What Everyone Has to Know about Open-Heart Surgery

What Everyone Has to Know about Open-Heart Surgery By George Silvay My neighbor, from across my weekend/vacation house is my source of information in West Hampton Beach. She is a middle age lady, I call her Ann. She called me “doc” since I have on my car MD plate. Recently during this spring, I did not see her for several weeks. Last weekend, Ann was waiting for me in the street and proudly was saying: “Doc, I had cardiac surgery, valve repair with heat-lung machine in Long Island hospital and I feel really great.” I was surprised, since I never knew about her medical problem. She asked me: “Please, tell me something about the heart-lung machine (HLM) for open heart surgery?” I said, “OK let’s have a seat in my garden.” “For operation of the heart, it was necessary to designed equipment, which will be able temporarily to replace the pumping function of the heart and provide oxygenation of the blood. Many discoveries were necessary to allow the start on the work of the HLM: blood groups, pharmacological ways to make blood not clotted for period of using machine, advances in precise diagnosis of defect in the heart, and finally to have surgical way to correct such abnormalities. In between many scientists and physicians the development of the heart-lung machine and its first successful clinical application was the culmination of Dr. John Gibbon’s lifetime research project. Despite many technical obstacle, financial problems, and discouragement from colleagues, his goal was achieved after twenty tedious years of tireless work.” Ann interrupted me, “How he, Dr. Gibbon, came to such an idea?” “Well, he was young physician and he was assigned to monitor the 53-year-old woman with postoperative complication, following gallbladder operation, with diagnosis of pulmonary embolism (blood clots in lung circulation). He was asked to recorded patient blood pressure, heart and respiratory rate for every 15 minutes. He spent 17 hours by the patient’s side and he witnessed the patient’s struggle for her life. She had massive venous engorgement, difficulties to breath with progressive pain. Her mental situation was deteriorated and only solution was surgical procedure (pulmonary embolectomy). At that time, such an operation had never been performed successfully, and it was a very last resort of treatment. After patient became unresponsive, the operation was performed, but the patient did not survive. Ann was pale and squeezing her hands, but she asked: “Doc, please continued.” And I did. “This death was not in vain, it was during the approximately 17 hours by the patient that Gibbon witnessed the patient’s struggle for life. This naturally led Dr. Gibbon to the hypothesis that if it was possible to remove continuously some of the blue blood from the patient’s distended vein, put oxygen into that blood and allow carbon dioxide to escape from it, and then pump to inject continuously into the patient’s arteries the patient could have been saved. This idea, although not fully supported by many investigators at this time, encouraged young Gibbon in a research project that would later represent a major landmark in the history of medicine.” Ann was very interested and asked: “Hey Doc, was this the beginning of the heart lung machine used in my open-heart surgery?” “Yes, I responded, but it takes little more time and effort. During following years, Gibbon devoted all his spare time to developing an artificial heart lung machine, capable for the short time of totally supporting the circulation (work of the heart) and providing oxygenation of blood (work of the lung). Such a complex and tireless dedication led to years of full time research focusing on building the device. There were many obstacles – material not causing problem with blood contact, artificial ventilation, and not traumatic pumping of the blood. Progress was slow, but in 1934, Gibbon was able to perfuse a feline model of pulmonary embolism for short time. In 1939, he had long term survival in the experiment on the perfused feline.” Ann was inpatient and interrupted me: “But humans are significantly larger than felines. What was happening then?” “Well Ann, Dr. Gibbon knew it and it was his and his research group the major problem. But even success with small animals increases his enthusiasm! Progress in his research stopped and forced break due to World War II. Ann, the story is not finished and as I know, you have to do cook dinner for your family, let’s continue tomorrow.” Ann was unstoppable and asked: “Please continue. I will order dinner from restaurant!” “Dr Gibbon recruited new group of enthusiastic physicians to resume his research activities to improve present status of the heart lung machine. The next step was to overcome technical difficulties with hemolysis (distraction of red cells with contact with foreign material and pumping), the inability to oxygenate large volume of blood (for future applicability in human) and obtain the financial support. The last was solved, after one of Gibbon’s students introduced to him Thomas Watson, Chairman of the IBM (International Business Machine). Watson immediately became very interested in project and provided great logistic and financial support. He assigned his chief engineer, Gustav Malmro, to optimize the mechanism of artificial oxygenation of blood (function of the human lung). In the next years (1949 to 1951), IBM not only funded the research, but also built three new types of machines with larger size of oxygenator, satisfactory for use in man. New device allowed Dr Gibbon to operate on larger animal models with long-term survival! The team felt that the time had come for the clinical application of the heart lung machine in human. In 1951, several physicians around the world made attempts to perform open-heart surgery with different types of machines. All of them, 18 patients total, unsuccessful for multiple reasons, some of which were unrelated to the machine. In February 1952, a 15-month-old female with inborn defect in the heart that divides right from left heart (atrial septal defect). Patient was the first operation on human by Dr Gibbon. After the patient was connected to machine, the defect was not found. Patient condition deteriorated, and she passed away on the operating table. The autopsy demonstrated an error in diagnosis since the patient had other heart defect. This experience not only reinforced the need for a successful technique for perfusion, but also exposed the urge for a better preoperative workup with exact diagnosis (role of cardiac catheterization). Dr Gibbon sends one of his young physicians to update knowledge in cardiac catheterization. In March 6th 1953, 18-year-old freshman at Wilkes College, PA was operated with severe right heart failure secondary to a large septal defect. Dr. Gibbon performed a closure of the defect with heart lung machine. The operation had an uneventful progress, and patient was transferred to the floor awake and recovered after operation. The patient married, had a healthy family, and was having normal life. This event marked, after 23 years of Dr Gibbon’s work, the first successful open heart surgery in the world using heart lung machine!” Ann was very satisfied with whole report, she inquired: “And what happen after?” “Dr. Gibbon’s device from 1953 was improved, and the new version is used presently all around the world. There are over one million open-heart surgery with heart lung machine performed in one year. In May 2013, we celebrated and remembered the 60th anniversary of the first successful used of heart lung machine in human. Ann, you know you are one of many patients from Long Island who is benefiting from Dr. Gibbon discovery.”