The First “Red Book” By Gary Grist RN CCP Emeritus and Thomas Muziani PA-C CP
The original hard bound book of any note about cardiopulmonary bypass was Heart-Lung Bypass: Principles and Techniques of Extracorporeal Circulation (HLB)(1). The primary author was Pierre M. Galletti MD PhD who was a pioneer in biomedical engineering. Gerhard A. Brecher MD PhD was an expert in venous physiology and the second author. HLB was published in 1962 and had a distinctive red cover which inspired the term “Red Book”, meaning any educational book about extracorporeal technology. This was 13 years before Reed and Clark’s Cardiopulmonary Perfusion (2) was published in 1975.
Fifty Years of Hind Sight
I had HLB in 1968 when I first started. I review it now with the hind sight of 50+ years since the book was written. Dr. Galletti tried to gather everything that was known about extracorporeal circuits in the 1950’s and early 60’s. He included concepts that were proposed but untried and untested. He was obviously trying to spread concepts around in hopes that the best application would evolve; i.e. throwing the Galletti spaghetti against to wall to see what would stick.
An Equipment “Shell Game”
For example, there are many ideas about removing bubbles; all relying on bubble buoyancy. There is nothing about filtering or whirlpool removal of bubbles. The only mention of a filter is to remove solid particulate debris from the blood; a device separate from the bubble trap. There are several suggested methods for venous return including active (with a pump), passive (with a siphon) and vacuum assisted. On one page alone he has 17 diagrams of different blood pump types with names such as Archimedean screw pump, single cone roller pump, multiple finger pump and the plunger pump. In the future, only two pumps would eventually emerge as the most practical and economically feasible pumps, the roller and centrifugal. But at the time, it was a real “shell game” to determine which combination of bubble trap, filter, venous return method and blood pump to use.
Dr. Galletti describes many different types of oxygenators including bubblers, foamers, sprayers (aerosol), sponge, membrane, disk, film, rotating cylinder, rotating spiral and screen oxygenators. Heterologous and homologous living lung oxygenators are even discussed. But at that point in time an oxygenator that incorporated a heat exchanger, a venous filter, cardiotomy and venous reservoirs and even a bubble trap into a single disposable unit was hardly more than a dream. Back in the 60’s, all those things were separate components in the circuit which needed to be cleaned, sterilized and re-used in subsequent cases.
The Power To Animate Severed Heads
Dr. Galletti describes multiple circuit designs, never really judging which is best. He even describes Dr. Brukhonenko’s autojector and his work in keeping severed dog’s heads alive with it (3). He goes on to suggest that the success of extracorporeal support can be attributed to “Plastic tubing and sheets, siliconized glass and highly polished stainless steel…” That is just the first half of the book.
The Eeny Meeny Miny Moe Of Induced Cardiac Arrest
The second half is about the physiology. Many of the principles we still use today are discussed, but from the standpoint of not being quite sure if they will work. For example, hypothermia on extracorporeal support was not well understood or even considered safe. In the chapter on induced cardiac arrest Dr. Galletti discusses 1. ventricular fibrillation, 2. potassium arrest, 3. magnesium arrest, 4. hypocalcemic arrest, 5. acetylcholine arrest, 6. anoxic arrest and 7. hypothermic arrest. Dr. Galletti never really says which is best. He even describes retrograde coronary perfusion with blood only, not with cardioplegia.
Hemodilution Was Considered A No-No.
There is no discussion of crystalloid in terms of pump prime. “Prime” is not even listed in the book’s index. Dr. Galletti does talk about “the priming blood” and collecting 1-5 liters of donor blood the morning of surgery or the day before surgery. Hemodilution was considered to be detrimental to oxygen delivery and therefor discouraged. But he describes the problem of the blood pH becoming too acidotic while just sitting in the pump before use.
A Book Ahead Of Its Time?
Dr. Galletti was doing his best to describe flying by the seat of one’s pants in terms of cardiopulmonary bypass. Was the Galletti Red Book “ahead of its time”? I would say “no”. Instead, it was a “reflection of its time”, the decade of the 1950’s and early 60’s. It was the first widely published book used to teach physicians (the HLB I currently own once belonged to the prominent CV surgeon Dr. James A. DeWeese MD – 1925-2013) and extracorporeal technicians (pump techs) before they were called “perfusionists”. Since I was working during the last part of the 60’s decade, the book was a resource and advisor to me as a perfusionist. Things are so different today I doubt if young perfusionists would even recognize most of the things in Dr. Galletti’s book. But a young perfusionist on a medical mission in an undeveloped country who might be called upon to use a bubbler or even a disk oxygenator would probably find Dr. Galletti’s book helpful.
I asked Thomas Muziani to contribute to this article. See his comments below:
“Gary asked me to contribute to this article on the first Red Book because I knew Dr. Galletti personally. I took the first AmSECT test with Pierre. He was a magnificent person with a singular vision. I always enjoyed the fact that so many people could not get through his book because he wrote as a scientist.
In the 1960’s, “Heart-Lung Bypass” was the Gold Standard by which all discussion would take place regarding existing and emerging technology. “Galletti said this…or Galletti mentioned that” was routine chatter whenever we broke bread.
“Galletti was not a perfusionist. He approached the writing of his book from a totally different angle and approach. The analogy I would use…He wrote his book as the inquisitive, exploring scientist describing what planets should look like…as opposed to the Astronaut (Perfusionist) who flies to the planet, touches it and utilizes all the equipment the scientist proposed he would require for the trip.
“Pierre presented concepts and scientific principals assuming the reader would digest the information and discover application for conducting perfusion while on bypass. I believe he felt no compulsion to tell us which oxygenator was best or even if 2.4L/M2 is standard or just a target.
“I believe Dr. Galletti thought of his book as merely a guide. He presented sound scientific principals knowing that how cardiac surgery and perfusion was conducted ran the gamut of techniques and perceptions.
“I firmly believe that by all metrics we judge an individual’s accomplishments, both large and miniscule, Dr. Pierre Galletti would be considered at the Top of the Pyramid. Without attempting hyperbole, he was both a Renaissance man and a Man for all Seasons. There were very few subjects that he was neither curious about or could not articulate cogent experiential thoughts.
“It is generally recognized that he was the architect for the emerging field of biomedical engineering. His leadership skills provided for the establishment of the medical school at Brown University, and assisted with the development of the Morehouse School of Medicine in Atlanta, GA.
“When I visited with Dr. Galletti in 1994, he was Chairman of the Board for Sorin Biomedical in Irvine, California. Our conversation was both animated and erudite. Eventually, it became reflective over the evolution of cardiac surgery, both in multitude of techniques and emerging devices. He was a true visionary.