Part II – Truly Remarkable Decades – Standing on Tall Shoulders The History of Cardiac Surgery – by Thomas N Muziani PA-C, CP
“I want to know God’s thoughts…all the rest are details.” Albert Einstein 1907
A small issue of extreme importance must be kept in context with regard to the invasive nature of cardiac surgery during the period of 1907 and before. These major surgeries were being performed before the era of endotracheal tubes, antibiotics and blood transfusion! By the time of the American Civil War broke out in 1861, both ether and chloroform had been in use for several years (developed in 1840). Chloroform soon emerged as the anesthetic of choice since ether was highly flammable. I can attest to this concern about ether and flammability because that was the anesthetic we used on babies at the University of Washington, Seattle, where I trained. The downside to chloroform was its ease in killing someone.
During the period of 1900-1902, blood typing was first identified by Landsteiner and others. Blood typing prior to transfusion was introduced by Ottenberg in 1907. However, in order to accomplish satisfactory anticoagulation of blood with citrate (A. Hustin and L. Agote) with the addition of glucose (Rous and Turner), in order for it to be bottled and stored to allow administration…that did not happen until 1915-1916. It is not a coincidence that blood typing and proper storage of blood occurred during this period…Europe was embroiled in a major war and the need for replacement blood was of paramount importance.
During 1902, Sir Lauder Brunton working at St. Bartholomew’s Hospital, London, England was ecstatic over the good results he was experiencing in surgically treating wounds of the heart based on his autopsy studies and animal experiments. He published his results in the journal The Lancet suggesting there might be a possibility for the surgical treatment of mitral stenosis. He made mention of how incapacitating this condition was and the fact that conventional medical therapy could do nothing to ameliorate the stenosis.
He made the astute observation of how easy it was to separate the adherent cusps (i.e. fused commissures) at autopsy and advocated consideration of surgically splitting the valve along the adherent contact margins (a procedure that would eventually be called commissurotomy).
However, as I have discovered so often, his suggestion was met with strong disapproval in subsequent issues of The Lancet, including an editorial, which excoriated his failure to completely study the problem experimentally. Then, they went on to suggest that such an operation would probably prove fatal…and if it did not prove fatal, its benefits would most likely be temporary. Finally, to insure his point, the editor went on to “instruct” Sir Brunton that the prognosis of mitral stenosis depended as much on the condition of the myocardium as on the size of the mitral orifice. Needless to say, these criticisms stifled and snuffed out any further research on the subject for the next 20 years.
In 1920, Elliott Cutler and C.S. Beck at the Peter Bent Brigham Hospital in Boston, Mass (Harvard), began experiments that eventually led to the first successful operation for mitral stenosis, on 20 May 1923. Unfortunately, their operation was designed to relieve the stenosis by cutting the leaflet (rather than splitting the commissure), with the false assumption that mitral insufficiency was less serious than mitral stenosis. In retrospect, the procedure was ill-conceived after operating on six subsequent patients. The last one occurring on 15 April 1928. None of the patients survived.
During this early period of the 1920’s, there was another successful mitral valve operation. This was performed by Henry Souttar in London on 6 May 1925. He used a transatrial digital dilitation- a technique that was resurrected by Brock in 1948. Unfortunately, the patient was found to have considerable mitral regurgitation on initial exploration and benefited minimally from the procedure.
However, Souttar was very pleased with the information he gleaned from the exploration-and he gained a true appreciation of the reality of stenosis and regurgitation. Once again, a surgeon was denied the opportunity to further experiment because: “The physicians declared that it was all nonsense and that the operation was unjustifiable”. “It was an article of faith with physicians that the valves were of no importance and that the only thing that mattered was the condition of the cardiac muscle. Successful conquest of mitral stenosis would have to wait another 23 years.
During the first quarter of the 20th century many notable developments occurred. Fredrich Trendelenburg, performing extensive experimentation in his laboratory in Leipzig, Germany, attempted the first pulmonary embolectomy with normothermic inflow occlusion (the Trendelenburg procedure) in two patients in 1907-1908, neither of whom survived. Despite numerous surgeons attempting this same procedure, success eluded them all. Finally, Martin Kirschner of Konigsberg, who was a student of Trendelenburg, finally reported success on 18 March 1924. By 1935 approximately 142 Trendelenburg operations had been performed. Unfortunately, there were only 9 hospital survivors. As will be described later, this operation provided a pivotal impetus in the development of the first successful heart-lung machine by Dr. John Gibbon Jr.
As a result of gaining a better understanding of the pathophysiology of chronic constrictive pericarditis as first described by Cheevers of London in 1882 and Friedel Pick of Germany in 1896, Ludwig Rehn of Frankfurt and Ferdinand Sauerbruch of Berlin both performed successful pericardiectomies in 1913. Claude Beck of Cleveland Clinic, utilized this procedure extensively, based on his observations of vascular adhesions between the pericardium and epicardium.
1938-1948: The Dawn of Closed Heart Surgery That Enthralls The World
This truly remarkable decade laid the foundations for the rapid acceleration in advancing cardiac surgery. Out of necessity (due to technological limitations), it began with closed heart surgery. Closed heart surgery became a reality on 28 August 1938, when a dynamic and curious 33-year-old chief resident at Children’s Hospital in Boston successfully ligated a patent ductus arteriosus (PDA) while his chief, William Ladd, was away on vacation.
Robert E. Gross had immersed himself for this surgery with copious experimentation in the laboratory coupled with 3 years of training in pathology. As history has displayed so often in cardiac surgery, another surgeon missed the opportunity for this historic first the previous year. John W. Strieder came very close to obliterating an infected ductus arteriosus on 16 March 1937. This was a young woman who was doing extremely well until she died suddenly 5 days post surgery from acute aspiration after emesis caused by gastric dilitation. Throughout my almost 50 years in cardiac surgery, we coined a phrase that was used too often: “Surgery was a success but the patient died”.
Clarence Crafoord of Stockholm in October of 1944 first successfully resected a coarctation of the aorta in two patients. This was followed by Gross’ first success with the same operation in June of 1945. Gross could well have been unaware of Crafoord’s work; both reports were published in the fall of 1945. I have discovered on numerous occasions while performing research that until around 1970, scientific experimentation and surgical procedures remained on their respective continents for some time before becoming disseminated worldwide.
Next Up- The Procedure That Shocked The World