|Year : 2019 | Volume
| Issue : 3 | Page : 156-164
Fifty years of cardiac surgery: Innovation, evolution, and revolution in cardiovascular therapies
Travis Bouchard1, Michael Subichin2, Michael S Firstenberg3
1 Department of General Surgery, Swedish Medical Center, Englewood, CO, USA
2 Department of Surgery, Summa Akron City Hospital, Akron, Ohio, USA
3 Department of Cardiothoracic and Vascular Surgery, The Medical Center of Aurora, Aurora, CO; Department of Surgery, Northeast Ohio Medical University, Rootstown, Ohio, USA
|Date of Submission||14-Oct-2018|
|Date of Decision||14-Oct-2018|
|Date of Acceptance||11-Nov-2018|
|Date of Web Publication||24-Dec-2019|
Dr. Michael S Firstenberg
Department of Cardiothoracic and Vascular Surgery, The Medical Center of Aurora, 1444 S. Potomac Street, Suite 390 Aurora, CO 80012; Northeast Ohio Medical University, Rootstown, Ohio
Source of Support: None, Conflict of Interest: None
The evolution of cardiac surgery reflects some of the greatest accomplishments in the history of medicine. Early work, staring with closed procedures on stenotic valves and repairs of traumatic injuries, while considered initially high risk, and challenges were associated with very high morbidity and mortality rates. Despite early concerns that surgery on the heart would never evolve beyond the most basic of procedures, devoted clinicians and researchers, motivated by the inability to help those suffering from what was generally considered untreatable or inherently fatal problems, persisted against much skepticism, failures, and lack of reliable and appropriate technology. However, over the years, with tremendous dedication to advancing the field, therapies for coronary artery disease, structural valve disease, arrhythmias, and heart failure evolved. While many consider “cardiac surgery” a separate field from “cardiology,” as our review of the history will demonstrate, much of the pioneering work done in the operating room – either with or without the use of the heart–lung machine (cardiopulmonary bypass) – set the foundation for further technological developments. The natural progression of such “operative surgical” therapies is to evolve into miniature, minimally invasive, or percutaneous catheter-based intervention. While there are clearly volumes written, and often fictionalized, on many of these topics, a basic understandable of the rich history of cardiac surgery should be of interest to all – especially since it serves as the basis for so much what is currently offered to patients to help extend both the quantity and quality of their lives.
The following core competencies are addressed in this article: Patient care, Medical knowledge, Practice-based learning and improvement.
Keywords: Cardiac surgery, coronary artery disease, heart disease, history, valve disease
|How to cite this article:|
Bouchard T, Subichin M, Firstenberg MS. Fifty years of cardiac surgery: Innovation, evolution, and revolution in cardiovascular therapies. Int J Acad Med 2019;5:156-64
|How to cite this URL:|
Bouchard T, Subichin M, Firstenberg MS. Fifty years of cardiac surgery: Innovation, evolution, and revolution in cardiovascular therapies. Int J Acad Med [serial online] 2019 [cited 2020 Jan 22];5:156-64. Available from: http://www.ijam-web.org/text.asp?2019/5/3/156/273933
“No surgeon who wished to preserve the respect of his colleagues would ever attempt to suture a wound of the heart.”
– Theodor Billroth at a meeting of the Vienna Medical Society in 1881.
| Origins of Cardiac Surgery|| |
Dr. Theodor Billroth was an innovator throughout the 19th century and is regarded as a Founding Father of Surgery. Regarded as an initial skeptic of the idea of cardiac surgery, he is quoted in his Handbook of General and Special Surgery, “The paracentesis of the hydropic pericardium is in my opinion, an operation approaching surgical frivolity.”
In 1938, Dr. Robert Gross—a chief surgical resident—came up with the idea to surgically correct a patent ductus arteriosus. Dr. William Ladd, the Chief Surgeon, forbid him to perform this procedure. Gross delayed his operation until Ladd boarded a ship for Europe and then performed the first successful ligation of a patent ductus arteriosus despite Ladd's objection. As late as 1957, cardiac surgery was neither widely accepted nor widely practiced. Famously, there is no mention of cardiac surgery in Thorwald's classic text ”The Century of the Surgeon.”
| Introduction|| |
The first successful surgery of the heart was by Dr. Ludwig Rehn, who repaired a stab wound to the right ventricle in September 1896. Other early developments in cardiac surgery mostly involved the repair of congenital cardiac anomalies. Advancements made in congenital repairs paved the future for cardiac surgery in adults. Sir Henry Souttar completed the first open mitral valvotomy in 1925 on a 15-year-old female child with severe mitral stenosis. Souttar's operation was done using manual dilation and is regarded as the first known successful intracardiac operation. Such open cardiac operations—as with many cardiac surgical procedures—paved the way for invasive, life-saving therapies.
Few areas of medicine have impacted the quality and quantity of life as much as cardiovascular surgery. The advancements made in the era of open-heart surgery, transplantation, mechanical circulatory support, and cardiac surgery have captivated the imagination and enthusiasm of humanity. Many of the great innovations in cardiac surgery have laid the foundation for additional therapies that are now widely used throughout the disciplines of cardiovascular care [Table 1].
Dr. Billroth's opinion of cardiac surgery was persistent well into the 20th century. Advances in cardiac surgery were slow as diagnostic technology for cardiac defects continued to be limited during this time. Even rudimentary echocardiography only began to be utilized in the 1950s. Not surprisingly, many surgical interventions failed due to incorrect preoperative diagnoses. In addition to these diagnostic errors, surgeons were also limited by operative time. Cardiopulmonary bypass would not come into use until the 1950s. Even then, its use was greatly limited by the physiologic and technical complexities between the human circulatory system and the artificial extracorporeal circuit. Nevertheless, many advances in diagnostic imaging and therapeutic tools were out of necessity to make cardiac surgery safer, easier, and more reliable.
In the 1940s, there were numerous advances in cardiac surgery stimulated by the technologic growth during the World War II. Several cases of successful closed mitral commissurotomy were described. In 1944, the surgical repair of coarctation of the aorta was described in two patients by Crafoord and Nylin. In addition, in 1944, Blalock and Taussig described a surgical treatment for tricuspid stenosis. They performed the first anastomosis of the left pulmonary artery to the left subclavian vein in hopes of mimicking the effect of a patent ductus arteriosus. Their report was a major advancement in cardiac surgery. Intentionally, rerouting the flow of blood around pathology – be it a stenotic valve, a ventricular malformation, and ultimately a stenosed coronary artery, this tenet remains a fundamental principle behind many cardiac surgery procedures.
Fueled by their frustrations of mortality in cases of massive pulmonary embolism—a problem that plagued clinicians since Trendelenburg proposed the direct removal of clot in 1908. Gibbon dedicated his life to the development of extracorporeal cardiopulmonary support. In 1953, at Thomas Jefferson University, Gibbon made perhaps the greatest advancement in the history of cardiac surgery. He closed a large atrial septal defect while his patient was supported by the cardiopulmonary bypass machine he had developed. While Gibbon eventually abandoned his research after poor outcomes, others were intrigued and propagated the advancement of cardiopulmonary bypass. Many large corporations that designed pneumatic pump technologies such as general motors were involved in bypass machine development. Kirklin et al. at the Mayo Clinic made their own modifications to Gibbon's design and published the use of cardiopulmonary bypass in eight patients. This work allowed cardiopulmonary bypass to become the standard of care by the 1960s and led to rapid growth in cardiac surgery in the second half of the 20th century. The ability to safely perfuse the body with oxygenated blood, while protecting a motionless and bloodless field, paved the way for therapies never before possible. With the basic tools now available, therapies for acquired and congenital cardiopulmonary problems – previously viewed as inherently fatal – evolved in a manner rate limited only by human imagination and ingenuity.
| Valvular Disease|| |
Throughout the 20th century, the surgical repair of heart valves made tremendous progress. Between 1923 and 1928, Cutler and Beck  and Souttar  reported 10 cases of surgical repair of mitral valve stenosis. Of those cases, only two patients survived the postoperative period. Of the two surviving patients, only one showed clinical improvement. While much was learned, these dismal results led to almost two decades of stagnation in the research of valve surgery. Independent breakthroughs made by Harken et al. and Bailey  in the 1940s began to revolutionize surgical repair of the mitral valve. Bailey would go onto complete over a thousand commissurotomies of the mitral valve in 1956 with a mortality rate of only 8%.
Before 1960, advancements in valve repair were greatly limited as cardiopulmonary bypass was not yet available. At this time, hypothermia was utilized but was limited to <10 min. The invention of Gibbon's heart–lung machine in 1953 ushered a wave of new advancements. Shortly after the introduction of cardiopulmonary bypass, the repair of both mitral stenosis and mitral insufficiency became common practice. Before valve prostheses, there were attempts to repair components of the mitral valve such as Dr. Gott's replacement of the posterior mitral valve leaflet  and Dr. King's replacement of the chordae tendineae. These repairs had poor outcomes and were soon replaced with full prosthetics. Carpentier's pioneering work in the 1980s has, without a doubt, established the long-term safety, durability, and clinical benefits for mitral valve repair for mitral regurgitation.
In 1960, Harken et al. and Starr and Edwards  would be the first to implant valve prosthesis to replace either the aortic or mitral valve. Engineering a prosthetic valve that was suitable for human tissue and avoided hemolysis and thrombosis was not an easy task. Surgeons had few ways to test new designs, and most new prosthetic valves were tested by trial and error. As development of prosthetic valves continued, two distinct valve types emerged: mechanical and biologic.
The first valve implanted in a human was a ball and cage valve inserted by Hufnagel and Harvey in 1952. They implanted the valve outside the heart in the thoracic aorta for a patient with aortic valve insufficiency. The Starr-Edwards valve—a more developed ball and cage valve—was first introduced in 1960 and has been modified several times since its inception. This valve had a significant thrombosis risk but was widely used and became the standard for valve replacement for many years. During the 1960s, disc valves and bileaflet valves also began being used. The Gott-Daggett mechanical valve was the first bileaflet valve introduced in 1963. Bileaflet valve use was initially limited until the creation of the St. Jude valve in 1977 and the Carbomedics valve in 1986. These types of valves remain the most commonly used mechanical valves.
Biologic valves also originated in the 1960s. In 1962, Heimbecker et al. at the University of Toronto were the first to use an aortic valve homograft to replace one patient's aortic valve and another patient's mitral valve. While neither patient lived long, the interest in biologic valves resulted in the first xenograft valve in 1964. These valves were very promising but degraded only after a few years. Biologic valves, specifically porcine valves, have improved by changing their support structure and their fixation processes and now have years, if not decades, of durability and predictable long-term clinical performance. Biologic valves offer significant advantages including no need for anticoagulation and increasing durability that makes them very popular today – particularly now that there exist percutaneous options for replacement of failing biologic valves  – a therapy that owes it origins to the decades of experiences with surgical valve replacement.
In addition to improved prosthetics, evolving surgical approaches have continued since the beginning of valve surgery. With improvement in surgical technique, multi-valve replacement procedures became commonly performed operations with reasonable outcomes. In the last few decades, many new valve techniques have also been developed. Carpentier et al. performed the first robotic valve repair in 1998. Further, in 2002, Cribier et al. performed the first transcatheter aortic valve replacement (TAVR) in France. TAVR has now become part of comprehensive valve replacement programs throughout the world—demonstrating that key therapies can be perfected in the operating room and eventually developed into less invasive, catheter-based therapies. Other catheter-directed valve repair options continue to emerge including mitral valve repair and other percutaneous clip techniques. Much work remains – but this progress emphasizes that the foundation for future successes is based on decades of innovative thought in cardiac surgery.
| Coronary Artery Surgery|| |
Early in cardiac surgery, a variety of therapies were proposed for the treatment of coronary artery disease. Despite limited success and some theoretical basis for patient improvement, widespread application was rare. One such instance is the Vineberg operation in which the internal mammary artery was anastomosed to the left ventricle. This experimentation may have induced some degree of neovascularization and collateralization, but long-term outcomes were difficult to define. In 1960, Konstantinov et al. performed the first coronary artery bypass surgery. They reported an anastomosis of the left internal mammary artery to the right coronary artery. While Demikhov of the Soviet Union had reported coronary artery bypass in dogs since 1952, there were few attempts of coronary artery bypass in humans before Dr. Goetz's report.
Soon afterward in 1962, Sones and Shirley at the Cleveland Clinic reported a major breakthrough demonstrating the first coronary artery angiography. During this period, coronary endarterectomy remained the most common coronary artery surgery. Indeed, Garrett et al. performed the first known saphenous vein bypass graft in 1964 only after coronary endarterectomy appeared too technically challenging. In 1968, Favaloro at the Cleveland Clinic reported a series of patients with successful saphenous vein bypass grafts. Many others improved bypass surgery including Green et al., who advocated the use of cardiopulmonary bypass, and Bailey and Hirose, who recommended the use of loupes for anastomoses.
Despite these advances and experimentations, improvements in coronary artery bypass were sporadic until Johnson et al. from Milwaukee, Wisconsin, reported a series of 301 coronary artery bypass surgeries by saphenous vein graft at the American Surgical Association in 1969. They reported multiple saphenous vein grafts, recommended an end-to-side anastomosis, and advocated placing grafts distal to severe atherosclerotic areas. At this time, Green et al. strongly advocated that while saphenous vein grafts were successful, internal mammary bypass grafts offered the best long-term patency. These successes led to a growth in coronary artery bypass surgery though many believed epicardial coronary surgery was still too morbid. Multiple studies conducted in the 1970s compared coronary artery bypass to medical therapy and showed that patients undergoing coronary artery bypass had improved survival. The landmark paper by Loop et al., of the Cleveland Clinic, documenting the long-term survival advantage of using the left internal mammary to the left anterior descending remains the gold standard in comparing revascularization therapies today. Without a doubt, the long-term durability and improvements in quality and quantity of life that results from surgical revascularization are well established.
As coronary bypass procedures increased in the 1980s, surgeons continued to improvise surgical techniques. Buffolo et al. and Benetti reported encouraging results performing coronary artery bypass without cardiopulmonary bypass. The “off-pump bypass” showed a decrease in morbidity and is still a frequently used modality when candidates are at high risk for complications of cardiopulmonary bypass., Many surgeons today argue that off-pump coronary bypass should be the standard of care. Another major advancement in the late 1980s was the implementation of retrograde cardioplegia. This improvement in myocardial protection—a field revolutionized by Buckberg —allowed for improved myocardial protection in complex operations and in patients with severe atherosclerotic disease. Much of the myocardial protection and hypothermia techniques for cardiac surgery have also migrated out of the operating room to critical care including the use of systemic hypothermia for witnessed out of hospital cardiac arrest.
The late 20th century ushered in new surgical techniques for accessing and treating coronary artery disease. In the 1990s, many institutions began offering the minimally invasive coronary artery bypass, a procedure using video-assisted internal mammary harvesting and a mini left thoracotomy. In the late 1990s, Loulmet et al. performed the first robotic totally endoscopic coronary artery bypass. Since then, many improvements have been made in robotic devices allowing complex multi-vessel procedures to be now performed. Although these procedures have been demonstrated to be effective and safe, conventional sternotomy has remained the standard of care. With the improvement in operative radiologic capabilities, additional procedures have been developed which combine traditional coronary artery bypass surgery and coronary stenting for patients with complex lesions.
| Cardiac Surgery for Arrhythmias|| |
Diagnosis and treatment of cardiac arrhythmias are now infrequently a focus in cardiac surgery. However, the evolution of ablation and pacemaker technology has important origins in cardiac surgery and sparked the entire field of cardiac electrophysiology. While many experimented with pacemaker technology, in 1952, Zoll published a series of patients with heart block treated by temporary external pacing. Lillehei et al. built on this work and in 1957 implanted pacemaker wires at the time of cardiac surgery for the treatment of postoperative arrhythmias. The use of temporary pacing wires in cardiac surgery is now considered the standard of care. These early developments rapidly led to wearable temporary pacing system and quickly evolved into totally implantable pacemakers, defibrillators, and systems with complex cardiac resynchronization algorithms. The current generation of devices incorporates leadless systems and sophisticated sensors that can provide rate adaptive pacing and arrhythmia termination protocols.
Cobb et al., considered the Father of Ablation Surgery, performed the first ablation at Duke University in 1968. With the assistance of electrophysiologists, Cobb et al. made an incision on the right atrium abolishing the aberrant pathway in a patient with Wolff-Parkinson-White syndrome. Many began to focus on the treatment of recurrent ventricular arrhythmias. In 1978, Guiraudon et al. in Paris described creating an endocardial ventriculotomy to ablate ventricular pathways. Then, in 1979, Josephson et al. described excision of the aberrant cardiac pathway after electrophysiology mapping. This concept of mapping followed by directed ablation no longer relies on cardiac surgery but is still used by electrophysiologists today for the treatment of the full spectrum of complex medically refractory atrial and ventricular arrhythmias.
After years of trial and research, Cox introduced the Maze procedure in 1987 to offer a surgical cure for atrial fibrillation. This procedure, using incisions to eliminate irregular conduction pathways, was refined in 1992 and has long been considered the gold standard for surgical atrial fibrillation ablation. Today, variations of the original Maze procedure are frequently performed in the setting of open-heart surgery for patients with atrial fibrillation. While most arrhythmias are now treated with medications and electrophysiology procedures, cardiac surgery treatment for arrhythmias continues to evolve, including minimally invasive techniques that do not require cardiopulmonary bypass to achieve excellent long-term freedom from arrhythmia recurrence. Although it appeared that cardiac surgery's role in the treatment of arrhythmias was being eliminated, over the last 10 years, the development of minimally invasive maze procedures and hybrid procedures has seen renewed enthusiasm for the surgical treatment of difficult to manage arrhythmias. The combination of electrophysiology endocardial ablation and cardiac surgery epicardial ablation can now be routinely performed with sophisticated pathway mapping to provide effective long-term relief of atrial fibrillation. As the use of multidisciplinary hybrid operating rooms continues to grow, it appears this growth will likely continue.
| Advanced Surgical Treatments for Heart Failure|| |
From its inception, the development of cardiopulmonary bypass has been paralleled by the growth of devices to augment or replace native cardiac function. In 1937, both Demikhov in the Soviet Union and Gibbon in the United States demonstrated that artificial cardiopulmonary support was possible. Langer et al. designed and implanted the first artificial heart into a dog, while Gibbon successfully placed animals on and off cardiopulmonary bypass. While these animals only survived a few hours, these were instrumental steps in the development of artificial cardiac support. Over the last 50 years, this vision has developed into a variety of devices including intra-aortic balloon pumps, artificial hearts, and extra- and para-corporeal ventricular-assisted devices.
The widespread use of cardiopulmonary bypass surgeries brought about new clinical problems in cardiac surgery including failure to wean cardiopulmonary bypass and perioperative cardiogenic shock. These clinical problems led to continued interest in cardiac support devices. In 1966, with development by Liotta, DeBakey implanted the first left ventricular-assisted device into a 37-year-old patient who could not be weaned off of cardiopulmonary bypass. Famously, this patient went on to have the device removed and was discharged from the hospital. Meanwhile, throughout the early 1960s, Kantrowitz et al. in Detroit developed early models of intra-aortic balloon pumps for patients in cardiogenic shock. It was not until the 1970s that these devices were safely and effectively used in patients. Their ability to augment coronary perfusion while decreasing afterload and increasing cardiac output without increasing myocardial oxygenation consumption was as revolutionary as the development of the heart–lung machine. Continuous refinements—with few changes in basic functionality—have resulted in a technology that has been utilized worldwide to stabilize and resuscitate critically ill patients. It has only been in recent years that inherent limitations of intra-aortic balloon pumps prompted the development and acceptance of more advanced longer-term percutaneous cardiac support therapies such as intra-ventricular axial flow pumps and extracorporeal membrane oxygenation.
The Holy Grail of Cardiac Surgery has been the total replacement of the dying or irreparable heart. As early as the 1950s, there were many proposed designs for artificial hearts and cardiopulmonary bypass machines. This included Kolff and Akutsu's design and successful implantation of a totally artificial heart into an animal in 1957 at the Cleveland Clinic. Despite this significant advance, several factors quelled the urgency for implantable artificial hearts. These included the first human heart transplantation in 1967 by Barnard's team at Groote Schuur Hospital in Cape Town, South Africa. This worldwide pinnacle event reflected the key step in the years of basic science and clinical research championed by Lower and Shumway at Stanford University in the United States. Although there was little early clinical success and many vocal critics, the spark was lit on what many consider one of the singular greatest advances in 20th-century medicine—the ability to replace the human heart.
After the first heart transplants, the 1970s led to the emergence of programs specializing in cardiac transplantation throughout the world. While this operation has remained mostly unchanged, medical therapy has been primarily responsible for improved outcomes. Changes in immunosuppression such as the development of cyclosporine and tacrolimus have drastically decreased morbidity and increased the long-term survival of cardiac transplantation. Ninety percent 1-year survival and 50% 10-year survival is now the standard. Now, almost 50 years after the first heart transplant, thousands of patients undergo successful cardiac replacement every year.
Recognizing the inherent limitations that plagued heart transplantation, Cooley et al. implanted the first totally artificial heart into a human as a bridge to cardiac transplant in 1969. While this patient died soon after transplant, the artificial heart functioned successfully for >2 days. After growth in transplant success, organ shortage continued to drive research and development in artificial hearts. Probably, the most famous artificial heart, the Jarvik 7, was successfully transplanted in 1982 at the University of Utah. While the external pneumatic pumps confined patients to a hospital, one early recipient was able to live over 600 days after the implantation. The Jarvik 7 has had many different names and versions over the years, and in 2004, one model gained full FDA approval as a bridge therapy to cardiac transplant. There have been continued models and implementations of artificial hearts, but given the morbidity and poor quality of life, research and clinical practice have greatly shifted toward ventricular assist devices.
The first extended use of a ventricular-assisted device was in 1988 by Bernhard et al. at Boston Children's Hospital. This ventricular-assisted device and subsequent models relied on generating a pulsatile flow and were viewed as a bridge to transplant or as a bridge to patient recovery. Infections, bleeding, and thrombotic events and mechanical failures plagued early use. However, in the early 2000s, ventricular-assisted devices demonstrated improved survival in advanced heart failure. Since then, they have become commonly used as destination therapies in select populations and as a bridge to transplant in critically ill patients too sick to wait for a donor heart. Second-generation models, including most notably the HeartMate II/III and HeartWare devices, have become smaller, continuous flow, durable, battery-powered pumps that have drastically improved patient quality of life outside of the hospital. As ventricular-assisted devices continue to improve in size, function, and versatility, it is likely that thousands of these devices will continue to be implanted in the coming decades. More importantly, with advances, some speculate that 1-day ventricular devices may replace the need for cardiac transplantation or become the standard of care for patients with symptomatic heart failure. As current techniques demonstrate that ventricular-assisted devices can be safely placed without the use of cardiopulmonary bypass, it is easy to speculate that the future is toward less invasive and may be even percutaneous nonoperative approaches to the mechanical treatments for end-stage heart disease.
| Conclusion|| |
Without a doubt, the evolution of cardiac surgery over the past 50 years has been tremendous. Much as the missions to the moon sparked the development in so many other areas, cardiac surgery has been the same. Many of the procedures and therapies in cardiovascular medicine pay homage to the minds of the great visionaries and in operating rooms all around the world. However, the advance in cardiac surgery that probably has had the greatest impact in medicine, and the delivery of health care is the dedication to reporting of outcomes and continuous quality improvement. Monitoring outcomes and quality metrics in cardiac surgery through public reporting is a professional obligation to do not only what is best for the patient but also to continually refine our practice. Few areas of medicine have openly adopted such introspection. As these outcome initiatives traverse to other fields, this will transition the health care systems from “service-”based to “performance-”based outcomes. Throughout the last 50 years, cardiac surgery has established this foundation and set the course.
Ethical conduct of research
The authors declare that they followed applicable EQUATOR Network (http://www.equator-network.org/) research reporting guidelines.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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