Heart: An American Medical Odyssey (13 page)

During that long night, helplessly watching the patient struggle for life, the idea naturally occurred to me that if it were possible to remove continuously some of the blue blood from the patient’s distended veins, put oxygen into that blood and allow carbon dioxide to escape from it, and then inject continuously the now red blood back into the patient’s arteries, we might have been able to save her life . . . and performed part of the work of the patient’s heart and lungs outside the body.

For Gibbon’s idea to work, he would need to devise a method not just to replace the blood pressure–producing left ventricular pump, but also solve the much more complex bioengineering problem of moving oxygen and carbon dioxide into and out of the blood. Eventually Gibbon’s epiphany would lead to development of the heart-lung machine, but it would take a quarter-century to achieve as his and other groups vied to be the first to artificially support a patient’s circulation during heart surgery.

•  •  •

In the first half of the twentieth century, there were very few people with more worldwide fame than the legendary aviator Charles Lindbergh. Lindbergh is best known for his landmark transatlantic flight in 1927, but the Medal of Honor winner was also a vocal isolationist, Nazi sympathizer, eugenicist, and inventor. Lindbergh’s sister-in-law, Elisabeth Morrow, suffered from mitral stenosis, a narrowing of the mitral valve (the valve that separates the left atrium from the left ventricle) caused by rheumatic fever, which in the 1930s was a fatal disease because there was no way to support a patient long enough to open the heart and repair the valve.
Determined to solve the problem, Lindbergh teamed with Dr. Alexis Carrel, a vascular surgeon and Nobel Prize winner (and later also a notorious eugenicist), and jointly they developed an apparatus capable of keeping an organ alive for days. Lindbergh and Carrel appeared together on the June 13, 1938, cover of
Time
magazine with their glass pump, which worked well in the laboratory but was never used clinically in humans.

Dr. C. Walton Lillehei, a surgeon at the University of Minnesota, developed a daring method to support children undergoing congenital heart surgery by connecting the child’s circulation to a parent with the same blood type.
The idea for this approach came from Lillehei’s surgical resident, Dr. Marley Cohen, who noted that his pregnant wife was the oxygenator for their fetus. In Lillehei’s “cross-circulation” technique, used in a few dozen patients in the mid-1950s, the child’s venous blood was pumped to the parent lying on an adjacent table, whose lungs oxygenated the blood before returning it to an artery in the child. The technique was groundbreaking but not adequate for adult surgery, and there were real risks to the parent. Dr. Willis Potts, surgeon-in-chief at Children’s Memorial Hospital in Chicago, referred to it “as the only operation that carried
a potential mortality of 200 percent.”

In Detroit, Dr. Forest Dodrill, a surgeon at Wayne State University, collaborated with engineers at General Motors Research to develop a mechanical pump capable of supporting the circulation of an adult.
The resulting stainless-steel and glass device, the Dodrill-GMR mechanical heart pump, had multiple cylinders from which blood circulated and, perhaps not surprisingly, bore an
uncanny resemblance to a Cadillac V-12 automobile engine. The device was intended to temporarily replace either the right or left ventricle and was first used in 1952 to support a patient for fifty minutes while Dr. Dodrill repaired a mitral valve.

Following his patient’s death from a pulmonary embolus in 1931, Dr. John Gibbon spent the next twenty-two years working to develop a heart-lung machine at Massachusetts General Hospital, the University of Pennsylvania, and finally Jefferson Medical College in Philadelphia. As early as 1935, Gibbon, working with his wife, Mary, demonstrated the ability of his invention to keep a cat alive, but achieving this in larger animals remained elusive because they could not build an oxygenator large enough to provide sufficient gas exchange. In a human lung, gas exchange occurs in the alveoli, where red blood cells pass through small vessels separated from air by one-cell-thick walls. An adult has almost half a billion alveoli in the two lungs with, collectively, approximately 750 square feet of surface area. A variety of novel approaches to creating an oxygenator were conceived, including one group that used isolated
monkey lungs.
Gibbon’s team finally discovered that creating turbulence in a thin film of blood increased the efficiency of gas exchange, and they could produce this by layering blood over vertical stainless-steel screens suspended in a plastic case infused with oxygen. Gibbon’s design, produced with engineering and construction support provided without charge by IBM, was first used in a patient in 1952, but because of an erroneous preoperative diagnosis, the patient died in the operating room.

On May 6, 1953, Dr. Gibbon
operated on Cecelia Bavolek, a Wilkes College freshman whose heart was failing because of a congenital hole in the wall separating her right and left atria (referred to as an atrial septal defect). To repair the defect, Gibbon connected the eighteen-year-old patient to his heart-lung machine, which supported her entire circulation for the twenty-six minutes it took him to sew closed
the hole in her heart, successfully accomplishing the world’s first surgery using cardiopulmonary support. Two months later, Gibbon attempted two more open heart repairs using his machine, but after the death of both children, he abandoned the procedure he pioneered and never again performed heart surgery.

In 1968, in recognition of his remarkable work, Gibbon received the
prestigious Albert Lasker Clinical Medical Research Award. The award states:

Untold numbers of people who would otherwise have remained incapacitated, or died because of previously incurable heart disease, are now living. . . . The vast impact of Dr. Gibbon’s discovery on medical science exemplifies the way in which new knowledge, gained from a single research project, can trigger a chain reaction of inquiries leading to additional knowledge, and ultimately to the prevention or cure of human diseases.

Dr. Gibbon died in 1973 at the age of sixty-nine, ironically from a heart attack. At the time of his Lasker Award, he concluded a review of the development of the heart-lung machine with the following prescient passage:

I would say that unquestionably it has proven its worth and has become a necessity in the armamentarium of the cardiac surgeon. It is used all over the world. It is used in the surgical correction of all congenital defects of the heart. Its employment is necessary for the replacement of diseased valves in the human heart with plastic prostheses. It is essential for the transplantation of the human heart, whatever may be the future of that extraordinary procedure. I believe also that we can look forward to the day it will be used to enable surgeons to replace a hopelessly diseased heart with an intracorporeal blood pump.

•  •  •

In the 1960s, armed with the ability to operate on a motionless heart and with detailed coronary images now obtainable following Mason Sones’s serendipitous discovery a few years earlier, surgeons became increasingly interested in “revascularizing” the heart, providing the muscle with new sources of blood. Early attempts at tunneling a new vessel into the muscle itself, like drip irrigation (referred to as the Vineberg procedure) or slicing open the arteries to peel out the obstructive plaque (endarterectomy), yielded mixed results. By the mid-1960s a new technique to directly suture new blood vessels onto the diseased coronaries, thereby “bypassing” atherosclerotic obstructions, was developing simultaneously in several centers around the world.

Controversy surrounds the question as to who performed the first coronary bypass operation, but two of the earliest were
Vasilii Kolesov, a surgeon from St. Petersburg, and
Michael DeBakey, from Baylor in Houston, who both performed cases in 1964. When Kolesov published his initial results of coronary artery bypass surgery in the
Journal of Thoracic and Cardiovascular Surgery
, it was accompanied by an editorial warning readers:

The opinions concerning the management and surgical treatment of angina pectoris as expressed in this paper by Professor VI Kolesov are at variance with the concepts of many surgeons in the United States.

Skepticism about coronary artery bypass graft (CABG) surgery would soon dissipate, and by 1996 the number of CABG operations performed per year in the United States would reach
its peak of 190,000.

•  •  •

The beating heart lies suspended in a cradle of pericardium, illuminated in the bright white light of the overhead surgical spots, exposed and vulnerable, inexorably pushing its contents into the aorta with a movement more like the wringing of a towel than the squeezing of a ball.
The surgeon inserts hollow cannulas the thickness of a thumb into the aorta and right atrium, ties them securely in place with heavy suture, and couples them to several feet of clear plastic tubing stretching across the room to the heart-lung machine. When clamps are removed, the circuit fills with color as the conduit sewn into the patient’s right atrium drains blood back to the heart-lung machine, its four centrifugal pump heads now spinning at 3,500 RPM, every minute transforming eight liters of dark venous blood into its crimson oxygenated form before returning it under pressure into the patient’s aorta.

You watch as the heart suddenly stops beating, the intentional result of an injection of a solution appropriately named cardioplegia. The scene in the room is remarkably calm; the players perform with a confident nonchalance born of skill and repetition. Using suture the diameter of a human hair, the surgeon sews to the aorta one end of a segment of the vein harvested from the leg and the other end to a vessel on the surface of the heart, now lying cool and still in the chest. This “bypass” graft is replicated for other regions of the heart, including one in which an artery from the wall of the chest is used as the conduit for new blood flow.

About forty-five minutes later, the “revascularization” is complete, and warm blood is allowed to enter the muscle through the newly constructed pathways. You watch as the dormant heart starts to beat again, its contractions becoming progressively more forceful until the heart-lung machine is no longer needed, the culmination of a procedure twenty-five hundred years in the making.

•  •  •

On August 19, 1988, the day after George Herbert Walker Bush accepted the Republican Party’s nomination for president of the United States in the Louisiana Superdome with a speech invoking “a thousand points of light,” Dick Cheney was wheeled into an operating room in George Washington University Hospital for heart surgery.

In a March 1989 letter to Senator Sam Nunn, chair of the Armed Services Committee, Dr. Allan Ross explained his rationale for recommending bypass surgery for Cheney:

Continued conservative management was contemplated, however follow-up exercise testing demonstrated ischemia (albeit at a respectable treadmill work load). After careful consideration, I advised the Congressman that in my opinion, although bypass surgery was probably not strictly required for longevity purposes (the usual surgical indication), it was advisable, in view of his lifestyle. Specifically, I felt that activities such as high altitude downhill skiing, backpacking, etc., would push him to his physiological limits and would be more safely undertaken if he had the bypass procedure.

Ross did not believe surgery would necessarily improve Cheney’s longevity because the artery supplying the front (anterior) wall of Cheney’s heart, the left anterior descending (LAD), did not have significant narrowing. Absent a significant blockage in that critical vessel, sometimes indelicately called “the widowmaker,” bypass surgery is usually no better than medical therapy in improving survival.

Dr. Benjamin Aaron performed Cheney’s surgery. Aaron, who came to GW in 1979 as chief of cardiac and thoracic surgery after spending twenty-two years in the Navy, received international recognition in 1981 when he removed an attempted assassin’s bullet from President Ronald Reagan’s left lung. The number of surgeons who have operated on a president of the United States is small, and Aaron is the only surgeon to ever operate on both a sitting president and a future vice president.

Cheney’s surgery was performed using cardiopulmonary bypass, allowing Aaron to work on a still target. Using a section of saphenous vein removed from Cheney’s left lower leg and both internal mammary arteries lying under the chest wall, Aaron performed a quadruple bypass, grafting the right coronary artery (the vessel responsible for the heart attack one month prior), the circumflex branch (the culprit in the
1978 and 1984 heart attacks), and the LAD and diagonal vessels on the front wall of the heart (arteries with only moderate disease). One day following surgery, Cheney was taken off the respirator, the next day he transferred out of the intensive care unit, and he was discharged from the hospital on August 26, 1988, postoperative day seven.

In his March 1989 letter to Senator Nunn, Dr. Ross summarized Cheney’s progress.

His recovery has been excellent and he has been advised to continue unrestricted professional and recreational objectives. Furthermore his formerly significant high cholesterol levels have been completely reversed on medical therapy. His pharmacological regimen is free of any side effects that would affect his judgment or behavior. The Congressman is presently fit to accept any position requiring the highest intellectual behavior and physical performance.

In January 1989, as Congress was reconvening, the House Republican leadership met with President-elect George H. W. Bush. We held regular weekly leadership meetings in room H-227 of the Capitol, but this one was very special because the new president came to the House for that first meeting, a thoughtful gesture by the man we were about to inaugurate as the forty-first president. As the meeting broke up, the president elect, whom I’d first met when he was a young congressman from Texas and I was working for his colleague, Bill Steiger of Wisconsin, twenty years before, took me aside to ask me how my health was. I told him the bypass surgery had gone remarkably well, that I’d had no further problems or complications, and that I’d finished out my year, four months after the surgery, skiing ten thousand feet up in the Rockies. At the time I didn’t attribute any special significance to his question. I just thought it was George Bush being George Bush, always thoughtful and considerate of others.