To operate on the human heart safely was a dream in the early twentieth century, and the object of derision by most well-known surgeons of that era. The world-famous Theodor Billroth once exclaimed that to operate on the human heart was folly at best and ignorance at worst. The men and women who pushed further, in creating the ability to work on the heart while stopped and continuing to sustain the body, advanced the medical field beyond their wildest dreams.

Cardiac surgery in the early twentieth century had begun to develop a number of life-saving operations. With the advent of vascular techniques and refined tools, quite a few advances had been made—repair of coarctation, the Blalock-Taussig shunt for Tetralogy of Fallot, mitral valve fracture and many others. Hypothermia and inflow occlusion were the mainstay of operating inside the heart for a few minutes. In September of 1952, Lewis and his colleagues at the University of Minnesota closed an atrial septal defect on a 5-year-old patient with this technique.¹ The advent of modern cardiac surgery began in May of 1953 when Dr. John Gibbon corrected an atrial septal defect in a young woman at Jefferson Hospital in Philadelphia with the assistance of a true heart-lung machine. This was the culmination of experimental successes and failures, and a collaboration between clinicians, scientists and engineers from the previous decade.

Dr. John Gibbon, graduating from Thomas Jefferson Medical College in Philadelphia in 1927, had obtained a research fellowship under Dr. Edward Churchill at the Massachusetts General Hospital to study the physiology and management of pulmonary embolism. Witnessing patients with this deadly diagnosis, he soon began to formulate the idea that the solution would come from some sort of temporary mechanical assistance that supported the circulation and took over the oxygenation. Thus, the seed was planted and, fortuitously, the technician assigned to him, Mary Hopkinson, would become his wife and partner for the ensuing years.

Gibbon realized that the mainstay of circulatory support was the oxygenation of blood. This rose from his interest in patients that suffered from pulmonary embolism. The first problem was to be able to remove the blood and return it—a problem solved with the original Dale-Schuster pumps. These were developed in 1928 with the intent of providing complete circulation to both the systemic vascular and pulmonary system.

The early oxygenator was nothing other than a rotating steel cylinder, where blood was introduced from the top and after coating an inner surface was exposed to oxygen.² After returning to Philadelphia in 1935, Gibbon began refining his "heart-lung" machine with the help of his Chief Resident, J. Y. Templeton. His research was briefly interrupted by the Second World War but upon returning to Philadelphia he continued his critical work. The first problem was mechanical: creating a machine that would be able to pump the volume required for a human being – 4-6 liters/minute. There would have to be a reservoir to collect the blood, compatible tubing to connect to the patient, controllers, pressure gauges and so on. A fortuitous connection with a medical student in his lab, E. J. Clark, led to a meeting with Thomas Watson, the leader of IBM. Watson assigned his chief engineer, Gustav Malmros, and provided resources to help Gibbon with the mechanical and electrical engineering aspects.

The second major problem was the oxygenation of blood. Direct-contact oxygenators had been developed, but were plagued with problem of hemolysis, thrombosis, foaming, air embolism and acid/base control. Through a series of experiments in dogs, Gibbon and his team were able to develop an oxygenator with multiple series of stainless-steel screens. Under tight control, the blood was spread as a film across the screen, and oxygen was flooded into the chamber. Using multiple DeBakey roller pumps, one was able to control the flow into the venous reservoir, flow into the oxygenator and eventual flow back through an arterial conduit. The pH was adjusted pharmacologically or with the aid of carbon dioxide infusion. Hemolysis was aided by controlling the flow so as to not create shear damage. The converse problem of thrombosis was obviated using heparin, which although discovered in 1916, had just entered clinical trial in the 1930s. The entire contraption was contained in a large stainless-steel cabinet that was 5 feet by 2 feet, 4 feet in height, and weighed almost 2000 pounds.

Gibbon and his team first attempted using the heart-lung machine on a child with a presumed atrial septal defect. But the diagnosis was wrong, and the patient succumbed to a patent ductus arteriosus. The second attempt came on May 6, 1953 on an 18-year-old, Cecilia Bavolek. An atrial septal defect was repaired with a continuous suture while the patient was completely supported by the heart-lung machine for 26 minutes. Although successful, Gibbon became discouraged after further surgeries and patient losses. In 19 years of developing the heart-lung machine, he performed only four open heart surgeries. Nonetheless, this pivotal momentous event heralded the beginning of modern cardiac surgery. Between 1950 and 1955, five medical centers were competing in the development of the heart-lung machine.

Sharing his experience and expertise with others, Gibbon sparked a number of surgeons who were on the horizon. Most promising of those was Dr. John Kirklin at the Mayo Clinic. In 1955, using some modifications, Kirklin operated on a series of 8 congenital cases with survival of 50%. Conjointly, Dr. C. Walton Lillehei was developing the technique of "controlled cross-circulation."³ This was a method by which a child was connected to his parent as a "biologic heart machine." Over a 2-year period, Lillehei was able to operate on 45 children, with 28 surviving.⁴ There were severe limitations to this methodology, as only small children could be supported this way and for only a short period of time.

Soon thereafter, Richard DeWall, from Lillehei's laboratory, developed the bubble oxygenator. With the ability to manufacture the oxygenator and pump with readily available materials, such as polyvinyl tubing and a commercially available pump (by the Sigmamotor Company), visiting surgeons quickly expanded the use beyond the laboratories of these world-famous surgeons. A third type of oxygenator, the rotating-disc oxygenator, was developed by Kay and Cross in Cleveland and was being mass produced.

The development of the heart-lung machine spurred innovation in a number of initiatives to treat heart disease. Soon coronary bypass grafting, valvular replacement, congenital correction and heart transplantation were to become standard treatment. The management of the heart-lung machine spawned its own specialty and profession—the cardiovascular perfusionist.

Today, mechanical circulatory support via implantable pumps owes its credits to a handful of researchers from over 60 years ago. Thousands of patients are the beneficiaries of one the most pioneering advances in medicine: the creation of the heart-lung machine.

References

1. Taufic M, Lewis FJ. A device for the experimental creation of ventricular septal defects; preliminary report. J Thorac Surg 1953;25:413-6.
2. Gibbon JH Jr. Artificial maintenance of the circulation during experimental occlusion of the pulmonary artery. Arch Surg 1937;34:1105-31.
3. Gott VL, Moller JH, Shaffer AW, Shumway SJ. Cross-circulation and the early days of cardiac surgery. Ann Surg 2019;269:443-5.
4. Kirklin JW. The middle 1950s and C. Walton Lillehei. J Thorac Cardiovasc Surg 1989;98:822-4.
5. Dale HH, Schuster EH. A double perfusion-pump. J Physiol 1928;64:356-64.
6. Stoney WS. Evolution of cardiopulmonary bypass. Circulation 2009;119:2844-53.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Congenital Heart Disease, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, Heart Transplant, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease, Interventions and Vascular Medicine

Keywords: Heart-Lung Machine, Ductus Arteriosus, Patent, Carbon Dioxide, Blalock-Taussig Procedure, Mitral Valve, Heparin, Hospitals, General, Cross Circulation, Oxygen, Hemolysis, Hypothermia, Embolism, Air, Tetralogy of Fallot, Heart Septal Defects, Atrial, Cardiac Surgical Procedures, Oxygenators, Coronary Artery Disease, Thrombosis, Heart Transplantation, Pulmonary Embolism, Surgeons, Sutures, Biological Products

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