In the year 1896, Sir Stephen Paget wrote a book titled “ Surgery of the Chest”. In his book, he elaborated on the then thoracic procedures in vogue but opined that the pleura should not be breached. He was supported by Theodore Billroth, one of the leading surgeons of the time. Operating on the heart was considered a crime, and Billroth made the famous statement of proposing ex-communication of so-called surgeons if they tried to do anything on the heart. Billroth’s sceptical attitude was also evident in his remarks in the surgery textbook, Handbook of General and Special Surgery. He stated, “The paracentesis of the hydropic pericardium is in my opinion, an operation approaching surgical frivolity.”
That the heart can take sutures and heal like other tissue was incomprehensible at that time. To quote Sir Stephen Paget “No new method, and no discovery can overcome the natural difficulties that attend a wound of the heart". The command of the German physician, geologist and naturalist, Ernest Dieffenbach to "stop at the pleura" was obeyed by all prudent surgeons of his time. It was strongly believed that to open the chest was to kill the patient. Surgeons believed that once a hole in the chest wall larger than the laryngeal aperture was created, ventilation would effectively cease. However, that very year something unusual happened and a heart wound was suture repaired by a courageous German surgeon, Dr. Ludwig Rehn. The patient survived. People became aware of the fact that heart wounds can be repaired by sutures and patients can survive with a usual heart function thereafter.
At that time, breaching the pleura was a major problem. We are all aware that the lung invested inside the pleural envelope is in an environment of negative pressure about the outer atmospheric pressure. So, the lung collapses the moment the pleura is breached. To keep the lung inflated during surgery, which required open ether or chloroform inhalation and spontaneous breathing during the process, an atmosphere in the operation theatre maintained this pressure difference. During that period the futile attempt by a young Polish surgeon from Danzig, H. M. Block, was still fresh. In 1882 he did an exploratory thoracotomy on one of his relatives suspected of having tuberculosis. The patient died during the procedure and the surgeon later committed suicide without keeping any record of the procedure.
Ferdinand Sauerbruch In 1904 introduced the German “unterdruck” technique which the entire operating theatre was converted into a negative pressure (-15 cm of H2O) to keep the lung expanded during surgery. A German alternative “uberdruck ” procedure was there but this required keeping the patient’s head in a positive pressure environment. The setup was complex and did not become popular.
Sauerbruch visited America and after a demonstration left the entire operating theatre set up with Willy Meyer, an avid fan of the idea. Meyer was interested in thoracic problems and involved his engineer brother. They came out with a “universal chamber” where either the patient with the entire surgical team had to stay the entire procedure in a negative pressure chamber, or a box with positive pressure was constructed for the patient’s head with the surgeons working outside at atmospheric pressure and the patient's thorax in a negative chamber. This remained the usual method for Thoracic exploration for a long time and Sauerbruch’s book, “Die Chirurgie der Brustorgane” was considered to be a bible for Thoracic Surgeons till the 1930s.
That the heart can withstand manipulation and suture had been proved earlier. There are circulated reports of Francisco Romero’s pericardial drainage methods way back in 1801 and is considered by some the first successful surgery on the heart. There have been claims by Baron Dominique Jean Larrey in the intervening period of successful treatment of a Napoleonic soldier with a thoracic injury with lung exposure. Animal experiments during this period also showed that the heart was able to withstand sutures. John Bingham Roberts first proposed, to quote him, “The time may come when wounds of the heart itself will be treated by pericardial incision to allow extraction of clots and perhaps to suture the cardiac muscle.” This was in 1881. Block’s work with sutures on rabbit hearts validated animal experiments. Similar work was done by Simplicio Del Vecchio in Italy (1885), and Charles Albert Elsberg in the Americas. The latter by his animal experiments theorized in 1909 that, quote, “Above all my experiments seem to show that a mammalian heart will bear a much greater amount of manipulation than has hitherto been suspected. Very large wounds of the heart can heal, and the healing process occurs in a manner entirely analogous to that in other muscular tissues.”
Rehn’s feat was not a mean one. His operation was not planned and was on a backdrop of reverence for the organ, disbelief, and against recommendations of greats of the time. So much so, that he appears apologetic in his opening remarks and states:
In the desperate case of a stab wound of the right ventricle, I was forced to operate... There was no other option open to me, with the patient lying before me, bleeding to death. After a perusal of the following case history, the surgeon will be able to place himself in my position. Though one would have liked to have had time to carefully consider the problem, it demanded an immediate solution...
Ludwig Rehn did the impossible at a time when nobody had any idea of cardiac surgery. Monitoring was non-existent and the physicians had to depend on clinical methods and visual evidence to care for a patient. His description of systole and diastole was accurate and the decision to take sutures during diastolic relaxation when the heart is soft and supple was right. He salvaged the patient after a stormy post-operative period marked by empyema and its drainage. He was considerably bolder at the end, and he concluded:
Gentlemen! The feasibility of cardiorrhaphy no longer remains in doubt. I need not fear any objections as to its propriety; the operation not only was lifesaving, but prevented the subsequent development of constrictive pericarditis. I trust that this case will not remain a curiosity, but rather, that the field of cardiac surgery will be further investigated. Let me speak once more my conviction that by means of the cardiorrhaphy, many lives can be saved that were previously counted as lost
This was the beginning of cardiac surgery and the 9th of September,1896.
Less than a year after Rehn's surgery, sternotomy for accessing the heart was suggested by the then director of the prestigious Lancet journal, Dr. Herbert Milton. He realized that no fancy imaginative process had any role in cardiac surgery and a practical approach to suit the situation as it presented. To quote him: "
Heart Surgery is still quite in its infancy, but it requires not a great stretch of fancy to imagine the possibility of plastic operations of its valvular lesions...
This was a prophecy. Although cardiac surgery was in its infancy at the turn of the 20th Century, several pioneers were in the field. Alexis Carrel collaborated with the aviation specialist Charles Lindbergh to carry out and understand the perfusion process. Carrel perfected the vascular anastomosis technique and was awarded the Nobel Prize for this. Theodore Tuffier was another person, and he was courageous enough to try his ideas on real patients. He, in 1924, invaginated his index finger through the aortic wall in a patient with aortic stenosis, a fracture that dilated the valve orifice. the patient survived and was alive even after 12 years. The other contributions included the creation of apical extra-pleural pneumothorax and or adhesiolysis and resection in between a clamp in tuberculosis. He earlier, in collaboration with Carrel, carried out animal experiments where they studied inflow occlusion and heart valves. Tuffier's work inspired many to the ways of beating heart cardiac surgery later.
Little happened between Rehn’s feat and the 1930s. Only a proposition of what might happen, Kirshner’s success with the Trendelenburg procedure and forays into treating mitral stenosis were the highlights. It is exciting to talk about heart surgery but to do it was a daunting task at that time. Reports of heart injury repair were sporadic and successful even so. A long time was required for recovery from such cases to even equal the predicted mortality and surgeons used to quote a modest 40% chance of survival at that time.
Actual pioneers like Tuffier were rare. Most theorized their ideas and, in some cases, years later courageous surgeons did a case proposed earlier. Trendelenburg procedure is a classical example. Trendelenburg theorized pulmonary embolectomy in 1908. Trendelenburg tried the procedure on moribund patients, and none survived. One of his students, Kirchner, reported a successful case in the year 1924. The other examples included the various suggestions for angina palliation in ischemic heart disease. Here the symptoms were treated and not the disease and the procedures were thoracic sympathectomy, creating pericardial adhesions to promote neo-vascularization, subtotal thyroidectomy, etc. The idea that the opening up of a restricted valve orifice like that in mitral or aortic stenosis was creeping into the thought process of some was the subject of interest in many animal experiments.
It was known that the heart had atrioventricular and ventricular-arterial or semilunar valves, separating the different chambers. Stenotic valves intrigued surgeons interested in the heart and the prevailing thought at that time was finding out a way to enlarge the opening of these valves with restricted openings. Theodore Tuffier found a way, though difficult to reproduce, to dilate an aortic valve. The procedure did not require a breach of the cardiac walls. The mitral valve was different. Not only it was deeply situated between the all-important left ventricle and left atrium, but it also regulated preload to the left ventricle and hence the contractility.
The World literature is silent or ambiguous about the methods of anaesthesia for these early surgery patients. Even if surgery is detailed nobody cares about the techniques to pacify and make a surgical patient free of pain. There was a remarkable advancement in anaesthesia techniques in the first decade of the 20th century. Sauerbruch’s unterdruck and uberdruck methods, adopted by Willy and Julius Meyer brothers to be converted into universal chambers, were soon overtaken by the far superior intra-tracheal anesthesia forwarded by Samuel Meltzer. Around this time Tuffier also experimented with a cuffed intratracheal tube. The problem of lung collapse was thus overcome and the era of positive pressure intra-tracheal anesthesia began.
Usually, a bilateral anterior thoracotomy was done to access the heart. Sternotomy, as a better method for cardiac access, was not realized and proved till 1957 and people were afraid to do a sternotomy fearing unmanageable complications and healing problems.
Positive pressure ventilation had decidedly more influence in thoracic operations as lung collapse could be prevented. That dependence on a separate group of physicians was needed during surgery was assuring. The surgeons were at that time engrossed with the problem of the stenotic mitral valve. As early as 1902 Sir Lauder Brunton suggested the possibility of treatment of mitral stenosis by surgery. A media flaying followed and is said to have dampened the spirit of the surgical fraternity. Later, in the year 1923, a surgeon named Elliot Cutler mastered the courage and with the belief that mitral regurgitation is better tolerated, inserted a tenotomy knife inside the left ventricle and divided the mitral leaflets to create a mitral regurgitation. The patient lived for four and half years after the operation and though initially showed some improvement, finally succumbed to mitral regurgitation. It is somewhat surprising that Cutler's one and only patient survived miraculously considering the description of a really ‘frightful’ operation: “A slightly curved tonsil knife was pushed through the ventricle upwards until it encountered what seemed to us must be the mitral orifice. A cut was made in what we thought to be the aortic leaflet… The knife was quickly turned, and a cut was made on the opposite side of the opening’!!
The subsequent six consecutive operations were a failure and probably surgical creation of mitral regurgitation to treat mitral stenosis was not the answer.
Henry Souttar, in 1925, in England, finger fractured and thus enlarged the mitral stenotic orifice. His patient lived a better life for the next five years ——— “in quite reasonable health, passing away at the end of that time from cerebral embolus arising undoubtedly from the heart . . .“ as stated by him. Ironically he was not sent a single more patient by the then physicians and cardiologists who held the view that this was not the right treatment for mitral stenosis —- “Although my patient made an uninterrupted recovery the physicians declared that it was all nonsense and in fact that the operation was unjustifiable. It is of no use to be ahead of one’s time!”. This was the actual answer given to Dwight Harken 25 years later in response to his query, in the 1940s, when he was doing his brilliant work in the extraction of cardiac foreign bodies during the war (World War II). Nevertheless, Souttar’s achievement was later hailed as the first. It was Charles Bailey’s and Harken’s work that popularised the surgical treatment of mitral stenosis.
“Lengthen the slit” was first suggested by Sir Lauder Brunton. The idea of dilatation of the mitral orifice along the commissures was taken from the principles of operating in microstomia. C. P. Bailey followed this and did a finger fracture commissurotomy as suggested by Henry Souttar. He noticed commissural re-fusion with clots and heavy calcification of the valve at autopsy in his first patient, who suddenly died on the 2nd postoperative day. Henceforth, Bailey used a commissurotomy guillotine, a personal modification of the Cutler valvulotome based on a tenotomy knife, for commissural lengthening. He did these procedures at both the Episcopal Hospital, where he had his first successful operation and the Hammersmith Hospital in Philadelphia. He had to endure a reputation as the “Butcher of Hammersmith” after consecutive failures. He posted two cases on the same day for the 4th and 5th patients. The moment he realized that the 4th patient was not going to live, he went to the other Hospital before news broke to the press and did the 5th operation. The patient lived this time, and the rest is history. Harken carried on the work further and popularised the procedure.
Apart from surgery of mitral stenosis (MS) patent ductus arteriosus (PDA) closure by Robert Gross, the famous Blalock-Taussig shunt for Tetralogy palliation by Blalock ( and as suggested by Taussig) and end-to-end repair of Co-arctation of the aorta by Crafoord were the only procedures related to the heart that was done.
Robert Gross was the first one to close a PDA. He was just waiting for the right opportunity. William Ladd, his senior who was in the way of his intentions, went off for a holiday. Gross took advantage of the situation and took a previously identified PDA patient to the operation theatre and surgically lighted the abnormal channel in between the aorta and the pulmonary artery. Though Ladd was not amused, Gross instantaneously became famous and dedicated himself to finding a solution to the prevailing cardiac surgery problems in addition to his work. This was in the year 1938 and is considered a landmark year.
Helen Taussig a pediatric cardiologist, suggested to Alfred Blalock devising a method to increase blood flow to the lungs. She had notified that the Tetralogy patients deteriorated once the PDA closed. Her observation was based on Paul Swenson’s communication to G.H. Humphreys I: “Patent ductus favours Tetralogy of Fallot patients’ survival”. Her observations were similar. Previously she had approached Robert Gross but was curtly told after making her wait for some time in the corridor that Robert Gross was in the habit of closing PDAs and not creating them. Blalock gave her a patient hearing and with his assistant, Vivien Thomas immersed in the problem at the Johns Hopkins Hospital Baltimore. This was in 1943. A method consisting of left subclavian turndown and anastomosis with the left pulmonary artery was perfected on dogs at the animal laboratory. Though monitoring was in its infancy, the first patient not only survived but showed features of clinical improvement. The year was 1944. Blalock was the surgeon, and the procedure became famous as the Blalock-Taussig shunt. Left thoracotomy and isolation of the left pulmonary artery and the left subclavian artery were initially planned as the team thought that the vessels had a predictable course. Also, an important consideration was the dominant nature of the right hand. This was the treatment of choice in cyanotic tetralogy patients of that time. The initial "classic" method has been modified and indications expanded to include conditions that could not be conceived before. The newer shunts may be condition-specific, still, the idea of systemic-pulmonary shunting to give some symptomatic relief and gain time was revolutionary. The contribution of Vivien Thomas was a later realization and included thereafter. Racial consideration did not allow his name to be mentioned along with other white people at that period.
Swedish surgeons were not far behind. By that time Clarence Crafoord had the experience of a successful Trendelenburg procedure in acute pulmonary embolism and was credited with the “spiro-pulsator” he devised with his mentor Giertz. The device was used for pulmonary ventilation and intubated with a cuffed endotracheal tube. He observed that in all probabilities a collateral circulation developed in co-arctation of the aorta and this prevented spinal ischemia and distal hypo-perfusion if cross-clamps interrupt aortic flow. In 1944 he went ahead and resected the co-arctated portion of the aorta and restored continuity by end-to-end suture anastomosis of the proximal and distal aorta. He performed a couple of more cases before reporting. His method remains the gold standard for treating co-arctation even today.
These were the three major procedures that were done before the introduction of Gibbon’s heart-lung machine and direct repair by visualizing a cardiac defect. We call this the era of open-heart surgery with a cardiopulmonary bypass machine.
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