Sixty-five years ago this week, on the 2nd September 1952, surgeons at the University of Minnesota, Floyd John Lewis (1916-1993) and Walton Lillehei (1918-1999), made medical history by performing the first successful open heart surgery. It was a milestone in cardiac surgery – as little as 25 years earlier, such an operation would have been seen as practically impossible. What developments in medical practice led to this landmark?
Operating on the heart was the last surgical frontier, as surgery on other organs was commonplace by the mid-twentieth century. As the heart is a high-pressure pump, any incision creates rapid blood loss, which gave early heart surgeons a very short time limit on operations, and copious blood loss meant the surgeon had very poor visibility during the operation, limiting the work they could do. Combined, these factors made heart surgery the surgical equivalent of running through a dark forest with a very small amount of time to find your way out… As a result, operating on the heart was seen as a taboo, and feared due to the high fatality rate.
In the medical journals of the early twentieth century, there was a certain degree of scepticism toward heart surgery progressing much further. For example, in 1902, The Clinical Review suggested that, although successful procedures had been performed on animals, “[they do] not warrant the assumption that the practical after effects would justify such proceedings in man”, with the benefits to humans only being of benefit in “extremely rare instances”.[1]
“Among the Conclusions Reached, and Recently Stated by an Experimental Investigator on the Surgery of the Heart, Is One to the Effect That Mitral Stenosis, Hypertrophy, and Dilatation Will Sooner or Later Find Complete or Partial Relief within the Domain of Surgery.” The Clinical Review, vol. XVII, no. 1, 1902, p. 70. Nineteenth Century Collections Online, tinyurl.galegroup.com/tinyurl/59Y9DX. Accessed 4 Sept. 2017.
More optimism was shown just over a decade later. The Daily Telegraph reported on a conference address by Dr. Alexis Carrel (1873-1944), where he theorised that quick heart operations on dogs could be replicated on humans “with an equal chance of success”. Although it only afforded a two and a half minute operating window, he was confident that this time “may be significantly increased” [2]. The innovation in his method was clamping the surrounding veins with forceps during the procedure, which, as far as we can tell, had not yet been attempted on human patients.
The disillusionment was broken by an American surgeon working in the field during World War II. Operating on patients with shrapnel in the heart was avoided as the risk of fatality was too high, until Dwight Emery Harken (1910-1993) proved that it could be done consistently, operating on over 130 soldiers without a fatality. Having decided it was a surgical problem and was therefore surmountable, Harken perfected his technique on animals, which involved creating an incision and using a clamp to locate and remove the shrapnel. The risk paid off, but the procedure still had the same limitations: the copious blood loss meant a blind race against time.
As The Times remarked in their article on Dwight Harken following his death, “Less than 60 years ago, the heart was believed to be so complex and vital an organ that surgeons were afraid to touch it. Before the second world war only a handful of operations were performed, usually attempts to repair stab wounds, and they were generally unsuccessful” [3]. Now that Harken had broken the barrier, surgeons turned to fixing other issues. Clamping the vessels around the heart provided more time and improved visibility, but there was now a new problem. Limiting the blood into the heart also meant limiting the blood in circulation, which caused deoxygenation in the brain. The brain could survive no more than four minutes without oxygen, which was not long enough for more complex procedures, and this time limit needed to be extended.
The most logical step would be to slow down all the organs to reduce the demand for oxygen throughout the body, and Wilfred Gordon Bigelow (1913-2005) thought that hypothermia would be the best solution. Unfortunately, it did not work. Hypothermia causes a rapid and significant increase in oxygen consumption—the opposite of the desired result—due to the rapid activity of the muscles that hypothermia induced: shivering. Bigelow’s innovation was introducing ether, as the addition of a general anaesthetic acted as a muscle relaxant, meaning that hypothermia could be induced without increasing the demand for oxygen throughout the body.
Bigelow’s method of dropping the body temperature was a crucial move, and Lewis and Lillehei used it to maximum effect. The patient was Jackie Johnson, a five-year-old girl with a life-threatening heart defect. Over the course of seventeen hours, they lowered her body temperature to 17 degrees Celsius, halving her heart rate. Despite the innovations of the method, they still only had a maximum of six minutes. After successfully closing the hole between two chambers, Jackie went home eleven days after the operation.
Many developments followed this landmark: “artificial hibernation” became a widely-adopted practice;[4] within a year, the first heart-lung machine had been used in an operation;[5] within fifteen years the first artificial heart had been implanted, and the first heart transplant had been attempted. After several hundred years of pessimism and limited expectations, it turns out that Harken’s risk was one worth taking.
[1] “Among the Conclusions Reached, and Recently Stated by an Experimental Investigator on the Surgery of the Heart, Is One to the Effect That Mitral Stenosis, Hypertrophy, and Dilatation Will Sooner or Later Find Complete or Partial Relief within the Domain of Surgery.” The Clinical Review, vol. XVII, no. 1, 1902, p. 70. Nineteenth Century Collections Online, tinyurl.galegroup.com/tinyurl/59Y9DX
[2] Our Own Correspondent. “Surgery of the Heart.” Daily Telegraph, 11 Apr. 1914, p. 10. The Telegraph Historical Archive, tinyurl.galegroup.com/tinyurl/59YAX5
[3] “Dwight Harken.” Times, 4 Sept. 1993, p. 15. The Times Digital Archive, tinyurl.galegroup.com/tinyurl/57SRo0.
[4] From Our Medical Correspondent. “Artificial Hibernation In Surgery.” Times, 9 Nov. 1956, p. 6. The Times Digital Archive, tinyurl.galegroup.com/tinyurl/59YQQ4
[5] Ubell, Earl. “Job of Heart, Lungs Done by Machine for First Time.” New York Herald Tribune [European Edition], 28 May 1953, p. 9. International Herald Tribune Historical Archive 1887-2013, tinyurl.galegroup.com/tinyurl/5AQG50. Accessed 4 Sept. 2017.
[6] From Our Medical Correspondent. “Artificial Hibernation In Surgery.” Times, 9 Nov. 1956, p. 6. The Times Digital Archive, tinyurl.galegroup.com/tinyurl/59YQQ4
[7] Barnard, Christian N. “Surgeon Explains First Heart Transplant.” Daily Telegraph, 11 Dec. 1967, p. 13. The Telegraph Historical Archive, tinyurl.galegroup.com/tinyurl/59YTA4
