CARDIAC SURGERY
Lawrence
Virginia
David H. Adams, MD
Cardiac
Icahn
Copyright © 2018 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.
ISBN: 978-0-07-184602-8
MHID: 0-07-184602-6.
The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-184487-1, MHID: 0-07-184487-2.
eBook conversion by codeMantra Version 1.0
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps.
McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs. To contact a representative, please visit the Contact Us page at www.mhprofessional.com.
TERMS OF USE
This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms.
THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Education and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill Education has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill Education and/ or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
Lawrence H. Cohn, MD
The 5th edition of Cardiac Surgery in the Adult is dedicated to Dr. Lawrence Cohn, Emeritus Chief of the Division of Cardiac Surgery at Brigham and Women’s Hospital and Virginia and James Hubbard Professor of Cardiac Surgery at Harvard Medical School, who sadly passed away unexpectedly during the final stages of preparation of this latest edition of “his” reference textbook. Dr. Cohn leaves a legacy of excellence seldom seen in academic surgery, and he will be sorely missed by all of us who knew him, and especially those of us lucky enough to have been mentored by him. Dr. Cohn received his training in cardiothoracic surgery under the tutelage of Dr. Norman Shumway at Stanford University, and after completing his fellowship in 1971 he joined the staff of the Peter Bent Brigham Hospital in Boston. Over the next 45 years he was the driving force behind the success of the Harvard program, and became the Chief of the Division of Cardiac Surgery in 1986. A clinical cardiac surgeon first and foremost, Dr. Cohn performed over 11,000 open heart procedures during his career, and was best known for his pioneering and international leadership in minimally invasive valve surgery. His academic contributions included over 500 peer-reviewed publications, 100 book chapters, and 750 invited lectures on virtually all topics in cardiac surgery, but perhaps his greatest academic legacy was his editorship of the 2nd, 3rd, and 4th editions of Cardiac Surgery in the Adult, which under his vision became the most widely referenced international textbook in
adult cardiac surgery. During his career Dr. Cohn earned the highest awards and honors a cardiac surgeon could possibly achieve, serving as the 79th President of the American Association for Thoracic Surgery, receiving an honorary Masters of Medicine from Harvard, and receiving the American Heart Association’s Paul Dudley White Award, among numerous others. He would claim his greatest honor, however, was the opportunity to train over 200 residents and fellows from all over the world, many of whom went on to become Division Chiefs, Department Chairs, and leaders in the specialty. His American Association for Thoracic Surgery presidential address “What the Cardiothoracic Surgeon of the 21st Century Ought to Be” personifies the essence of what made him one of the masters of cardiac surgery who will be remembered by generations to come. Through leadership by example in all phases of his career, his unwavering commitment to the individual patient was the foundation of all of his accomplishments, and few surgeons have had such a profound impact on our specialty. Dr. Cohn was my teacher, mentor, and friend, and it was an honor to be asked by his wife of 55 years, Roberta, to assume the role of Co-Editor to complete this 5th edition of his textbook. Dr. Cohn left footprints too large to fill, but with the help of the many authors who contributed chapters and the publisher’s leadership, we now present this peer tribute to one of the greatest cardiac surgeons of all time.
David H. Adams, MD
Contributors xi
I
FUNDAMENTALS 1
1. History of Cardiac Surgery 3
Larry W. Stephenson / Frank A. Baciewicz, Jr.
2. Surgical Anatomy of the Heart 21
Michael R. Mill / Robert H. Anderson / Lawrence H. Cohn
3. Cardiac Surgical Physiology 43
Edward B. Savage / Nicolas A. Brozzi
4. Cardiac Surgical Pharmacology 71
Jerrold H. Levy / Jacob N. Schroder / James G. Ramsay
5. Cardiovascular Pathology 99
Frederick J. Schoen / Robert F. Padera
6. Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications 157
Andreas A. Giannopoulos / Frank J. Rybicki / Tarang Sheth / Frederick Y. Chen
7. Risk Assessment and Performance Improvement in Cardiac Surgery 183
Victor A. Ferraris / Fred H. Edwards / Jeremiah T. Martin
8. Simulation in Cardiac Surgery 207
Jennifer D. Walker / Philip J. Spencer / Toni B. Walzer / Jeffrey B. Cooper
9. The Integrated Cardiovascular Center 217
T. Konrad Rajab / Lawrence Lee / Vakhtang Tchantchaleishvili / Mandeep R. Mehra / John G. Byrne
PERIOPERATIVE/INTRAOPERATIVE CARE 221
10. Preoperative Evaluation for Cardiac Surgery 223
Christian T. Ruff / Patrick T. O’Gara
11. Cardiac Anesthesia 233
John G. Augoustides / William C. Culp / Wendy Gross / Annette Mizuguchi / Prakash A. Patel / Kent Rehfeldt / Pinak Shah / Usha Tedrow / Stanton K. Shernan
12. Echocardiography in Cardiac Surgery 267
Eliza P. Teo / Michael H. Picard / Hanjo Ko / Michael N. D’Ambra
13. Extracorporeal Circulation 299
John W. Hammon / Michael H. Hines
14. Transfusion Therapy and Blood Conservation 347
Andreas R. de Biasi / William J. DeBois / O. Wayne Isom / Arash Salemi
15. Deep Hypothermic Circulatory Arrest 361
Bradley G. Leshnower / Edward P. Chen
16. Myocardial Protection 373
M. Salik Jahania / Roberta A. Gottlieb / Robert M. Mentzer, Jr.
17. Postoperative Care of Cardiac Surgery Patients 405
Farhang Yazdchi / James D. Rawn
18. Temporary Mechanical Circulatory Support 429
Edwin C. McGee, Jr. / Nader Moazami
ISCHEMIC HEART DISEASE 451
19. Myocardial Revascularization with Percutaneous Devices 453
James M. Wilson / James T. Willerson
20. Myocardial Revascularization with Cardiopulmonary Bypass 471
Michael H. Kwon / George Tolis, Jr. / Thoralf M. Sundt
21. Myocardial Revascularization Without Cardiopulmonary Bypass 519
Bobby Yanagawa / Michael E. Halkos / John D. Puskas
22. Myocardial Revascularization after Acute Myocardial Infarction 539
Deane E. Smith III / Mathew R. Williams
23. Minimally Invasive Myocardial Revascularization 559
Piroze M. Davierwala / David M. Holzhey / Friedrich W. Mohr
24. Coronary Artery Reoperations 575
Bruce W. Lytle / George Tolis, Jr.
25. Surgical Treatment of Complications of Myocardial Infarction, Ventricular Septal Defect, Myocardial Rupture, and Left Ventricular Aneurysm 595
Donald D. Glower
IV
26. Pathophysiology of Aortic Valve Disease 633
Anna Brzezinski / Marijan Koprivanac / A. Marc Gillinov / Tomislav Mihaljevic
27. Aortic Valve Replacement with a Mechanical Cardiac Valve Prosthesis 649
Robert W. Emery / Rochus K. Voeller / Robert J. Emery
28. Stented Bioprosthetic Aortic Valve Replacement 665
Bobby Yanagawa / Subodh Verma / George T. Christakis
29. Stentless Aortic Valve and Root Replacement 695
Paul Stelzer / Robin Varghese
30. Aortic Valve Repair and Aortic Valve-Sparing Operations 717
Tirone E. David
31. Surgical Treatment of Aortic Valve Endocarditis 731
Gösta B. Pettersson / Syed T. Hussain
32. Minimally Invasive Aortic Valve Surgery 743
Prem S. Shekar / Lawrence S. Lee / Lawrence H. Cohn
33. Percutaneous Treatment of Aortic Valve Disease 751
Stephanie L. Mick / Lars G. Svensson
MITRAL VALVE DISEASE
759
34. Pathophysiology of Mitral Valve Disease 761
James I. Fann / Neil B. Ingels, Jr. / D. Craig Miller
35. Mitral Valve Repair 797
Dan Loberman / Paul A. Pirundini / John G. Byrne / Lawrence H. Cohn
36. Mitral Valve Repair: Rheumatic 817
Javier G. Castillo / David H. Adams
37. Surgery for Functional Mitral Regurgitation 825
Matthew A. Romano / Steven F. Bolling
38. Surgical Treatment of Mitral Valve Endocarditis 835
Gösta B. Pettersson / Syed T. Hussain
39. Mitral Valve Repair for Congenital Mitral Valve Disease in the Adult 847
David P. Bichell / Bret Mettler
40. Minimally Invasive and Robotic Mitral and Tricuspid Valve Surgery 855
W. Randolph Chitwood, Jr./ Barbara Robinson / L. Wiley Nifong
41. Percutaneous Catheter-based Mitral Valve Repair 885
Mani Arsalan / J. Michael DiMaio / Michael Mack
42. Mitral Valve Replacement 895
Tsuyoshi Kaneko / Maroun Yammine / Dan Loberman / Sary Aranki
VALVULAR HEART DISEASE (OTHER)
925
43. Tricuspid Valve Disease 927
Richard J. Shemin / Peyman Benharash
44. Multiple Valve Disease 943
Hartzell V. Schaff / Rakesh M. Suri
45. Valvular and Ischemic Heart Disease 965
Kevin D. Accola / Clay M. Burnett
46. Reoperative Valve Surgery 983
Julius I. Ejiofor / John G. Byrne / Marzia Leacche
SURGERY OF THE GREAT VESSELS 1001
47. Aortic Dissection 1003
Ravi K. Ghanta / Carlos M. Mery / Irving L. Kron
48. Ascending and Arch Aortic Aneurysms 1037
Chase R. Brown / Joseph E. Bavaria / Nimesh D. Desai
49. Descending and Thoracoabdominal Aortic Aneurysms 1075
Joseph S. Coselli / Kim de la Cruz / Ourania Preventza / Scott A. LeMaire
50. Endovascular Therapy for the Treatment of Thoracic Aortic Disease 1101
Susan D. Moffatt-Bruce / R. Scott Mitchell
51. Trauma to the Great Vessels 1109
Tom P. Theruvath / Claudio J. Schonholz / John S. Ikonomidis
52. Pulmonary Embolism and Pulmonary Thromboendarterectomy 1127
Stuart W. Jamieson / Michael M. Madani
SURGERY FOR CARDIAC ARRHYTHMIAS 1145
53. Interventional Therapy for Atrial and Ventricular Arrhythmias 1147
Jason S. Chinitz / Robert E. Eckart / Laurence M. Epstein
54. Surgery for Atrial Fibrillation 1167
Matthew C. Henn / Spencer J. Melby / Ralph J. Damiano, Jr.
55. Surgical Implantation of Pacemakers and Automatic Defibrillators 1181
Henry M. Spotnitz / Michelle D. Spotnitz
OTHER CARDIAC OPERATIONS 1213
56. Surgery for Adult Congenital Heart Disease 1215
Redmond P. Burke
57. Pericardial Disease 1225
Eric N. Feins / Jennifer D. Walker
58. Cardiac Neoplasms 1243
Basel Ramlawi / Michael J. Reardon
TRANSPLANT AND MECHANICAL CIRCULATORY SUPPORT 1277
59. Immunobiology of Heart and Lung Transplantation 1279
Bartley P. Griffith / Agnes Azimzadeh
60. Heart Transplantation 1299
Richard J. Shemin / Mario Deng
61. Lung Transplantation and Heart-lung Transplantation 1331
Hari R. Mallidi / Jatin Anand / Robert C. Robbins
62. Long-term Mechanical Circulatory Support and the Total Artificial Heart 1361
Andrew C. W. Baldwin / Courtney J. Gemmato / William E. Cohn / O. H. Frazier
63. Tissue Engineering for Cardiac Valve Surgery 1391
Danielle Gottlieb / John E. Mayer
Index 1401
Kevin D. Accola, MD
Director, Valve Center of Excellence
Florida Hospital Cardiovascular Institute Cardiovascular Surgeons, PA Orlando, Florida
David H. Adams, MD
Cardiac Surgeon-in-Chief, Mount Sinai Health System Marie-Josée and Henry R. Kravis Professor and Chairman Department of Cardiovascular Surgery Icahn School of Medicine at Mount Sinai and The Mount Sinai Hospital New York, New York
Jatin Anand, MD
Duke University Medical Center Durham, North Carolina
Robert H. Anderson, BSc, MD, FRCPath
Visiting Professorial Fellow Institute of Genetic Medicine Newcastle University Newcastle-upon-Tyne United Kingdom
Sary Aranki, MD
Associate Professor of Surgery Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts
Mani Arsalan, MD Department Cardiac Surgery Kerckhoff Heart Center Bad Nauheim, Germany
The Heart Hospital Baylor Plano Plano, Texas
John G. Augoustides, MD, FASE, FAHA
Professor
Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania
CONTRIBUTORS
Agnes Azimzadeh, PhD
Associate Professor Department of Surgery University of Maryland School of Medicine Baltimore, Maryland
Frank A. Baciewicz, Jr., MD
Professor and Chief
Division of Cardiothoracic Surgery Wayne State University Harper University Hospital/Karmanos Cancer Center Detroit, Michigan
Andrew C. W. Baldwin, MD
Clinical Fellow in Cardiothoracic Transplant Texas Heart Institute Houston, Texas
Resident in General Surgery Yale School of Medicine New Haven, Connecticut
Joseph E. Bavaria, MD
Roberts-Measey Professor and Vice-Chief Department of Cardiovascular Surgery Hospital of the University of Pennsylvania Philadelphia, Pennsylvania
Peyman Benharash, MD
Assistant Professor in-Residence Division of Cardiac Surgery Department of Surgery David Geffen School of Medicine at UCLA Los Angeles, California
David P. Bichell, MD
Cornelius Vanderbilt Chair in Surgery Chief, Pediatric Cardiac Surgery Vanderbilt University
Monroe Carell Jr. Children’s Hospital Nashville, Tennessee
Steven F. Bolling, MD
The University of Michigan Hospitals Department of Cardiac Surgery Cardiovascular Center Ann Arbor, Michigan
Chase R. Brown, MD
Cardiothoracic Surgery
Department of Cardiovascular Surgery
Hospital of the University of Pennsylvania Philadelphia, Pennsylvania
Nicolas A. Brozzi, MD
Department of Cardiothoracic Surgery Cleveland Clinic Florida Weston, Florida
Anna Brzezinski, MD Medical Student (M2)
University of Illinois at Chicago Chicago, Illinois
Redmond P. Burke, MD
Chief, Division of Cardiovascular and Thoracic Surgery Miami Children’s Hospital Miami, Florida
Clay M. Burnett, MD Florida Hospital Cardiovascular Institute Orlando, Florida
John G. Byrne, MD
Hospital Corporation of America Houston, Texas
Javier G. Castillo, MD
Assistant Professor Department of Cardiovascular Surgery
The Mount Sinai Medical Center New York, New York
Edward P. Chen, MD
Director of Thoracic Aortic Surgery
Associate Professor Division of Cardiothoracic Surgery Emory University School of Medicine Atlanta, Georgia
Frederick Y. Chen, MD, PhD
Associate Surgeon
Director, Cardiac Surgery Research Laboratory Division of Cardiac Surgery
Brigham and Women’s Hospital Associate Professor of Surgery
Harvard Medical School Boston, Massachusetts
Jason S. Chinitz, MD, FACC, FHRS Director, Cardiac Electrophysiology
Assistant Professor, Hofstra Northwell School of Medicine Southside Hospital Bayshore, New York
W. Randolph Chitwood, Jr, MD, FACS, FRCS (Eng) Emeritus Professor and Chairman Department of Surgery
Founder—East Carolina Heart Institute Brody School of Medicine
East Carolina University Greenville, North Carolina
George T. Christakis, MD, FRCS(C)
Professor, Department of Surgery
Division of Cardiac Surgery, Schulich Heart Centre
Sunnybrook Health Sciences Centre
Director, Undergraduate Medical Education
University of Toronto Ontario, Canada
William E. Cohn, MD, FACS, FACCP
Professor of Surgery
Director of Surgical Innovation
Baylor College of Medicine
Director of Minimally Invasive Surgical Technology
Texas Heart Institute
Houston, Texas
Lawrence H. Cohn, MD*
Emeritus Virginia and James Hubbard Professor
Harvard Medical School
Division of Cardiac Surgery
Brigham and Women’s Hospital Boston, Massachusetts
*Deceased
Jeffrey B. Cooper, PhD Professor of Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Harvard Medical School
Massachusetts General Hospital
Executive Director Emeritus and Senior Fellow
Center for Medical Simulation
Boston, Massachusetts
Joseph S. Coselli, MD
Professor and Chief of the Division of Cardiothoracic Surgery
Vice Chair, Michael E. DeBakey Department of Surgery
Baylor College of Medicine
Chief of the Section of Adult Cardiac Surgery
Texas Heart Institute Houston, Texas
Kim I. de la Cruz, MD, FACS Assistant Professor Division of Cardiothoracic Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine, and Clinical Staff
Texas Heart Institute Houston, Texas
William C. Culp, Jr., MD Professor
Scott & White Hospital
Department of Anesthesiology
The Texas A&M University System Health Science Center College of Medicine Bryan, Texas
Michael D’Ambra, MD
Associate Professor of Anesthesia
Harvard Medical School
Boston, Massachusetts
Ralph J. Damiano, Jr., MD
Evarts A. Graham Professor of Surgery Chief, Division of Cardiothoracic Surgery
Co-Chair, Heart & Vascular Center
Washington University School of Medicine St. Louis, Missouri
Tirone E. David, MD Professor of Surgery University of Toronto Toronto, Ontario, Canada
Piroze M. Davierwala, MD Department of Cardiac Surgery Heart Center Leipzig Leipzig, Germany
Andreas R. de Biasi, MD Research Fellow
Department of Cardiothoracic Surgery
Weill Cornell Medical College New York-Presbyterian Hospital New York, New York
William J. DeBois, CCP, MBA
Chief Perfusionist and Director
Department of Perioperative Services
New York-Presbyterian Hospital Weill Cornell Medical Center New York, New York
Mario Deng, MD, FACC, FESC Professor of Medicine
Advanced Heart Failure/Mechanical Support/Heart Transplant
David Geffen School of Medicine at UCLA Ronald Reagan UCLA Medical Center Los Angeles, California
Nimesh D. Desai, MD, PhD, FRCSC, FAHA
Co-Director, Aortic and Vascular Center of Excellence Director, Thoracic Aortic Surgery Research Program Assistant Professor, Division of Cardiovascular Surgery Hospital of the University of Pennsylvania Philadelphia, Pennsylvania
J. Michael DiMaio, MD
The Heart Hospital Baylor Plano Plano, Texas
Robert E. Eckart, DO Heart Specialists of Sarasota Sarasota, Florida
Fred H. Edwards, MD
Emeritus Professor of Surgery University of Florida Jacksonville, Florida
Julius I. Ejiofor, MD Division of Cardiac Surgery
Brigham and Women’s Hospital
Harvard Medical School
Boston, Massachusetts
Robert J. Emery, BS, MMS
Medical University Medical School
Philadelphia, Pennsylvania
Robert W. Emery, MD
Director Emeritus, Cardiovascular and Thoracic Surgery
HealthEast Care System
St Joseph’s Hospital
St Paul, Minnesota
Laurence M. Epstein, MD Professor of Medicine
Harvard Medical School Chief, Arrhythmia Service
Brigham and Women’s Hospital Boston, Massachusetts
James I. Fann, MD Professor
Department of Cardiothoracic Surgery
Stanford University Stanford, California
Eric N. Feins, MD Division of Cardiac Surgery Department of Surgery Massachusetts General Hospital Boston, Massachusetts
Victor A. Ferraris, MD, PhD
Tyler Gill Professor of Surgery Division of Cardiothoracic Surgery University of Kentucky Chandler Medical Center Lexington, Kentucky
O.H. Frazier, MD
Professor of Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine Chief of the Center for Cardiac Support Texas Heart Institute Houston, Texas
Courtney J. Gemmato, MD Resident in Cardiothoracic Surgery
Texas Heart Institute
Baylor College of Medicine Houston, Texas
Ravi K. Ghanta, MD
Assistant Professor of Surgery Department of Surgery University of Virginia Charlottesville, Virginia
Andreas A. Giannopoulos, MD Research Fellow
Applied Imaging Science Laboratory Brigham and Women’s Hospital
Harvard Medical School Boston, Massachusetts
A. Marc Gillinov, MD
The Judith Dion Pyle Chair in Heart Valve Research Department of Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland, Ohio
Donald D. Glower, MD Professor of Surgery
Duke University Medical Center Durham, North Carolina
Danielle Gottlieb Sen, MS, MD, MPH
Assistant Professor of Surgery
Pediatric Cardiovascular Surgery Children’s Hospital of New Orleans/LSU Health Science Center New Orleans, Louisiana
Roberta A. Gottlieb, MD
Director, Molecular Cardiobiology
Dorothy and E. Phillip Lyon Chair in Molecular Cardiology in honor of Clarence M. Agress MD Research Scientist, Heart Institute Los Angeles, California
Bartley P. Griffith, MD
The Thomas E. and Alice Marie Hales
Distinguished Professor in Transplantation Executive Director, Program in Lung Healing University of Maryland School of Medicine Baltimore, Maryland
Wendy Gross, MD
Assistant Professor of Anesthesia Department of Anesthesiology, Perioperative and Pain Medicine
Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts
Michael E. Halkos, MD, MSc, FACS, FACC
Associate Professor of Surgery Division of Cardiothoracic Surgery
Scientific Director, Cardiothoracic Center for Clinical Research Associate Program Director Thoracic Surgery Residency Program Atlanta, Georgia
John W. Hammon, MD Professor of Surgery, Emeritus Department of Cardiothoracic Surgery Wake Forest University School of Medicine Winston-Salem, North Carolina
Matthew C. Henn, MS, MD
Cardiac Surgery Research Fellow Washington University School of Medicine
St. Louis, Missouri
David M. Holzhey, MD
Department of Cardiac Surgery Heart Center Leipzig Leipzig, Germany
Syed T. Hussain, MD
Assistant Professor of Surgery
Department of Thoracic & Cardiovascular Surgery
Cleveland Clinic Cleveland, Ohio
John S. Ikonomidis, MD, PhD
Professor of Surgery
Chief, Division of Cardiothoracic Surgery
University of North Carolina at Chapel Hill Chapel Hill, North Carolina
Neil B. Ingels, Jr., PhD
Consulting Professor Department of Cardiothoracic Surgery
Stanford University School of Medicine Stanford, California
O. Wayne Isom, MD
The Terry Allen Kramer Professor of Cardiothoracic Surgery
Chairman, Department of Cardiothoracic Surgery Cardiothoracic Surgeon-in-Chief Weill Cornell Medical College New York-Presbyterian Hospital New York, New York
M. Salik Jahania, MD
Associate Professor of Surgery Cardiothoracic Surgery
Wayne State University Detroit, Michigan
Stuart W. Jamieson, MD, FRCS, FACS
Endowed Chair and Distinguished Professor Dean, Cardiovascular Affairs University of California San Diego, California
Tsuyoshi Kaneko, MD Division of Cardiac Surgery Brigham and Women’s Hospital Boston, Massachusetts
Hanjo Ko, MD
Assistant Professor Department of Anesthesiology and Critical Care University of Pennsylvania Health System Philadelphia, Pennsylvania
Marijan Koprivanac, MD, MS Resident, Department of General surgery Cleveland Clinic Research Fellow Department of Cardiothoracic Surgery, Cleveland Clinic Clinical Instructor, Case Western University Cleveland, Ohio
Irving L. Kron, MD
S. Hurt Watts Professor and Chair Department of Surgery University of Virginia Charlottesville, Virginia
Michael H. Kwon, MD
Research Fellow, Brigham and Women’s Hospital
Clinical Fellow in Surgery (EXT), Harvard Medical School Boston, Massachusetts
Marzia Leacche, MD
Spectrum Health Meijer Heart Center Grand Rapids, Michigan
Lawrence Lee, MD
Clinical Fellow in Surgery
Harvard Medical School
Resident in Cardiothoracic Surgery
Brigham and Women’s Hospital Boston, Massachusetts
Lawrence S. Lee, MD
Assistant Professor of Surgery Division of Cardiothoracic Surgery
University of Tennessee Graduate School of Medicine Knoxville, Tennessee
Scott A. LeMaire, MD
Professor and Director of Research Division of Cardiothoracic Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine, and Cardiovascular Surgery Staff Texas Heart Institute Houston, Texas
Bradley G. Leshnower, MD
Assistant Professor of Surgery Division of Cardiothoracic Surgery
Emory University School of Medicine Atlanta, Georgia
Jerrold H. Levy, MD, FAHA, FCCM
Professor of Anesthesiology
Associate Professor of Surgery
Co-Director Cardiothoracic Intensive Care Unit Duke University School of Medicine Durham, North Carolina
Dan Loberman, MD Division of Cardiac Surgery
Brigham and Women’s Hospital Harvard Medical school Boston, Massachusetts
Bruce W. Lytle, MD
Director of Strategic Operations
The Heart Hospital Baylor-Plano Dallas, Texas
Michael Mack, MD
The Heart Hospital Baylor Plano Plano, Texas
Michael M. Madani, MD
Professor and Chief
Division of Cardiovascular and Thoracic Surgery
University of California, San Diego La Jolla, California
Hari R. Mallidi, MD
BWH Thoracic and Cardiac Surgery
Co-Director, Program in Heart and Lung Transplant and MCS
Surgical Director of Lung Transplant and Pulmonary Vascular Disease
Senior Surgeon, Collaborative Center for Advanced Heart Failure
Executive Director, BWH ECMO Program Boston, Massachusetts
Jeremiah T. Martin, MBBCh, FRCSI
Assistant Professor of Surgery University of Kentucky Chandler Medical Center Lexington, Kentucky
John E. Mayer, Jr., MD
Senior Associate in Cardiac Surgery
Childrens Hospital, Boston Professor of Surgery
Harvard Medical School
Department of Cardiac Surgery
Children’s Hospital Boston, Massachusetts
Edwin C. McGee, Jr., MD
Thoracic and Cardiovascular Surgery Professor
Director, Heart Transplant & Ventricular Assist Device Program Loyola Medicine Maywood, Illinois
Mandeep R. Mehra, MD
Professor of Medicine
Harvard Medical School
Medical Director
Heart and Vascular Center
Brigham and Women’s Hospital Boston, Massachusetts
Spencer J. Melby, MD
Associate Professor of Surgery Department of Surgery Division of Cardiothoracic Surgery
Washington University in St. Louis and Barnes Jewish Hospital St. Louis, Missouri
Robert M. Mentzer, Jr., MD
Professor of Medicine and Surgery
Cedars-Sinai Heart Institute
Cedars-Sinai Medical Center Los Angeles, California
Carlos M. Mery, MD, MPH
Assistant Professor of Surgery and Pediatrics Department of Surgery
Texas Children’s Hospital/Baylor College of Medicine Houston, Texas
Bret A. Mettler, MD
Assistant Professor in Surgery Vanderbilt University
Monroe Carell Jr. Children’s Hospital Nashville, Tennessee
Stephanie L. Mick, MD
Cardiac Surgery, Surgical Director of Transcatheter Valve Insertion Program
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute
Cleveland Clinic Cleveland, Ohio
Tomislav Mihaljevic, MD
Professor of Surgery
Cleveland Clinic Lerner College of Medicine Cleveland, Ohio
Chief Executive Officer
Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates
Michael R. Mill, MD
Professor
Departments of Surgery and Pediatrics
University of North Carolina Chapel Hill, North Carolina
D. Craig Miller, MD
Thelma and Henry Doelger Professor of Cardiovascular Surgery
Dept. of Cardiothoracic Surgery
Stanford University School of Medicine
Falk CV Research Building Stanford, California
R. Scott Mitchell, MD
Professor Emeritus
Department of Cardiothoracic Surgery
Stanford University School of Medicine
Falk Cardiovascular Research Building Stanford, California
Attending Surgeon
Division of Cardiac Surgery
V.A. Hospital Palo Alto Palo Alto, California
Annette Mizuguchi, MD
Assistant Professor of Anesthesia
Department of Anesthesiology, Perioperative and Pain Medicine
Brigham and Women’s Hospital
Harvard Medical School Boston, Massachusetts
Nader Moazami, MD
Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland, Ohio
Susan D. Moffatt-Bruce, MD, PhD
Associate Professor, Division of Thoracic Surgery
Department of Surgery
Ohio State University
Wexner Medical Center Columbus, Ohio
Friedrich-Wilhelm Mohr, MD, PhD
Professor of Cardiac Surgery
University of Leipzig
Medical Director Heart Center Leipzig Director Department of Cardiac Surgery Heart Center Leipzig Leipzig, Germany
L. Wiley Nifong, MD
Division of Cardiothoracic Surgery Department of Cardiovascular Sciences East Carolina Heart Institute
Brody School of Medicine at East Carolina University Greenville, North Carolina
Patrick T. O’Gara, MD
Watkins Family Distinguished Chair in Cardiology
Brigham and Women’s Hospital Professor of Medicine
Harvard Medical School Boston, Massachusetts
Robert F. Padera, MD, PhD
Associate Pathologist Department of Pathology
Brigham and Women’s Hospital Assistant Professor of Pathology
Harvard Medical School Boston, Massachusetts
Prakash A. Patel, MD Assistant Professor Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania
Gösta B. Pettersson, MD, PhD Professor of Surgery Vice Chairman Department of Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland, Ohio
Michael H. Picard, MD Professor of Medicine
Harvard Medical School Director, Echocardiography
Massachusetts General Hospital Boston, Massachusetts
Paul A. Pirundini, MD Chief, Cardiac Surgery Cape Cod Hospital Hyannis, Massachusetts Associate Surgeon Brigham and Women’s Hospital Boston, Massachusetts
Ourania Preventza, MD
Associate Professor of Surgery
Division of Cardiothoracic Surgery
Michael E DeBakey Department of Surgery
Baylor College of Surgery
Attending Cardiac and Endovascular Surgeon
Texas Heart Institute
Baylor St Luke’s Medical Center Houston, Texas
John D. Puskas, MD
Chair, Cardiovascular Surgery
Mount Sinai St. Luke’s, Mount Sinai Beth Israel, and Mount Sinai West New York, New York
T. Konrad Rajab, MD
Clinical Fellow in Surgery
Harvard Medical School
Resident in Cardiothoracic Surgery
Brigham and Women’s Hospital Boston, Massachusetts
Basel Ramlawi, MD, FACC, FACS
Chairman, Heart & Vascular Center
Director, Advanced Valve & Aortic Center Valley Health System Winchester, Virginia
James G. Ramsay, MD
Professor Anesthesiology
Director of Cardiothoracic Intensive Care Unit
University of California San Francisco, California
James D. Rawn, MD
Director, Cardiac Surgery Intensive Care Unit
Instructor in Surgery, Harvard Medical School Cardiac Surgery
Boston, Massachusetts
Michael J. Reardon, MD, FACS, FACC
Professor of Cardiothoracic Surgery
Allison Family Distinguished Chair of Cardiovascular Research
Department of Cardiovascular Surgery
Houston Methodist DeBakey Heart & Vascular center Houston, Texas
Kent Rehfeldt, MD, FASE
Associate Professor of Anesthesiology Mayo Clinic Rochester, Minnesota
Robert C. Robbins, MD
President and CEO
Texas Medical Center Houston, Texas
Barbara Robinson, MD, MS, FACS, FAHA, FACC
Division of Cardiothoracic Surgery
Department of Cardiovascular Sciences East Carolina Heart Institute
Brody School of Medicine at East Carolina University Greenville, North Carolina
Matthew A. Romano, MD
Assistant Professor Department of Cardiac Surgery University of Michigan Ann Arbor, Michigan
Christian T. Ruff, MD, MPH
Assistant Professor of Medicine Cardiovascular Medicine Division Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts
Frank J. Rybicki, MD, PhD
Professor, Chair and Chief, Department of Radiology
The University of Ottawa Faculty of Medicine and The Ottawa Hospital Ottawa, Ontario, Canada
Arash Salemi, MD
Associate Professor of Cardiothoracic Surgery Department of Cardiothoracic Surgery Weill Cornell Medical College New York-Presbyterian Hospital New York, New York
Edward B. Savage, MD
Clinical Professor Cleveland Clinic Lerner College of Medicine Chairman Department of Cardiothoracic Surgery
Director Heart and Vascular Institute Cleveland Clinic Florida Weston, Florida
Hartzell Schaff, MD
Professor of Surgery, College of Medicine Department of Cardiovascular Surgery Mayo Clinic Rochester, Minnesota
Frederick J. Schoen, MD, PhD
Executive Vice Chairman Department of Pathology Brigham and Women’s Hospital Professor of Pathology and Health Sciences and Technology (HST), Harvard Medical School Boston, Massachusetts
Claudio J. Schonholz, MD
Department of Surgery, Division of Cardiothoracic Surgery Department of Radiology, Division of Interventional Radiology Medical University of South Carolina Charleston, South Carolina
Jacob N. Schroder, MD
Assistant Professor of Surgery Co-Director, Cardiothoracic Intensive Care Unit Duke University School of Medicine Durham, North Carolina
Pinak Shah, MD
Associate Professor of Medicine
Division of Cardiology Department of Medicine
Brigham and Women’s Hospital
Harvard Medical School Boston, Massachusetts
Prem S. Shekar, MD
Assistant Professor of Surgery
Harvard Medical School Chief, Division of Cardiac Surgery Brigham and Women’s Hospital Boston, Massachusetts
Richard J. Shemin, MD
Robert and Kelly Day Professor and Chief Division of Cardiac Surgery
Vice Chairman, Department of Surgery Co-director, Cardiovascular Center at UCLA
David Geffen School of Medicine at UCLA Los Angeles, California
Stanton K. Shernan, MD, FAHA, FASE Professor of Anesthesia Department of Anesthesiology, Perioperative and Pain Medicine
Brigham and Women’s Hospital
Harvard Medical School Boston, Massachusetts
Tarang Sheth, MD, FRCPC
Cardiovascular Radiologist Director of Cardiac CT and MR Department of Diagnostic Imaging
Trillium Health Partners Mississauga, Ontario, Canada
Deane E. Smith III, MD
Assistant Professor of Cardiothoracic Surgery
NYU School of Medicine New York, New York
Philip J. Spencer, MD Department of Surgery Massachusetts General Hospital Boston, Massachusetts
Michelle D. Spotnitz, MD
Cardiologist
EHE International New York, New York
Henry M. Spotnitz, MD
George H. Humphreys, II, Professor of Surgery Department of Surgery
Columbia University New York, New York
Paul Stelzer, MD Professor
Department of Cardiovascular Surgery
Icahn School of Medicine at Mount Sinai
New York, New York
Larry W. Stephenson, MD
Professor Emeritus
Ford Webber Professor of Surgery Department of Surgery
Wayne State University Detroit, Michigan
Thoralf M. Sundt, MD
Edward D. Churchill Professor of Surgery
Harvard Medical School Chief, Division of Cardiac Surgery Massachusetts General Hospital Boston, Massachusetts
Rakesh Mark Suri, MD, D.Phil Cleveland Clinic Foundation Department of Thoracic and Cardiovascular Surgery Cleveland, Ohio
Lars G. Svensson, MD, PhD
Chairman, Heart and Vascular Institute Cleveland Clinic Cleveland, Ohio
Vakhtang Tchantchaleishvili, MD
Cardiothoracic Surgery University of Rochester Medical Center Rochester, New York
Usha Tedrow, MD
Assistant Professor of Medicine Division of Cardiology Department of Medicine
Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts
Eliza P. Teo, MBBS
Clinical and Research Fellow in Medicine Massachusetts General Hospital Research Fellow
Harvard Medical School Boston, Massachusetts
Tom P. Theruvath, MD, PhD
Department of Surgery, Division of Cardiothoracic Surgery Department of Radiology, Division of Interventional Radiology Medical University of South Carolina Charleston, South Carolina
George Tolis, Jr., MD
Assistant Professor of Surgery
Harvard Medical School Boston, Massachusetts
Robin Varghese, MD, MS, FRCSC
Associate Professor Department of Cardiovascular Surgery
Icahn School of Medicine at Mount Sinai New York, New York
Subodh Verma, MD, PhD, FRCSC
Cardiac Surgeon St Michael’s Hospital Professor of Surgery & Pharmacology and Toxicology University of Toronto Canada Research Chair in Atherosclerosis Toronto, Ontario
Rochus K. Voeller, MD
Cardiovascular Surgeon Fairview Health System Fairview Southdale Hospital Edina, Minnesota
Jennifer D. Walker, MD
Professor and Chief Division of Cardiac Surgery
Surgical Director Heart & Vascular Center of Excellence UMass Memorial Medical Center Worcester, Massachusetts
Toni B. Walzer, MD, FACOG Assistant Professor, Part-Time, of Obstetrics, Gynecology, and Reproductive Biology
Harvard Medical School Department of Obstetrics and Gynecology Brigham and Women’s Hospital Assistant in Healthcare Education Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital Director, Labor and Delivery Program Center for Medical Simulation Boston, Massachusetts
James T. Willerson, MD, FACC President and Medical Director Texas Heart Institute Houston, Texas
Mathew R. Williams, MD
Associate Professor of Cardiothoracic Surgery & Medicine Chief, Division of Adult Cardiac Surgery Director, CVI Structural Heart Program Director, Interventional Cardiology NYU School of Medicine New York, New York
James M. Wilson, MD Director, Cardiology Education Texas Heart Institute Houston, Texas
Maroun Yammine, MD Division of Cardiac Surgery Brigham and Women’s Hospital Boston, Massachusetts
Bobby Yanagawa, MD, PhD, FRCSC Assistant Professor Division of Cardiac Surgery St Michael’s Hospital Toronto, Canada
Farhang Yazdchi, MD, MS
Clinical Fellow in Surgery (EXT) Brigham and Women’s Hospital Surgery Brigham and Women’s Hospital Cardiac Surgery Boston, Massachusetts
History of Cardiac Surgery
Larry W. Stephenson • Frank A. Baciewicz, Jr.
The development of major surgery was retarded for centuries by a lack of knowledge and technology. Significantly, the general anesthetics ether and chloroform were not developed until the middle of the nineteenth century. These agents made major surgical operations possible, which created an interest in repairing wounds to the heart, leading some investigators in Europe to conduct studies in the animal laboratory on the repair of heart wounds. The first simple operations in humans for heart wounds soon were reported in the medical literature.
HEART WOUNDS
On July 10, 1893, Dr. Daniel Hale Williams (Fig. 1-1), a surgeon from Chicago, successfully operated on a 24-year-old man who had been stabbed in the heart during a fight. The stab wound was slightly to the left of the sternum and dead center over the heart. Initially, the wound was thought to be superficial, but during the night the patient experienced persistent bleeding, pain, and pronounced symptoms of shock. Williams opened the patient’s chest and tied off an artery and vein that had been injured inside the chest wall, likely causing the blood loss. Then he noticed a tear in the pericardium and a puncture wound to the heart “about one-tenth of an inch in length.”1
The wound in the right ventricle was not bleeding, so Williams did not place a stitch through the heart wound. He did, however, stitch closed the hole in the pericardium. Williams reported this case 4 years later.1 This operation, which is referred to frequently, is probably the first successful surgery involving a documented stab wound to the heart. At the time Williams’ surgery was considered bold and daring, and although he did not actually place a stitch through the wound in the heart, his treatment seems to have been appropriate. Under the circumstances, he most likely saved the patient’s life.
A few years after Williams’ case, a couple of other surgeons actually sutured heart wounds, but the patients did not survive. Dr. Ludwig Rehn (Fig. 1-2), a surgeon in Frankfurt, Germany, performed what many consider the first successful heart operation.2 On September 7, 1896, a 22-year-old
man was stabbed in the heart and collapsed. The police found him pale, covered with cold sweat, and extremely short of breath. His pulse was irregular and his clothes were soaked with blood. By September 9, his condition was worsening, as shown in Dr. Rehn’s case notes:
Pulse weaker, increasing cardiac dullness on percussion, respiration 76, further deterioration during the day, diagnostic tap reveals dark blood. Patient appears moribund. Diagnosis: increasing hemothorax. I decided to operate entering the chest through the left fourth intercostal space, there is massive blood in the pleural cavity. The mammary artery is not injured. There is continuous bleeding from a hole in the pericardium. This opening is enlarged. The heart is exposed. Old blood and clots are emptied. There is a 1.5 cm gaping right ventricular wound. Bleeding is controlled with finger pressure. …
I decided to suture the heart wound. I used a small intestinal needle and silk suture. The suture was tied in diastole. Bleeding diminished remarkably with the third suture, all bleeding was controlled. The pulse improved. The pleural cavity was irrigated. Pleura and pericardium were drained with iodoform gauze. The incision was approximated, heart rate and respiratory rate decreased and pulse improved postoperatively.
… Today the patient is cured. He looks very good. His heart action is regular. I have not allowed him to work physically hard. This proves the feasibility of cardiac suture repair without a doubt! I hope this will lead to more investigation regarding surgery of the heart. This may save many lives
Ten years after Rehn’s initial repair, he had accumulated a series of 124 cases with a mortality of only 60%, quite a feat at that time.3
Dr. Luther Hill was the first American to report the successful repair of a cardiac wound, in a 13-year-old boy who was a victim of multiple stab wounds.4 When the first doctor arrived, the boy was in profound shock. The doctor remembered that Dr. Luther Hill had spoken on the subject of repair of cardiac wounds at a local medical society meeting in Montgomery, Alabama. With the consent of the boy’s parents, Dr. Hill was summoned. He arrived sometime after midnight with six other physicians. One was his brother. The surgery
FIGURE 1-1 Daniel Hale Williams, a surgeon from Chicago, who successfully operated on a patient with a wound to the chest involving the pericardium and the heart. (Reproduced with permission from Organ CH Jr., Kosiba MM: The Century of the Black Surgeons: A USA Experience. Norman, OK: Transcript Press, 1937; p 312.)
took place on the patient’s kitchen table in a rundown shack. Lighting was provided by two kerosene lamps borrowed from neighbors. One physician administered chloroform anesthesia. The boy was suffering from cardiac tamponade as a result of a stab wound to the left ventricle. The stab wound to the ventricle was repaired with two catgut sutures. Although the early postoperative course was stormy, the boy made a complete recovery. That patient, Henry Myrick, eventually moved to Chicago, where, in 1942, at the age of 53, he got into a heated argument and was stabbed in the heart again, very close to the original stab wound. This time, Henry was not as lucky and died from the wound.
Another milestone in cardiac surgery for trauma occurred during World War II when Dwight Harken, then a U.S. Army surgeon, removed 134 missiles from the mediastinum, including 55 from the pericardium and 13 from cardiac chambers, without a death.5 It is hard to imagine this type of elective (and semielective) surgery taking place without sophisticated indwelling pulmonary artery catheters, blood banks, and electronic monitoring equipment.
FIGURE 1-2 Ludwig Rehn, a surgeon from Frankfurt, Germany, who performed the first successful suture of a human heart wound. (Reproduced with permission from Mead R: A History of Thoracic Surgery. Springfield: Charles C Thomas; 1961.)
Rapid blood infusion consisted of pumping air into glass bottles of blood.
OPERATIVE MANAGEMENT OF PULMONARY EMBOLI
Martin Kirschner reported the first patient who recovered fully after undergoing pulmonary embolectomy in 1924.6 In 1937, John Gibbon estimated that nine of 142 patients who had undergone the procedure worldwide left the hospital alive.7 These dismal results were a stimulus for Gibbon to start work on a pump oxygenator that could maintain the circulation during pulmonary embolectomy. Sharp was the first to perform pulmonary embolectomy using cardiopulmonary bypass, in 1962.8
SURGERY OF THE PERICARDIUM
Pericardial resection was introduced independently by Rehn9 and Sauerbruch.10 Since Rehn’s report, there have been few advances in the surgical treatment of constrictive pericarditis.
Some operations are now performed with the aid of cardiopulmonary bypass. In certain situations, radical pericardiectomy that removes most of the pericardium posterior to the phrenic nerves is done.
CATHETERIZATION OF THE RIGHT SIDE OF THE HEART
Although cardiac catheterization is not considered heart surgery, it is an invasive procedure, and some catheter procedures have replaced heart operations. Werner Forssmann is credited with the first heart catheterization. He performed the procedure on himself and reported it in Klrinische Wochenschrift. 11 In 1956 Forssmann shared the Nobel Prize in Physiology or Medicine with Andre F. Cournand and Dickenson W. Richards, Jr. His 1929 paper states, “One often hesitates to use intercardiac injections promptly, and often, time is wasted with other measures. This is why I kept looking for a different, safer access to the cardiac chambers: the catheterization of the right heart via the venous system.”
In this report by Forssmann, a photograph of the x-ray taken of Forssmann with the catheter in his own heart is presented. Forssmann, in that same report, goes on to present the first clinical application of the central venous catheter for a patient in shock with generalized peritonitis. Forssmann concludes his paper by stating, “I also want to mention that this method allows new options for metabolic studies and studies about cardiac physiology.”
In a 1951 lecture Forssmann discussed the tremendous resistance he faced during his initial experiments.12 “Such methods are good for a circus, but not for a respected hospital” was the answer to his request to pursue physiologic studies using cardiac catheterization. His progressive ideas pushed him into the position of an outsider with ideas too crazy to give him a clinical position. Klein applied cardiac catheterization for cardiac output determinations using the Fick method a half year after Forssmann’s first report.13 In 1930, Forssmann described his experiments with catheter cardiac angiography.14 Further use of this new methodology had to wait until Cournand’s work in the 1940s.
HEART VALVE SURGERY BEFORE THE ERA OF CARDIOPULMONARY BYPASS
The first clinical attempt to open a stenotic valve was carried out by Theodore Tuffier on July 13, 1912.15 Tuffier used his finger to reach the stenotic aortic valve. He was able to dilate the valve supposedly by pushing the invaginated aortic wall through the stenotic valve. The patient recovered, but one must be skeptical as to what was accomplished. Russell Brock attempted to dilate calcified aortic valves in humans in the late 1940s by passing an instrument through the valve from the innominate or another artery.16 His results were poor, and he abandoned the approach. During the next several years, Brock17 and Bailey and colleagues18 used different
dilators and various approaches to dilate stenotic aortic valves in patients. Mortality for these procedures, which was often done in conjunction with mitral commissurotomy, was high.
Elliott Cutler worked for 2 years on a mitral valvulotomy procedure in the laboratory. His first patient underwent successful valvulotomy on May 20, 1923, using a tetrasomy knife.19 Unfortunately, most of Cutler’s subsequent patients died because he created too much regurgitation with his valvulotome, and he soon gave up the operation.
In Charles Bailey’s 1949 paper entitled, “The Surgical Treatment of Mitral Stenosis,” he states, “After 1929 no more surgical attempts [on mitral stenosis] were made until 1945. Dr. Dwight Harken, Dr. Horace Smithy, and the author recently made operative attempts to improve mitral stenosis. Our clinical experience with the surgery of the mitral valves has been five cases to date.” He then describes his five patients, four of whom died and only one of whom lived a long life.20,21
A few days after Bailey’s success, on June 16 in Boston, Dr. Dwight Harken successfully performed his first valvulotomy for mitral stenosis.22
The first successful pulmonary valvulotomy was performed by Thomas Holmes Sellers on December 4, 1947.23
Charles Hufnagel reported a series of 23 patients starting September 1952 who had operation for aortic insufficiency.24 There were four deaths among the first 10 patients and two deaths among the next 13. Hufnagel’s caged-ball valve, which used multiple-point fixation rings to secure the apparatus to the descending aorta, was the only surgical treatment for aortic valvular incompetence until the advent of cardiopulmonary bypass and the development of heart valves that could be sewn into the aortic annulus position.
CONGENITAL CARDIAC SURGERY BEFORE THE HEART-LUNG MACHINE ERA
Congenital cardiac surgery began when John Strieder at Massachusetts General Hospital first successfully interrupted a ductus on March 6, 1937. The patient was septic and died on the fourth postoperative day. At autopsy, vegetations filled the pulmonary artery down to the valve.25 On August 16, 1938, Robert Gross, at Boston Children’s Hospital, operated on a 7-year-old girl with dyspnea after moderate exercise.26 The ductus was ligated and the patient made an uneventful recovery.
Modifications of the ductus operation soon followed. In 1944, Dr. Gross reported a technique for dividing the ductus successfully. The next major congenital lesion to be overcome was coarctation of the aorta. Dr. Clarence Crafoord, in Stockholm, Sweden, successfully resected a coarctation of the aorta in a 12-year-old boy on October 19, 1944.27 Twelve days later he successfully resected the coarctation of a 27-yearold patient. Dr. Gross first operated on a 5-year-old boy with this condition on June 28, 1945.28 After he excised the coarctation and rejoined the aorta, the patient’s heart stopped suddenly. The patient died in the operating room. One week
later, however, Dr. Gross operated on a second patient, a 12-year-old girl. This patient’s operation was successful. Dr. Gross had been unaware of Dr. Crafoord’s successful surgery several months previously, probably because of World War II.
In 1945, Dr. Gross reported the first successful case of surgical relief for tracheal obstruction from a vascular ring.29 In the 5 years that followed Gross’s first successful operation, he reported 40 more cases.
The famous Blalock-Taussig operation also was first reported in 1945. The first patient was a 15-month-old girl with a clinical diagnosis of tetralogy of Fallot with a severe pulmonary stenosis. 30 At age 8 months, the baby had her first cyanotic spell, which occurred after eating. Dr. Helen Taussig, the cardiologist, followed the child for 3 months, and during that time, cyanosis increased, and the child failed to gain weight. The operation was performed by Dr. Alfred Blalock at Johns Hopkins University on November 29, 1944. The left subclavian artery was anastomosed to the left pulmonary artery in an endto-side fashion. The postoperative course was described as stormy; the patient was discharged 2 months postoperatively. Two additional successful cases were done within 3 months of that first patient.
Thus, within a 7-year period, three congenital cardiovascular defects, patent ductus arteriosus, coarctation of the aorta, and vascular ring, were attacked surgically and treated successfully. However, the introduction of the Blalock-Taussig shunt probably was the most powerful stimulus to the development of cardiac surgery because this operation palliated a complex intracardiac lesion and focused attention on the pathophysiology of cardiac disease.
Anomalous coronary artery in which the left coronary artery communicates with the pulmonary artery was the next surgical conquest. The surgery was performed on July 22, 1946, and was reported by Gunnar Biorck and Clarence Crafoord.31 The anomalous coronary artery was identified and doubly ligated. The patient made an uneventful recovery.
Muller32 reported successful surgical treatment of transposition of the pulmonary veins in 1951, but the operation addressed a partial form of the anomaly. Later in the 1950s, Gott, Varco, Lillehei, and Cooley reported successful operative variations for anomalous pulmonary veins.
Another of Gross’s pioneering surgical procedures was surgical closure of an aortopulmonary window on May 22, 1948.33 Cooley and colleagues34 were the first to report on the use of cardiopulmonary bypass to repair this defect and converted a difficult and hazardous procedure into a relatively straightforward one.
Glenn35 reported the first successful clinical application of the cavopulmonary anastomosis in the United States in 1958 for what has been termed the Glenn shunt. Similar work was done in Russia during the 1950s by several investigators. On January 3, 1957, Galankin,36 a Russian surgeon, performed a cavopulmonary anastomosis in a 16-year-old patient with tetralogy of Fallot. The patient made a good recovery with significant improvement in exercise tolerance and cyanosis.
THE DEVELOPMENT OF CARDIOPULMONARY BYPASS
The development of the heart-lung machine made repair of intracardiac lesions possible. To bypass the heart, one needs a basic understanding of the physiology of the circulation, a method of preventing the blood from clotting, a mechanism to pump blood, and finally, a method to ventilate the blood.
One of the key requirements of the heart-lung machine was anticoagulation. Heparin was discovered in 1915 by a medical student, Jay McLean, working in the laboratory of Dr. William Howell, a physiologist at Johns Hopkins.37
John Gibbon contributed more to the success of the development of the heart-lung machine than anyone else.
Gibbon’s work on the heart-lung machine took place over 20 years in laboratories at Massachusetts General Hospital, the University of Pennsylvania, and Thomas Jefferson University. In 1937, Gibbon reported the first successful demonstration that life could be maintained by an artificial heart and lung and that the native heart and lungs could resume function. Unfortunately, only three animals recovered adequate cardiorespiratory function after total pulmonary artery occlusion and bypass, and even they died a few hours later.38 Gibbon’s work was interrupted by World War II; afterward, he resumed his work at Thomas Jefferson Medical College in Philadelphia (Table 1-1).
Forest Dodrill and colleagues used the mechanical blood pump they developed with General Motors on a 41-yearold man 43 (Fig. 1-3). The machine was used to substitute for the left ventricle for 50 minutes while a surgical procedure was carried out to repair the mitral valve; the patient’s own lungs were used to oxygenate the blood. This, the first clinically successful total left-sided heart bypass in a human, was performed on July 3, 1952, and followed from Dodrill’s experimental work with a mechanical pump for univentricular, biventricular, or cardiopulmonary bypass. Although Dodrill and colleagues had used their pump with an oxygenator for total heart bypass in animals,54 they felt that left-sided heart bypass was the most practical method for their first clinical case.
Later, on October 21, 1952, Dodrill and colleagues used their machine in a 16-year-old boy with congenital pulmonary stenosis to perform a pulmonary valvuloplasty under direct vision; this was the first successful right-sided heart bypass.44 Between July 1952 and December 1954, Dodrill performed approximately 13 clinical operations on the heart and thoracic aorta using the Dodrill—General Motors machine, with at least five hospital survivors.55 Although he used this machine with an oxygenator in the animal laboratory, he did not start using an oxygenator with the Dodrill— General Motors mechanical heart clinically until early 1955.
Hypothermia was another method to stop the heart and allow it to be opened.44
John Lewis closed an atrial septal defect (ASD) in a 5-year-old girl on September 2, 1952 using a hypothermic technique.44
CHAPTER VII. Store Sauces.
Mushrooms, Eschalots, and Tomatas.
OBSERVATIONS.
A selected stock of these will always prove a convenient resource in simple cookery for giving colour and flavour to soups, gravies, and made dishes; but unless the consumption be considerable, they should not be over-abundantly provided, as few of them are improved by age, and many are altogether spoiled by long keeping, especially if they be not perfectly secured from the air by sound corking, or if stored where there is the slightest degree of damp. To prevent loss, they should be examined at short intervals, and at the first appearance of mould or fermentation, such as will bear the process should be reboiled, and put, when again quite cold, into clean bottles; a precaution often especially needful for mushroom catsup when it has been made in a wet season, or when it has not been very carefully prepared. This, with essence of anchovies, walnut catsup, Harvey’s sauce, cavice, lemon-pickle, chili, cucumber, and eschalot vinegar, will be all that is commonly needed for family use; but there is at the present day an extensive choice of these stores on sale, some of which are excellent.
Garlic.
CHETNEY SAUCE.
(Bengal Receipt).
Stone four ounces of good raisins, and chop them small, with half a pound of crabs, sour apples, unripe bullaces,[66] or of any other hard acid fruit. Take four ounces of coarse brown sugar, two of powdered ginger, and the same quantity of salt and cayenne pepper; grind these ingredients separately in a mortar, as fine as possible; then pound the fruits well, and mix the spices with them, one by one; beat them together until they are perfectly blended, and add gradually as much vinegar as will make the sauce of the consistence of thick cream. Put it into bottles with an ounce of garlic, divided into cloves, and cork it tightly
66 Hard acid fruit in a crude state is, we think, an ingredient not much to be recommended; and it is always better to deviate a little from “an approved receipt” than to endanger health by the use of ingredients of a questionable character. Gooseberries or tomatas, after being subjected to a moderate degree of heat, might be eaten with far less hazard.
Stoned raisins, 4 oz.; crabs, or other acid fruit, 1/2 lb.; coarse sugar, 4 oz.; powdered ginger, 2 oz.; salt, 2 oz.; cayenne pepper, 2 oz.; garlic, 1 oz.; vinegar, enough to dilute it properly
Obs.—This favourite oriental sauce is compounded in a great variety of ways; but some kind of acid fruit is essential to it. The mango is used in India; here gooseberries, while still hard and green, are sometimes used for it; and ripe red chilies and tomatas are mixed with the other ingredients. The sauce keeps better if it be exposed to a gentle degree of heat for a week or two, either by the
side of the fire, or in a full southern aspect in the sun: the heat of a very slow oven, in which it might be left for a night, would probably have a still better effect. In this case it must be put into a jar or bottles, and well secured from the air. Half a pound of gooseberries, or of these and tamarinds from the shell, and green apples mixed, and the same weight of salt, stoned raisins, brown sugar, powdered ginger, chilies, and garlic, with a pint and a half of vinegar, and the juice of three large lemons, will make another genuine Bengal chetney.
FINE MUSHROOM CATSUP.
One of the very best and most useful of store sauces is good home-made mushroom catsup, which, if really well prepared, imparts an agreeable flavour to any soup or sauce with which it is mingled, and at the same time heightens the colour without imparting the “bitter sweetness” which the burnt sugar used as “browning” in clumsy cookery so often does. The catsup ought, in fact, to be rather the pure essence of mushrooms, made with so much salt and spice only as are required to preserve it for a year or longer, than the compound of mushroom-juice, anchovies, shalots, allspice, and other condiments of which it is commonly composed, especially for sale.
Directions to be observed in making and for keeping the catsup.— Let the mushrooms be collected when the weather is dry, for if gathered during, or immediately after rain, the catsup made with them will not keep well.
Cut off the stalk-ends to which the earth adheres, before the mushrooms are broken up, and throw them aside, as they should never be used for the catsup. Reject also such of the flaps as are worm-eaten or decayed. Those which are too stale for use may be detected by the smell, which is very offensive.
When the mushroom first opens, the underside is of a fine pale salmon colour; this changes soon to a sort of ashy-brown, which deepens almost to black as the mushroom passes from its maturity to a state of decay. As it yields a greater abundance of juice when it is fully ripe, it is usually taken in that state for these sauces; but catsup of fine and delicate flavour, though somewhat pale in colour, can be made even of mushroom-buttons if they be sliced up small and turned often in the liquid which will be speedily drawn from them by the application of salt; a rather smaller proportion of which should be mingled with them than is directed for the following receipt.
Every thing used in preparing the catsup should be delicately clean and very dry. The bottles in which it is stored, after being dried
in the usual way, should be laid into a cool oven for an hour or two before they are filled, to ensure their being free from the slightest degree of moisture, but they must be quite cold before the catsup is poured into them. If the corks be sealed so as to exclude the air effectually, or if well-cleansed bits of bladder first dried, and then rendered flexible with a little spirit of any kind (spirits of wine is convenient for such purposes), be tied closely over them, and the bottles can be kept in a cool place free from damp, the catsup will remain good for a long time.
MUSHROOM CATSUP.
Receipt:—Break up small into a deep earthen pan, two gallons of large ripe mushroom-flaps, and strew amongst them three quarters of a pound of salt, reserving the larger portion of it for the top. Let them remain two days, and stir them gently with a wooden spoon often during the time; then turn them into a large stewpan or enamelled saucepan, heat them slowly, and simmer them for fifteen or twenty minutes. Strain the liquor closely from them without pressure; strain and measure it; put it into a very clean stewpan, and boil it quickly until it is reduced nearly half. For every quart allow half an ounce of black peppercorns and a drachm of mace; or, instead of the pepper, a quarter of a teaspoonful (ten grains) of good cayenne; pour the catsup into a clean jug or jar, lay a folded cloth over it, and keep it in a cool place until the following day; pour it gently from the sediment, put into small bottles, cork them well, and rosin them down. A teaspoonful of salad oil may be poured into each bottle before it is corked, the better to exclude the air from the catsup.
Mushrooms, 2 gallons; salt, 3/4 lb.; to macerate three or four days. To each quart of liquor, 1/2 oz. black pepper, or quarter of a teaspoonful of cayenne; and 1 drachm of mace: to be reduced nearly half.
Obs. 1.—Catsup made thus will not be too salt, nor will the flavour of the mushrooms be overpowered by that of the spices; of which a larger quantity, and a greater variety, can be used at will.
We can, however, answer for the excellence of the present receipt from long experience of it. When the catsup is boiled down quite early in the day, it may be bottled the same night: it is necessary only, that it should perfectly cold before this is done.
Obs. 2.—When the mushrooms are crushed, or mashed, as some authors direct, the liquor will necessarily be very thick; it is better to proceed as above, and then to boil the liquor which may afterwards be extracted from the mushrooms by pressure, with the sediment of the catsup, and sufficient cloves, pepper, allspice, and ginger, to
flavour it highly: this second catsup will be found very useful to mix with common thickened sauces, hashes, and stews.
MUSHROOM CATSUP.
(Another
Receipt.
)
Break a peck of large mushrooms into a deep earthenpan; strew three quarters of a pound of salt amongst them, and set them into a very cool oven for one night, with a fold of cloth or paper over them. The following day strain off the liquor, measure, and boil it for fifteen minutes; then, for each quart, add an ounce of black pepper, a quarter of an ounce of allspice, half an ounce of ginger, and two large blades of mace, and let it boil fast for twenty minutes longer. When thoroughly cold, put it into bottles, cork them well, and dip the necks into melted bottle-cement, or seal them so as to secure the catsup from the air.
Mushrooms, 1 peck; salt, 3/4 lb. Liquor to boil, 15 minutes. To each quart, 1/2 oz. black pepper; 1/4 oz. allspice; 1/2 oz. ginger; 2 blades mace: 20 minutes.
DOUBLE MUSHROOM CATSUP.
On a gallon of fresh mushrooms strew three ounces of salt, and pour to them a quart of ready-made catsup (that which is a year old will do if it be perfectly good); keep these stirred occasionally for four days, then drain the liquor very dry from the mushrooms, and boil it for fifteen minutes with an ounce of whole black pepper, a drachm of mace, an ounce of ginger, and three or four grains only of cayenne.
Mushrooms, 1 gallon; salt, 3 oz.; mushroom catsup, 1 quart; peppercorns, 1 oz.; mace, 1 drachm; ginger, 1 oz.; cayenne, 3 to 4 grains: 15 minutes.
COMPOUND, OR COOK’S CATSUP.
Take a pint and a half of mushroom catsup when it is first made, and ready boiled (the double is best for the purpose), simmer in it for five minutes an ounce of small eschalots nicely peeled; add to these half a pint of walnut catsup, and a wineglassful of cayenne vinegar, or of chili vinegar; give the whole one boil, pour it out, and when cold, bottle it with the eschalots in it.
Mushroom catsup, 1-1/2 pint; eschalots, 1 oz.; walnut catsup or pickle, 1/2 pint; cayenne or chili vinegar, 1 wineglassful.
WALNUT CATSUP.
The vinegar in which walnuts have been pickled, when they have remained in it a year, will generally answer all the purposes for which this catsup is required, particularly if it be drained from them and boiled for a few minutes, with a little additional spice, and a few eschalots; but where the vinegar is objected to, it may be made either by boiling the expressed juice of young walnuts for an hour, with six ounces of fine anchovies, four ounces of eschalots, half an ounce of black pepper, a quarter of an ounce of cloves, and a drachm of mace, to every quart; or as follows:—
Pound in a mortar a hundred young walnuts, strewing amongst them as they are done half a pound of salt; then pour to them a quart of strong vinegar, and let them stand until they have become quite black, keeping them stirred three or four times a day; next add a quart of strong old beer, and boil the whole together for ten minutes; strain it, and let it remain until the next day; then pour it off clear from the sediment, add to it half a pound of anchovies, one large head of garlic bruised, half an ounce of nutmegs bruised, the same quantity of cloves and black pepper, and two drachms of mace: boil these together for half an hour, and the following day bottle and cork the catsup well. It will keep for a dozen years. Many persons add to it, before it is boiled, a bottle of port wine; and others recommend a large bunch of sweet herbs to be put in with the spice.
1st Recipe. Expressed juice of walnuts, 1 quart; anchovies, 6 oz.; eschalots, 4 oz.; black pepper, 1/2 oz.; cloves, 1/4 oz.; mace, 1 drachm: 1 hour.
2nd. Walnuts, 100; salt, 1/2 lb.; vinegar, 1 quart; to stand till black. Strong beer, 1 quart; anchovies, 1/2 lb.; 1 head garlic; nutmegs, 1/2 oz.; cloves, 1/2 oz.; black pepper, 1/2 oz.; mace, 2 drachms: 1/2 hour.
ANOTHER GOOD RECEIPT FOR WALNUT CATSUP.
Beat a hundred green walnuts in a large marble mortar until they are thoroughly bruised and broken, and then put them into a stone jar, with half a pound of eschalots, cut in slices, one head of garlic, half a pound of salt, and two quarts of vinegar; let them stand for ten days, and stir them night and morning. Strain off the liquor, and boil it for half an hour with the addition of two ounces of anchovies, two of whole pepper, half an ounce of cloves, and two drachms of mace; skim it well, strain it off, and when it is quite cold pour it gently from the sediment (which may be reserved for flavouring common sauces) into small dry bottles, secure it from air by sound corking, and store it in a dry place.
Walnuts, 100; eschalots, 1/2 lb.; garlic, 1 head, salt, 1/2 lb.; vinegar, 2 quarts: 10 days. Anchovies, 2 oz.; black pepper, 2 oz.; mace, 1/4 oz.; cloves, 1/2 oz.: 1/2 hour.
LEMON PICKLE OR CATSUP.
Either divide six small lemons into quarters, remove all the pips that are in sight, and strew three ounces of salt upon them, and keep them turned in it for a week, or, merely make deep incisions in them, and proceed as directed for pickled lemons. When they have stood in a warm place for eight days, put into a stone jar two ounces and a half of finely-scraped horseradish, and two ounces of eschalots, or one and a half of garlic; to these add the lemons with all their liquor, and pour on them a pint and a half of boiling vinegar in which half an ounce of bruised ginger, a quarter of an ounce of whole white pepper, and two blades of mace have been simmered for two or three minutes. The pickle will be fit for use in two or three months, but may stand four or five before it is strained off.
Small lemons, 6; salt, 3 oz.: 8 days. Horseradish, 2-1/2 oz.; eschalots, 2 oz., or garlic 1-1/2 oz.; vinegar, 1-1/2 pint; ginger, 1/2 oz.; whole white pepper, 1/4 oz.; mace, 2 blades: 3 to 6 months.
Obs.—These highly-flavoured compounds are still much in favour with a certain class of housekeepers; but they belong exclusively to English cookery: they are altogether opposed to the practice of the French cuisine, as well as to that of other foreign countries.
PONTAC CATSUP FOR FISH.
On one pint of ripe elderberries stripped from the stalks, pour three quarters of a pint of boiling vinegar, and let it stand in a cool oven all night; the next day strain off the liquid without pressure, and boil it for five minutes with a half-teaspoonful of salt, a small race of ginger, a blade of mace, forty corns of pepper, twelve cloves and four eschalots. Bottle it with the spice when it is quite cold.
BOTTLED TOMATAS, OR TOMATA CATSUP.
Cut half a peck of ripe tomatas into quarters; lay them on dishes and sprinkle over them half a pound of salt. The next day drain the juice from them through a hair-sieve into a stewpan, and boil it for half an hour with three dozens of small capsicums and half a pound of eschalots; then add the tomatas, which should be ready pulped through a strainer. Boil the whole for thirty minutes longer; have some clean wide-necked bottles, kept warm by the fire, fill them with the catsup while it is quite hot; cork, and dip the necks into melted bottle-resin or cement.
Tomatas, 1/2 peck; salt, 1/2 lb.; capsicums, 3 doz.; eschalots, 1/2 lb.: 1/2 hour. After pulp is added, 1/2 hour.
Obs.—This receipt has been kindly contributed by a person who makes by it every year large quantities of the catsup, which is considered excellent: for sauce it must be mixed with gravy or melted butter. We have not ourselves been able to make trial of it.
