of circulatory arrest and accomplished open repair of both valvular or infundibular pulmonic stenosis and ASD in 12 patients between 19 February and 9 July 1953, with only one death. This method, although it continued to be used for several years for surgical repair of these defects, had the obvious time limitation of about 8 to 10 minutes. It was apparent to everyone that a machine to support the patient and permit the surgeon time to accomplish complex intracardiac repairs under direct vision was necessary.
This leads me to the remarkable story of John H. and Mary Gibbon.
The date was 3 October 1930. John Gibbon had just started a 1-year surgical research fellowship (this was immediately after his internship) at Massachusetts General Hospital under the guidance of Dr. Edward D. Churchill. John was assigned to study animal models of pulmonary embolism. Dr. Churchill felt John would benefit from the task of monitoring a young woman who had suffered a massive pulmonary embolism following a cholecystectomy. The patient was transferred to the operating room (this was standard procedure), where she was to be observed until she had deteriorated sufficiently to justify an attempt to perform a Trendelenburg procedure (closed pulmonary embolectomy).
These patients are in a tremendous amount of pain and John Gibbon was assigned to watch her all night. As he observed her and began to fixate on her distended veins and increasing cyanosis…he realized that if he could only remove her venous blood, bypass her heart and lungs, then oxygenate the blood and return it to her arterial system…she could be saved. But such technology did not yet exist. The patient did not recover from the pulmonary embolectomy performed the next morning.
However, this experience convinced Dr. Gibbon that he must try to develop a heart-lung machine. Over the next three years, he poured over all the previous work he could find on the subject and discussed his ambition with numerous colleagues, with mostly negative positions and the supposed experts doubting its feasibility. John Gibbon remained positive and more intractable in his desire to develop a machine that could take over the function of the heart and lungs and provide anesthesia. He obtained a second year research fellowship with Dr. Churchill in 1934-1935 and, together with his new wife Mary, who had been Dr. Churchill’s research assistant, built a working heart-lung machine. Without going into too much detail, I will mention that Mary Gibbon should be considered very much the equal in research, enthusiasm and pragmatic approach in the development of the heart-lung machine as Dr. John Gibbon. She was a brilliant woman, kindred spirit, the kindest soul and a true visionary in the field of perfusion.
I sincerely hope someday the American Society of Extracorporeal Technology places her on the Pedestal she deserves. For all intents and purposes, she was the First Perfusionist.
By the end of 1935, they had supported cats for up to 171 minutes of total cardiopulmonary bypass (CPB). John and Mary continued their research at University of Pennsylvania and by 1939 they were able to report long-term survivors among cats subjected to total CPB for 10 to 20 minutes. With the outbreak of World War II, John enlisted in the service and spent 4 years on active duty.
Eventually, after years of work, experimentation and failed surgeries, Dr. Gibbon became dejected and declared a moratorium on the use of his Heart-Lung Machine.