Back to Founding of AATS
Previous to 1918, cardiac surgery was a rare event. However, some
Founders were quite optimistic and forecast many present-day concepts. Samuel
Robinson's writing was typical: 1
Surgery of the heart is dangerous ... (however) ... Experimental
investigations have demonstrated possible means of lessening these dangers ...
Carrel at work in
laboratory at Rockefeller Institute of Medical Research where he did much of
his experimental vascular and cardiac surgery.
Carrel examining culture
of cells of chicken heart embryo.
Carrel wearing gown,
mask and gloves in line with his own insistence on maximum asepsis during
cardiac and vascular surgery.
Nobel Award for
medicine received by Alexis Carrel. This was the first time the Award came to
America.
On heart injuries:
Sudden death is the usual
sequel to gunshot and stab wounds of the heart. A small proportion - are
followed by an interval
- in which surgical aid should be, but rarely is,
seriously considered. The victim is already dying in consequence of the
assault. Operation seems for the moment like a repetition of the crime and
surgeons tend to leave such situations in the hands of God, lawyers and police
officers.
This not uncommon attitude should cease. As the
hemorrhage increases - 'Heart Tamponade' arises ... expectant treatment is
indicated in but one group of heart wounds, namely a small wound that is
occluded by clot formation in the pericardium - before heart tamponade ensues.
With this one exception - an operation should be
promptly and seriously considered in every case in which there is reason to
believe that the heart has been wounded.
Experimental chest surgery has demonstrated the
usefulness and safety of wide open thoracic intercostal exposures for approach
to the heart, lung, esophagus and diaphragm.
It is at the moment of the pericardiotomy that the
critical moments of these operations sometimes presents.
The writer has employed manual compression of the
vessels at the base during repair of a bullet wound of the left ventricle. The
heart suture was materially facilitated by the resulting hemostasis.
The following is strange:
Drainage of the pleural cavity should not be
established at the end of operation for two reasons. First - infection. Second
- it is a well established fact that the presence of
pneumothorax favors infection after operation. The presence of drainage at once
establishes this infection. In this connection it should be remembered that it
is quite as important to obliterate the pleural space before closure as it is
to omit drainage.
He had this comment on pericardial effusion:
Hemorrhagic and purulent exudates are seldom relieved
by aspiration. In such cases the fourth or fifth costal cartilage should be
carefully excised, and an incision made into the pericardial sac with
evacuation of clots or pus, followed by drainage.
Certainly Dr. Robinson was not conservative.
Carrel's report to the American Surgical Association
on May 5, 1910, provides amazing excerpts: 2.
It seems possible, also, that some valvular and
vascular diseases of the heart might be improved by surgical therapeutics. A
few experimental studies of this subject, however, have been made ... but ...
have been followed by a heavy mortality. Their results ... show that the
general technic of intro-thoracic surgery is still insufficiently developed ...
... It is, therefore, necessary to use in vascular and
intra-pleural operations better asepsis than exists in many hospitals and
laboratories.
I made twelve operations similar to those performed by
previous experimenters, resection of pulmonary lobes, resection of a small
segment of the middle part of the oesophagus, simultaneous opening of both
pleurae and pericardium, dissection of mediastinum and ascending aorta. I
employed only the simplest sutures or ligatures, and the animals, without
exception, recovered.
The apparatus I used is composed of only a
foot-bellows, a rubber tubing connected with an ether bottle, and a manometer,
and a small intratracheal catheter. With the method ofMeltzer and Auer, the
spontaneous respiration becomes a luxury.
I attempted also to find out some method for the
treatment of valvular diseases and localized sclerosis' of the coronarian
arteries. Theoretically, many operations can be performed on the heart, -
incision and dilatation of stenosed valves, cuneiform resection and stenosis of
the upper part of the ventricle in case of mitral insufficiency, curettage of
endocardiac vegetations, grafting of new vessels on the auricle and ventricle,
... aorto-coronarian anastomosis, etc. The development of these technics is not
far advanced for I have studied the conditions under which the operations must
be performed rather than the operations themselves. Plastic operations on the
heart are not very much more difficult than on any other parts of the body. But
to perform the operations without disturbing in an irreparable manner the
functions of the nervous system and of the heart itself is a very complicated
problem.
The cardiac operations can be artificially divided into
three classes: operations which do not require the haemostasis of the heart,
operations which require the haemostasis for a very short time, and operations
which require the haemostasis for a longer time and the stopping of the heart.
1. Several
operations can be performed without the help of the temporary haemostasis, such
as digital exploration of the auricles, dilatation of the mitral valve,
dissection and preparation of a coronarian vessel for anastomosis, incomplete
ventriculectomy and suture, etc.... A dog which has undergone this partial
ventriculectomy two months ago is still in good health.
2. In the
operations of the second class, the cavities of the heart are open for about
one minute, during, which time it becomes possible to insert and fix a tube or
vessel into the ventricular or auricular cavities, to open largely and suture
the ventricular wall ... to cut a mitral or tricuspidian valve, ... to perform
the curettage of endocardiac vegetations. The haemostasis can be secured by the
clamping of the venae cavae ... But it is simpler to clamp ... the entire
pedicle of the heart. As the interruption of the circulation does not last more
than one or two minutes, it causes no cerebral complications. The main danger
is the occurrence of fibrillary contractions ... I performed clamping of the
heart eight times, with or without cardiotomy, for from one to five minutes.
One dog died of respiratory complication, another one of fibrillary
contractions, ... and the others recovered. In case of mitral stenosis, it
would be easy to make an incision of the valve : . . I succeeded in fastening
temporarily a tube into the left auricle and ventricle ... At the end of the
operation, the tube was removed. The animal remained in good health.
3. To the
third class belong the operations requiring the interruption of the circulation
for a longer time. In certain cases of angina pectoris, ... it would be useful
to establish a complementary circulation ... In one case I implanted one end of
a long carotid artery, preserved in cold storage, on the descending aorta. The
other end was ... anastomosed to the peripheral end of the coronary, near the
pulmonary artery. Three minutes after the interruption of the circulation,
fibrillary contractions appeared, but the anastomosis took five minutes. By
message of the heart, the dog was kept alive. But he died less than two hours
afterwards. It shows that the anastomosis must be done in less than three
minutes. Perhaps this can be done by using a lateral implantation with a Payr's
canula.
The safest method of performing a comparatively long operation would be
to suddenly place the heart in a condition of anaemia ... We do not know
exactly for how long it is safe to keep the heart motionless. But the complete
stopping of the circulation is more for the organism than for the heart.
Four years later he reported progress: 3
... in
1913 and 1914, an attempt was made to develop technics by means of which
plastic operations on the pulmonary and the aortic orifices of the heart could
be performed. As it is the object of these operations that they be ultimately
applied to human surgery, it was primarily necessary to accumulate about the
operative procedure a number of factors of safety. It is not sufficient that
plastic operation be possible in order to be practicable. It must also be not
dangerous.
The animals were etherized according to the Meltzer-Auer method, then
according to the operation to be performed, the circulation of the heart was
arrested and the pulmonary or aortic orifices were exposed and opened.
1. ...
Finally we adopted the method of the clamping in mass of the pedicle of the
heart ... It was important to allow the heart to be in a normal condition
before clamping the pedicle ... It was noticed that if the heart was clamped
before it was in excellent condition the interruption of the circulation could
not be as innocuous as when the heart was filled with well-oxygenated blood.
When the above-mentioned precautions were taken, it
was possible to clamp the pedicle of the heart ... three minutes. As soon as
the clamp was removed the heart resumed its pulsation and after a very short
time the pulsations were again normal.
2. The aortic
and pulmonary orifices were exposed by means of incisions made through the
anterior wall of the arteries ... Several times the valves were exposed by an
incision made only on the pulmonary artery. Generally they were exposed by an
incision of about 4 cm. made half on the pulmonary artery and half on the
ventricle of the heart. In that region the branches of the coronary artery are
small and can be cut without danger. The exposure of the aortic valves are made
through an incision located on the right side of the aorta between the mouth of
the right and left coronary arteries ... Great care was taken not to injure the
mouth or the branches of the coronary arteries.
3. The
opening of the ventricles ... pulmonary artery ... aorta is always followed by
entrance of air ... No accidents have been observed after the entrance of air
into the right heart and the lungs. But the introduction of air into the aorta
and the left ventricle was very dangerous. When the operation was completed and
the circulation re-established the air emboli were sent through the coronary
vessels, and this caused fibrillary contractions of the heart and consequent
death. On several occasions it was possible to see the air emboli in the
coronary arteries. It was, therefore, necessary for the safety of the operation
to eliminate the possibility of such a complication. This could be done by aspirating
the air contained in the heart by means of a large needle or cannula introduced
into the ventricle or into the aorta and connected with a vacuum apparatus.
This operation was performed rapidly just before the removal of the clamp and
the re-establishment of the circulation.
These three operations were performed with the purpose of ascertaining
whether operations such as should be made incases of inflammation, stenosis, or
dilatation of the orifices would be possible.
1. Opening of
the Aorta and Cauterization of the Sigmoid Valves. After the artery was exposed
and the pedicle clamped the aorta was opened ... The valves ... were cauterized
with a thermocautery. The aortic incision was next closed by means of a
continuous suture with Chinese silk No. 1 sterilized in vaseline. Through ... a
curved cannula ... the air contained in the left heart was aspirated. Then the
clamp was removed after the circulation had been interrupted for about three
minutes. After ... the treatment of air emboli of the right coronary artery,
the heart resumed its normal pulsation, the pericardium was closed, and the
operation was completed in the ordinary manner.
2. Patching
of the Pulmonary Artery and Arterial Cone. This operation was made with the
purpose of ascertaining whether the pulmonary orifice could be made larger. The
operation consisted in suturing on to the surface of the pulmonary artery a
patch of vein preserved in cold storage and in cutting the edge of the orifice
underneath the patch.... The operation was performed without stopping the
circulation of the heart ...
3. Suture of
the Sigmoid Valves of the Puhnonary Artery. After the pedicle of the heart was
clamped the pulmonary artery and the ... ventricle were opened by means of an
incision about 4 cm. long ... Half of the incision was on the artery and half
on the ventricle ... The sigmoid valves could easily be seen ... In one case
the posterior parts of the left and the right sigmoid valves were united by a
stitch at about 3 mm. distance from their insertion to the wall. In another
case the right sigmoid valve was cut in the middle part with the scissors and
the edges of the wound were united by a stitch ... When the operation was
completed the edges of the incision were united ... Then the clamp was removed
and the circulation re-established. The duration of the interruption of the
circulation was a little more or less than two and one-half minutes. As soon as
the clamp was removed and without the necessity of any massage, the heart
resumed its pulsations. After a short while the pulsations were normal...
The results of these operations must be considered from two
standpoints: (1) the dangers involved to the life of the animal by these
operations and (2) the general and local results of the operations.
When the technic which has been described above is carefully followed
out, the operation is of little danger to the life of the animal. In eight
cases ... performed the patching and the incision of the pulmonary orifice. One
dog died of pericarditis ... the heart was handled with rubber gloves. Another
dog died ... of fibrillary contractions ... In six other cases the animals ...
are still normal six months after the operation ... It must be noted also that
these remote results demonstrated that a piece of vein put on the pulmonary
artery in contact on the one side with dark blood, on the other with the
pericardium, that is in an unfavorable condition of nutrition, did not undergo
necrosis. The results of the suture of the sigmoid valves were better ...
Although there was an interruption of the circulation ... and the heart and
artery were widely opened ... their condition at the end of the operation was
exactly the same as after the mildest kind of operation and twenty-five days
after ... , they are in excellent condition ...
The purpose of these operations was to show how extensive a plastic
operation on the heart can be made without danger to the life of the animal ...
It is not impossible that someday surgeons will be able to cauterize valvular
lesions or to repair them as we do today in our experimental operations.
Observations such as these form the basis for present-day methods. Some
contemporary surgeons have expressed amazement that it took so long to develop
current applications. Yet, though fundamentals hadbeen established,
actual victory awaited antibiotics, better anesthesia, prostheses, pumps and
trained surgeons with an interest in the field. However it is well to remember
that the desire to advance these developments was uppermost in the minds of
those who formed the AATS.
