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Pioneers of Heart Surgery

  • Posted 04.08.97
  • NOVA

For most of history, the human heart has been regarded as an organ too delicate to tamper with. But daring and innovative doctors from WWII onward, aided by advances such as the heart-lung machine and immuno-suppressant drugs, have ushered in a new era of heart transplants and open-heart surgery.

Battlefront injuries gave new urgency to the need to develop better surgical techniques. Here, a U.S. soldier is given blood plasma after being wounded by shrapnel. Enlarge Photo credit: NARA

Daring procedures

During World War II military doctors, facing injury and suffering on a massive scale, pioneered advances in antibiotics, anesthesia, and blood transfusions—advances that would usher in the age of modern surgery. One of the first doctors to use these medical advancements to gain access to the heart was Dr. Dwight Harken, a young U.S. Army surgeon. Many of Harken's patients were young soldiers evacuated from the European front with shell fragments and bullets lodged inside their hearts. To leave the shrapnel in was dangerous, but removing it was almost surely fatal. Harken began operating on animals, trying to develop a technique that would allow him to cut into the wall of a still beating heart, insert a finger, locate the shrapnel and remove it. All of his first 14 animals subjects died. Of the second group of 14, half died. Of the third group of 14, only two died. Harken felt ready to try the technique on humans. All of his patients survived, proving that the human heart could be operated upon.

It wasn't long before surgeons began wondering if Harken's technique might be applied to defective heart valves. In 1948, within days of each other, Harken and a Philadelphia surgeon, Dr. Charles Bailey, independently reported on a daring procedure to correct mitral stenosis, a condition where the mitral valve (see Map of the Human Heart) is narrowed and won't open properly. Just as with the soldiers, a small hole was cut in the side of a beating heart and a finger was inserted to find and very carefully widen the narrowed valve. Early results were disastrous, with the majority of patients dying. Gradually, though, surgeons improved their technique and the procedure became quite safe. This kind of blind surgery—or closed heart surgery—spread to hospitals around the world.

A portriat of Dr. Dwight Harken from 1951. Harken's experience as an army surgeon in WWII inspired his pioneering work. Enlarge Photo credit: © Fabian Bachrach

Impressive as the technique was, it made little difference to patients suffering from more serious heart defects—for instance, children born with congenital heart disorders, breathless and blue and condemned to an early death, and victims of rheumatic fever whose heart valves were narrowed or stuck. If surgeons couldn't work on the heart from the inside, nothing could be done. But how could surgeons open up the heart without their patients bleeding to death? Temporarily stopping a patient's circulation only gave doctors about four minutes to work before brain damage from oxygen deprivation took place.

cold treatment

At the University of Minnesota, a young Canadian surgeon named Dr. Bill Bigelow came up with the first workable, if highly bizarre, answer. He had noticed how hibernating animals, like ground hogs, survived the bitterly cold Canadian winters. Their hearts beat slower, allowing them to survive for months without food. Wondering if cold might be the key to operating inside the heart, Bigelow began animal experiments and found that when dogs were cooled, open heart surgery could be done for long periods—much longer than four minutes—and they didn't die. He showed that at lower temperatures, the tissues of the body and brain didn't need as much oxygen, and could survive without oxygenated blood for longer.

On September 2, 1952, two University of Minnesota surgeons, Dr. Walton Lillehei and Dr. John Lewis, attempted the first open heart surgery on a five-year-old girl who had been born with a hole in her heart. Anaesthetized to stop her shivering, the girl was cooled by a special blanket until her body temperature reached 81 degrees F. At this temperature, she could survive without a pumping heart for 10 minutes, not four. Clamping the inflow to her heart so that it emptied of blood, Lillehei and Lewis cut open her heart, which was still slowly beating, and quickly sewed up the hole. With the repaired heart working properly for the first time in her life, the girl was then immersed in a bath of warm water to bring her body temperature back to normal. The operation was a success.

Four physicians aided by several technicians perform open heart surgery in this photo from the mid-1950s. Enlarge Photo credit: P. Almasy/World Health Organization

The "hypothermic approach" became very successful in treating small heart defects. But all too often, surgeons opened hearts to find more complex defects—defects that couldn't be repaired in 10 minutes. With the clock ticking away, they did what they could, but it was clear that a better approach needed to be found.

Heart-Lung Machines

The dream of building a machine to take over the function of the heart and lungs during surgery had existed before World War II. Early prototypes, built by pioneers like Dr. John Gibbon in Great Britain, were cumbersome and dangerous—often leaking blood, damaging blood cells and causing air embolisms. It wasn't until 1958, when a system that involved bubbling blood was perfected, that "heart-lung" machines came of age. Dr. Dennis Melrose of London further increased chances for success when he pioneered an injection that stopped the heart from beating during surgery.

During the risky operation, a large mechanical device performs the functions of the heart. Enlarge Photo credit: World Health Organization

Now surgeons had time to work on a heart that was not only empty of blood, but which wasn't moving. And they had time to correct the most serious abnormalities. Holes which were too big to be sewn up were patched. Where valves were damaged beyond repair, artificial valves were put in. Blocked arteries were bypassed. Weakened arteries were replaced altogether. Modern heart surgery seemed unstoppable.

But a major problem still remained—what to do for patients whose very heart muscle was diseased beyond repair? Could these patients be given new hearts? By 1966, heart surgeons were ready to take on the challenge. Most, like Dr. Michael DeBakey of Houston, thought the answer lay in artificial hearts. But the future would lie in a different direction: heart transplants. Kidneys had been transplanted successfully as early as 1963, after the complexities of tissue rejection were solved with drugs that suppressed the immune response. If the barrier had been breached for the kidney, why not for the heart?

What first looked like another surgical miracle had turned into a disaster.

In December of 1967, a South African surgeon, Dr. Christiaan Barnard, transplanted the heart of a 23-year-old woman killed in a motor vehicle accident into the chest of a middle-aged man. He lived for 18 days, until the powerful drugs used to suppress rejection weakened him and he died of pneumonia. The second patient to receive a heart transplant, at the hands of Dr. Adrian Kantrowitz in the United States, lived only six hours. But Dr. Barnard's next heart-transplant patient lived for 18 months and became a symbol of hope for victims of heart disease. All over the world patients were asking and receiving the new miracle operation.

But these surgical triumphs proved short-lived. Patients began dying of either rejection or infection. By 1971, 146 of the first 170 heart transplant recipients were dead. What first looked like another surgical miracle had turned into a disaster. Heart surgeons who had promoted the operation admitted defeat.

A NEW DAWN FOR TRANSPLANT SURGERY

Only one American surgeon would continue—Dr. Norman Shumway. Throughout the 1970's, he built a team of scientists and doctors to tackle the complex biological problem of tissue rejection in a careful, scientific manner. His team devised a way of spotting rejection attacks, by feeding a catheter into the heart and removing a piece of heart muscle for examination. Only when signs of rejection were seen were doses of the dangerous immuno-suppressive drugs increased. Shumway also benefited from a chance discovery made in another part of the world.

Dr. Norman Shumway rose to prominence in the high-profile world of heart surgery in the late 1960s. Enlarge Photo credit: © N. Shumway

In the soil of Norway's Hardaangerfjord a fungus was found which contained a compound that would revolutionize transplant surgery. The substance, called cyclosporin, appeared to have exquisite immuno-suppressant properties—controlling organ rejection without knocking out all resistance to infection. In the hands of Dr. Shumway, cyclosporin transformed the picture for heart transplant recipients. Hospitals around the world began to re-open their heart transplant units and their patients began to survive and prosper.

But this breakthrough has come with limitations, too. The problem with heart transplants now has become finding enough hearts. Today in the United States alone, two million people suffer from congestive heart failure. When drug treatments fail, transplants are the best hope. But fewer than 2,500 donor hearts are available each year, leaving thousands of patients desperate for an alternative.

In 1994, Dr. Randas Batista of Brazil devised a radical new surgical technique to treat a common form of heart failure for people with enlarged hearts. Normally, oxygen-rich blood flows into the left side of the heart from the lungs (see Map of the Human Heart). The left ventricle is responsible for pumping the blood out to the rest of the body. When the heart becomes diseased, it sometimes dilates or swells. The contractions become sluggish and the left ventricle is unable to squeeze out enough blood. Blood backs up in the heart and the lungs, resulting in congestive heart failure.

Batista's idea was to cut a swath out of the left ventricle and sew the chamber back together, thereby reducing its size and increasing its efficiency. Gradually, news of Batista's radical approach spread and, currently, a small number of surgeons around the world are experimenting with the procedure. Their results, so far, have been mixed. More time and innovation are needed before it's known whether this technique will be the next milestone in the history of heart surgery.

Whether Batista's new surgical technique, which diminishes the size of the diseased heart, will be widely adopted remains to be seen. Enlarge Photo credit: © WGBH Educational Foundation

This feature originally appeared on the site for the NOVA program Cut to the Heart.

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