Part V – Drs. Gibbon and Lellehei – Standing on Tall Shoulders – The History of Cardiac Surgery by Thomas N Muziani PA-C, CP

“What mankind can dream-research and technology can achieve”

  1. Walton Lillehei

Dr. John Gibbon had completed his full 4 year term of active duty service during World War II and now he was able to return to Mary and their animal experimentation in the hope of creating a viable  heart-lung machine at University of Pennsylvania. The skeptics and pessimists were as vocal as ever, which promulgated a widespread dismissal and concern that a viable heart-lung machine would never be produced. Even the University had subtly informed John and Mary that funds for their project would not be forthcoming. Fortunately, several power players at International Business Machines Corporation (IBM) assured John and Mary that funds would be available and they could proceed. IBM thereby entered into collaboration on the project and the clout behind that name. This assurance from such a prestigious corporation kept the University silent, the laboratory available and the pessimists mute.

By the end of 1952, John and Mary had developed a heart-lung machine that featured a vertical screen oxygenator and, from a flow standpoint, was capable of supporting a human. With this machine, he achieved an almost 90% survival in maintaining the circulation in dogs.

In February of 1952, Dr. John Gibbon, with Mary as his Perfusionist, first used his heart-lung machine clinically on a 15-month-old child . She died during surgery because she had an undiagnosed PDA* instead of the anticipated ASD. However, his next patient, an 18-year-old operated on 6 May 1953, had her ASD successfully closed during 26 minutes of full bypass. Thus, after 23 years  John and Mary Gibbon achieved that elusive goal conceived as a resident physician and despite the public acrimony that weighed heavily during all the trials and experimentations.

To compound his issues with self doubt and the unfortunate set of circumstances that one cannot foresee at the time, there presented two patients, both 5½ years old with ASD’s. He operated on them during July of 1953. Both died-one from cardiac arrest prior to cannulation and the other from an unsuspected coexisting ventricular septal defect (VSD) and PDA resulting in exsanguinating blood loss in the field*.

Upon reflection and with pragmatic logic, Dr. Gibbon declared a moratorium on further use of the heart-lung machine. To compound this feeling of hopelessness, the next 12 attempts at cardiopulmonary bypass (CPB) conducted by 5 other groups, all ended with the death of their patient. This appeared to reinforce the general belief that a heart-lung machine required way too many parameters to constantly monitor in order to maintain a viable patient.

The Father of Open Heart Surgery:

Throughout history, you will always find certain individuals that, for a myriad of reasons, propel their respective profession to a much higher level. The reasons for this are as varied as the professions. I believe I have found one common trait that is suffused into their psyche and most likely at an early age.

The gift of tenacity.

John Gibbon faced a relentless fusillade of criticism, detractors and pessimists for over a quarter century on why the heart-lung machine would not work. It placed a heavy toll on John and Mary. However, in the short period of one  generation, the heart-lung machine and as a result, cardiac surgery has evolved into the elegant science where we can place a person on CPB for over 10 hours with a 7 hour cross clamp, and their heart spontaneously conducts in normal sinus rhythm prior to cross clamp removal.

Dr. Clarence Walton Lillehei, as the ever inquisitive “tinkerer” that he was, realized the main drawback to John Gibbon’s heart-lung machine was not in the apparatus itself, as was the general assumption…but in the oxygenator. Gibbon’s vertical stainless steel screen oxygenator was too cumbersome, prone to too many problems such as foaming and clotting…it also leaked like it was made of cheesecloth.

Walt Lillehei was born in Minneapolis in 1918. Very early on Walt displayed technical dexterity in taking apart and rebuilding the family’s Model-T Ford. He received his pre-medical and medical training at University of Minnesota, earning an undergraduate degree in 1939, an MD in 1942, a master’s in physiology, and a doctorate in surgery in 1951.

With the outbreak of World War II, Dr. Lillehei served in the Army Medical Corp, rising to the rank of lieutenant colonel and earning a Bronze Star for meritorious services. In 1945, he returned to University of Minnesota to complete his residency under Dr. Owen Wangensteen, who demanded a close collaboration between surgeons and physiologists and insisted that all surgeons participate in laboratory research.

By the mid-1950’s Dr. Lillehei had become a full-time instructor and then clinical professor when his career was interrupted by a devastating health crisis: at age 31, he was diagnosed with lymphosarcoma of the parotid gland. He underwent head and neck surgery with mediastinal exploration and subsequent radiation. He recovered slowly but completely, albeit, with a lifelong head tilt.

Upon regaining his health Dr. Lillehei decided to focus all his efforts on cardiac surgery, particularly the development of open heart surgery. Knowing John Gibbon extremely well and sharing extensive discussions on Johns’ frustrations with the technical minefields he was encountering, Walt Lillehei formulated his own plan that he considered two-fold. The first would be to find a way in which he could perform the necessary repair without utilizing a heart-lung machine. The second was to fully entrench himself and his students in finding a solution to the current pitfalls of extracorporeal circulation.

In March of 1954, C. Walton Lillehei accomplished the first goal. Along with his associates, Morley Cohen, Herb Warden and Richard Varco, he 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 boy’s caval system to the father’s femoral vein and lungs, where it was oxygenated and then returned to the boy’s carotid artery. The cardiac defect was repaired with a total “pump time” of 19 minutes. Over the next 15 months, Lillehei operated on 45 patients with otherwise irreparable complex interventricular defects; most of these patients were less than 2 years old.

Although cross-circulation was a major advance and accomplished Dr. Lillehei’s first goal, it did pose a major risk; the possibility of having two dead patients from one surgery. Nevertheless, this method provided the way for the open heart surgery era. Lillehei and associates had proven that intracardiac repair was not only viable but, it could provide a quality of life that without the operation would mean certain death.

For this achievement, Drs. Lillehei, Cohen, Warden and Varco won the Albert Lasker Award in medical research in 1955. For this and many other accomplishments, almost all surgeons around the world consider Dr. C. Walton Lillehei the “Father of Open Heart Surgery”.

Next: Chapter VI: Dr. Lillehei’s Second Plan Takes Root

* Surgeons quickly realized that an unsuspected patent ductus would certainly cause excessive bleeding while on CPB, and thus they routinely sought to look for its presence (and ligate it if observed) prior to proceeding on with CPB.

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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.