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A History of Innovation: Cardiac Surgery in Minnesota

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A History of Innovation: Cardiac Surgery in Minnesota RETROSPECTIVE A LOOK BACK AT MEDICINE A History of Innovation CARDIAC SURGERY IN MINNESOTA COURTESYPHOTO OF MINNESOTA UNIVERSITY ABOVE: C. Walton BY JOHNATHON M. AHO, MD, MATTHEW S. SCHAFF, MD, CORNELIUS A. THIELS, DO, MBA, ROBERT A. DARLING, MD, Lillehei and team MARK N. PRICE KOERNER AND HARTZELL V. SCHAFF, MD performing a controlled cross-circulation For centuries, the heart was believed to be an inoperable organ. Through the development of new technologies operation in the mid-1950s. and techniques, the initial difficulties inherent with operating on a moving organ began to fade. But as surgeons in the last century pushed the boundaries of cardiac repair, new problems arose. To solve them, they enlisted the help of physiologists, residents and engineers. By taking a multidisciplinary approach, sharing information and ideas, and working collaboratively, University of Minnesota and Mayo Clinic investigators found themselves at the forefront of cardiac surgery. This article reviews Minnesota’s contributions to the field. “There, for a shining moment, the THE EARLY YEARS ment of shrapnel.6 The early successes of only institutions where one could As surgery involving other organs ad- Harken and other combat surgeons as well as vanced, Aristotle’s conviction that the the development of extracardiac procedures go for open heart surgery were heart was inoperable prevailed and most such as closure of the patent ductus arterio- 90 miles apart, at the Mayo Clinic surgeons viewed operating on the heart as sus in 1939, repair of an aortic coarctation and the University of Minnesota.” taboo.3 That thinking was challenged to in 1945 and development of the Blalock- some extent in the early 19th century with Taussig shunt for treating cyanotic heart — Norman Shumway, MD the development of extracardiac procedures disease in the 1940s convinced surgeons that for treating penetrating thoracic injuries. they could at least operate near the heart.7 n the mid-1900s, the University of Min- Although cases of survival after surgery Subsequently, they devised methods for re- nesota and Mayo Clinic were at the on the pericardium were documented as pairing simple atrial septal defects (ASDs). Iforefront of cardiac surgery.1,2 Research- early as 1801,4 cardiac surgery at the end One involved closing the defect beneath a ers from these two institutions developed of the 19th century remained very limited. pool of blood. However, because results were techniques and devices that made heart Austrian surgeon Theodor Billroth, who is imprecise and repair of more complex intra- surgery possible and spawned a medical considered the father of modern abdominal cardiac defects required direct visualization, device industry. The achievements of key surgery, called it “an intervention which they needed to find a way to stop blood flow- individuals have long been recognized. some surgeons would term a prostitution of ing through the heart long enough to correct This article suggests Minnesota’s contribu- the surgical act and other madness.”5 the problem while avoiding exsanguination. tions to cardiac surgery were not only the During the first half of the 20th century, result of efforts by individuals but also by cardiac surgery was limited primarily to the THE BIRTH OF teams of surgeons and surgical residents, management of traumatic injuries. Dwight CARDIOPULMONARY BYPASS physiologists and engineers working Harken, MD, a World War II combat sur- In 1945, University of Minnesota chief of together. geon, discovered it was possible to make a surgery Owen Wangensteen, MD, PhD, small incision in a beating heart and insert a recognized this problem and suggested finger to locate and remove a bullet or frag- that surgical staff member Clarence Den- 32 | MINNESOTA MEDICINE | JANUARY 2015 A LOOK BACK AT MEDICINE RETROSPECTIVE nis, MD, PhD, consider trained at the University of developing a pump and ox- Minnesota, was working on ygenator circuit that would an alternative approach. He support the body during noticed that hibernating an- cardiovascular surgical pro- imals had drastically slower cedures.8 heart rates. He therefore In 1947, Dennis, along began animal experiments with fellow surgeon Rich- with controlled hypother- PHOTO COURTESYMINNESOTA UNIVERSITY OF ard Varco, MD, PhD, began mia, demonstrating that the working on a machine to heart could be opened and facilitate cardiopulmonary operated on for approxi- bypass. The team developed mately 10 minutes without a cardiopulmonary sup- permanent damage.14 A port system that employed slowed heart rate and low- a series of discs rotating in ered metabolic demand an extracorporeal pool of provided a relatively stable venous blood to expose it to platform for surgery. Richard DeWall operating his invention, the DeWall Bubble Oxygenator, for use during open oxygen so gaseous exchange heart surgery circa 1956. In 1952, John Lewis, MD, would take place.9 Their de- PhD, and C. Walton Lillehei, velopment was a massively MD, PhD, performed the complex machine that re- first open-heart procedure quired 16 people to operate. using whole-body hypo- The first clinical trials of thermia.15 The patient, a the device were conducted 5-year-old girl born with an in 1951.10 Unfortunately, ASD, was cooled to 27°C because of inaccurate pre- (81°F) using a special blan- operative diagnoses and PHOTO COURTESYMINNESOTA UNIVERSITY OF ket. As a result, her brain technician error, the first and other tissues required two patients to undergo less oxygen, and her heart surgery with the cardio- rate slowed enough so Lewis pulmonary support system and Lillehei could repair the died.3 The system, however, defect. Although it was con- was considered successful, sidered groundbreaking, the as it proved that a patient’s hypothermic protocol only heart and lung function allowed surgeons to repair could be maintained dur- relatively simple defects that ing intracardiac surgery Clarence Dennis and W. Harris showing operation of the heart-lung machine in 1951. could be completed in 10 using mechanical support.11 minutes or less. Their experience with the device made patient died during the operation. Gibbon To do more complex repairs, surgeons researchers realize they needed to simplify persevered and in 1953 successfully closed needed a more sophisticated method for the technology in order to minimize the an ASD in an 18-year-old woman using maintaining physiologic homeostasis. chance of operator error. his screen oxygenator device. Although Lillehei and Morley Cohen, MD, PhD, a Dennis and Varco’s efforts to develop this operation was successful, it was fol- surgical resident and investigator at the an oxygenator system were not the first. lowed by five consecutive attempts at University of Minnesota who would even- John Gibbon, MD, a surgeon at Jefferson intracardiac repair that resulted in death. tually become an expert in the oxygen- Medical College in Philadelphia, had been Discouraged, Gibbon ceased development ation of blood, began studying techniques working on a screen oxygenator system of cardiopulmonary bypass and attempts that would provide surgeons with more since 1937. He attempted to close a pre- at intracardiac surgery.1,12,13 time to perform intracardiac repairs. The sumed ASD in a 1-year-old child using first experiments used a dog’s autologous the cardiopulmonary bypass machine in SPECIALIZED SUPPORT SYSTEMS pulmonary lobe as an organic oxygenator. 1952. Unfortunately, the preoperative di- While Dennis and Varco were developing Although the oxygenator was functional agnosis was incorrect (the patient in fact their heart-lung bypass machine, William and successful overall, it was too delicate had a patent ductus arteriosus) and the Bigelow, MD, a Canadian surgeon who to be used clinically and edema formed JANUARY 2015 | MINNESOTA MEDICINE | 33 RETROSPECTIVE A LOOK BACK AT MEDICINE with higher flows or any obstruction to plicated pathology rather than failure of group built on Gibbon’s screen oxygenator venous outflow.10 the support method. design. The resulting machine was a com- Given the limitations of early attempts During this time, surgeons achieved plex device with an oxygenator consisting at mechanical support, a University of many “firsts” in lesion repairs including of 14 mesh screens. It also had several safety Minnesota team that included Cohen, closure of ventricular septal defects, repair features including occluder mechanisms to Lillehei and Herbert Warden, a colleague of atrioventricular canals and correction of maintain flow to the oxygenator as well as of Cohen’s, came up with a simple solution: Fallot’s tetralogy.2,19 In a series of ground- sensors for the arterial filter, pH control and using a surrogate patient for cardiopulmo- breaking operations, Lillehei demonstrated venous reservoir volume. The cardiopulmo- nary support in a technique termed “con- that intracardiac repairs were possible with nary bypass system required a large volume trolled cross-circulation.”13,16 The donor’s this method. His team found that they of blood (six units), which family members and recipient’s blood types were matched were now limited by their understanding would either supply or pay for.21 The device and major veins and arteries connected, of the pathology and anatomical structure was developed and tested over two years and eventually produced as the Mayo-Gib- The Mayo-Gibbon Heart-Lung Bypass Machine. 22 Permission of the Mayo Historical Unit, Mayo bon heart-lung bypass machine. Clinic, Rochester, Minnesota. In 1955, the Mayo group planned a series of five operations using the cardiopulmo- nary bypass machine. Kirklin and colleagues performed an intracardiac procedure on a 5-year-old child with a ventricular septal defect (VSD) on March 22, 1955.23,24 This was the first successful operation using me- chanical cardiopulmonary bypass since Gib- bon’s procedure in 1952. That first patient returned for a visit to Mayo Clinic 50 years later. With the success of the procedure, Kirklin’s series of five patients became a series of eight.1,25 In addition, operating the bypass machine, which originally required more than a dozen people, was simplified so it could be managed by a smaller team.
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