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Ann Thorac Surg 1997;63:869-878
© 1997 The Society of Thoracic Surgeons
Division of Cardiology and Department of Cardiothoracic Surgery, The New York Hospital–Cornell Medical Center, New York, New York
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Abstract |
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 TopFootnotes Abstract IntroductionThe First Era (1880-1934):...The Second Era (1935-1953):...The Third Era (1954-1966):...The Fourth Era (1967-Present):...References |
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Introduction |
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TopFootnotesAbstractIntroductionThe First Era (1880-1934):...The Second Era (1935-1953):...The Third Era (1954-1966):...The Fourth Era (1967-Present):...References |
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The surgical therapy for coronary artery disease can be viewed as having progressed through several eras, each one witnessing the development of more direct approaches to the surgical treatment of coronary artery disease. The first era saw the advent of palliative, indirect efforts designed to ameliorate the ischemia or its sensation, but which also often produced undesirable sequelae. The second era saw the use of dynamic efforts to promote collateral revascularization of the myocardium from surrounding tissues and the development of methods designed to redirect venous drainage of the heart back into the myocardium. The third was marked by a series of ingenious but crude strategies for direct revascularization of the myocardium and the fourth, by direct coronary artery procedures. The pioneering approaches to the surgical treatment of myocardial ischemia were generally inadequate and some are bizarre by today's standards, but they did serve as experimental and clinical springboards for the development of saphenous vein– and internal mammary artery–coronary artery bypass grafting. As is well known, the merits of the last of these techniques were ultimately validated by multicenter randomized trials of coronary artery bypass grafting conducted in the 1970s and early 1980s [1–3].
The history of these techniques, like that of most important discoveries, is a story of innovators and visionaries, of perseverance despite failure and criticism, of serendipitous discoveries, and of delays in progress while the technology caught up with inspired ideas. As occurs so often when it comes to important medical discoveries, chance favored the prepared mind alert and open enough to recognize an important yet unexpected observation. Likewise, this history often involved the rediscovery of previously unrecognized findings, workers laboring simultaneously on identical projects in ignorance of each other, and progress advancing not rationally and stepwise, but in unpredictable fits and starts, as well as by quantum advances. In this review the history of surgical procedures performed for coronary artery disease is recounted in chronologic order, rather than compartmentalized by specific procedure, so as to better convey a sense of the flow of time and events as they occurred, as well as the interplay of the various techniques as they matured. The recent repopularization of "minimally invasive" cardiac surgical procedures and indirect myocardial revascularization made possible through the development of such technologies as laser transmyocardial revascularization and therapeutic angiogenesis make the history of this field particularly relevant today; because many techniques currently being examined are incredibly similar to techniques tried and abandoned nearly half a century ago.
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The First Era (1880–1934): Basic Observations and Extracardiac Operations for Angina |
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TopFootnotesAbstractIntroductionThe First Era (1880-1934):...The Second Era (1935-1953):...The Third Era (1954-1966):...The Fourth Era (1967-Present):...References |
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The legendary French-born Alexis Carrel was the first worker to advance beyond speculation and theory and into the operating room and in so doing laid the groundwork for coronary artery bypass grafting using arterial as well as venous grafts. In 1910 he reported on an amazing series of experiments that constitute the earliest forms of direct coronary artery bypass. In these experiments he anastomosed the innominate artery of one dog into the distal coronary artery of another. In other animals, he performed direct coronary artery bypass by suturing a homologous, free carotid artery graft between the descending thoracic aorta and the left coronary artery [8]. Although unfortunately the animals died quickly, these procedures were the ancestors of today's mammary artery bypass procedures. In still other animals, Carrel performed the first vein bypass grafting of the arterial tree by interposing a vein segment into a dog's transected aorta [9]. This work was thus the forerunner of the current saphenous vein bypass procedure. Carrel's 1912 Nobel Prize in Medicine or Physiology, awarded for his work on transplantation and vascular grafting, was the first to be awarded for medical research performed in the United States. Unfortunately, his brilliant career ended in a downward spiral, starting with his leaving Rockefeller University in a bitter dispute with the institution and followed by his subsequent return to France, his being accused of being a Nazi collaborator in 1943, and his death the next year.
In 1916 Jonnesco followed through on François-Franck's suggestions by performing the first cardiac sympathectomy in a human, reporting on his work in 1920 [10]. Working in Bucharest, Romania, he performed bilateral extirpation of the cervical sympathetic trunk as well as the first dorsal ganglia. This work ushered in a period during which various procedures for cardiac sympathetic denervation became popular. Such denervation not only was reasonably effective in relieving the sensations of angina but was also thought to produce a state of coronary vasodilation. Various means of doing this were employed; Mandl, in 1925, was the first to inject alcohol paravertebrally in humans for this purpose, Richardson and White reported on their series of patients undergoing sympathetic ganglionectomy in 1929, and White and Bland reviewed their experience with posterior rhizotomy in 1948. Such was the early appeal of these procedures that the preeminent cardiologist of the time, Paul Dudley White, was an enthusiastic proponent of them. In fact, use of cardiac denervation procedures persisted into the early 1960s.
There were also other indirect approaches to the surgical treatment of ischemic heart disease, including those designed to prevent the generation of angina. Recognizing the ability of thyroid hormone and its excess to increase myocardial demand and induce ischemia, Boas, in 1926, was the first to perform subtotal thyroidectomy on patients in an effort to treat angina, but with unsuccessful results. Wearn [11], in 1928, was the first to suggest that, if coronary flow were occluded, the thebesian vessels could reverse flow, thus supplying blood from the ventricular cavities to the myocardium. Others would subsequently exploit this concept by partially ligating the venous drainage of the heart to redirect flow back into the myocardium. In 1930 Sussman [12] was the first to report the use of cardiac irradiation to denervate the heart in an attempt to produce coronary vasodilation.
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The Second Era (1935–1953): Indirect Revascularization Operations by Beck, Vineberg, and Murray |
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TopFootnotesAbstractIntroductionThe First Era (1880-1934):...The Second Era (1935-1953):...The Third Era (1954-1966):...The Fourth Era (1967-Present):...References |
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This era of indirect methods of revascularization began with the efforts of a pivotal figure in cardiac surgery, Claude S. Beck (Fig 1
), a surgeon at Western Reserve University and The Cleveland Clinic, who in 1930 made the first of several observations that would launch his pioneering career. After originally practicing neurosurgery, Beck began studying the effects of compression of the heart by experimentally inducing pericardial scars and adhesions; he incidentally noted that these scars were quite vascular [13]. In 1932 he read the work of Moritz, who injected carbon particles into the coronary arteries of cadaver hearts and analyzed the extensive network of collaterals between vascular territories, as well as the vascularization of pericardial adhesions. Moritz and his colleagues [14] also noted enhanced anastomoses between the coronary arteries and extracardiac structures in humans dying of pericarditis, as well as vascular anastomoses between pericardial fat pads and branches of the aorta. In 1934 Beck noted brisk bleeding from both ends of a transected pericardial scar, and this sparked in him an interest in devising methods of coronary revascularization. He developed several procedures for increasing the vascular anastomoses between the coronary arteries and surrounding tissues, beginning in 1932 with animals and in 1935 in patients. In the first of these procedures, he induced sterile pericarditis by mechanically abrading the epicardium and visceral pericardium. This caused vascular adhesions to form, leading him to hope that this neovascularization would communicate with myocardial vessels. This procedure, termed cardiopericardiopexy or pericardial poudrage, was described in the literature in 1935 [15] and would be the first in a long series of operations Beck would develop or apply during his career.
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Others explored different, intersecting avenues. In the early 1930s famed aviator Charles Lindbergh developed a primitive prototype heart-lung bypass machine. Disturbed by the impotence of physicians in the face of massive pulmonary embolism, John Gibbon, Jr (Fig 2), succeeded in bypassing dog hearts during pulmonary artery occlusion in 1937 [21], providing a critical starting point for the clinical development of heart-lung machines, which were to become essential to the development of open heart surgical procedures in the 1950s.
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In 1937 O'Shaughnessy became the first of several investigators to modify Beck's cardiomyopexy by bringing a variety of vascular organs into contact with the abraded epicardium. O'Shaughnessy [22] used omentum (cardioomentopexy), whereas others used lung (cardiopneumopexy), jejunum (cardiojejunopexy), pedicled skin grafts, stomach (cardiogastropexy), and spleen (cardiolienopexy). Many of these workers reported on their methods as late as the 1950s, illustrating how popular and accepted these techniques became. In 1956 Kline and associates [19] occluded the left pulmonary artery in dogs in order to increase bronchial artery collateral flow (intended to then improve myocardial flow by anastomoses), then sutured parts of the lung to epicardium denuded by silver nitrate. Similarly, in 1957 Kownacki increased pulmonary collateral flow to the heart by ligating the lingular vein, then suturing the lingula to the epicardium.
The direct implantation of vessels into the myocardium was first reported by Griffith and Bates [23] in 1938. They discovered this procedure when, in the course of an operation for coronary artery disease, they accidentally perforated the left ventricle; to repair the defect, they sutured part of the pectoral muscle, along with its branches of the internal mammary artery, into the opening, presaging the Vineberg procedure of the next decade. Meanwhile, in 1939 Fieschi [24] suggested that bilateral ligation of the distal internal mammary arteries would shunt flow through branches of the pericardiophrenic arteries back to the heart through vascular anastomoses with the epicardium. Zoja and Cesa-Branchi performed the procedure on angina patients that year, with Fieschi reporting their results in 1942 [24]. Also in 1939 Lillehei created a surgical communication between the pulmonary artery and the left atrium in patients in an effort to increase left heart and thus anterograde coronary artery blood flow.
University of Toronto surgeon Gordon Murray, who subsequently made pioneering contributions in the prophylactic use of heparin for the prevention of postoperative venous thrombosis, began to make a long series of contributions to the development of several types of coronary artery surgical procedures in 1940, ultimately reporting the first experimental coronary divisions followed by direct arterial repair and venous interposition homografts (paper read at the Graduate Fortnight of The New York Academy of Medicine, October 17, 1951). Like Carrel's pioneering interposition of a vein segment in a dog's aorta, this technique would be an ancestor of the current saphenous vein bypass grafting procedure. Like Beck, Murray was a prolific figure in the history of coronary surgery, having performed pioneering work in almost all types of the early procedures described here. However, Murray seemed to lack the optimism of his contemporaries, as one by one he abandoned each procedure soon after turning to it, though he later claimed to have performed various unpublished experiments before the published studies of his colleagues.
Meanwhile, Fauteux and Palmer [25] used Gross's technique of great cardiac vein ligation in humans in 1939 and reported on their work in 1941. Although Beck had initially concluded that coronary sinus ligation was not justified for clinical use, by 1954 he was employing it routinely; this became the main feature, along with pericardial poudrage and mediastinal fat grafting, of what became known as the Beck I operation [26]. In 1943 Roberts and his colleagues [27] took the next step in utilizing the coronary sinus to increase myocardial blood flow by becoming the first to experimentally arterialize it using brachiocephalic, subclavian, or innominate arterial grafts placed through glass tubes and sutured onto the coronary sinus. In 1946 Fauteux reported on his performance of great cardiac vein ligation in combination with pericoronary plexus neurectomy, using sharp dissection and chemical sclerosis, a procedure reminiscent of experimental work he had reported on 10 years earlier.
In 1946, another important advance occurred when Arthur Vineberg (Fig 3) of McGill University reported on what became known as the Vineberg operation. Using dogs, he implanted internal mammary arteries directly into ventricular myocardium to increase myocardial flow [28]. He founded his procedure on his belief that the myocardium contains relatively large venous sinusoids that would absorb the flow from the bleeding mammary vessels, but at the same time myocardial hemorrhage or rupture would be averted. Vineberg's procedure was a logical exploitation of the small anastomoses known to exist between mammary arteries in the mediastinum and the epicardium. Vineberg performed the first human mammary artery myocardial implantations in 1950, reporting them the following year. The procedure was often effective in relieving angina and was used until the early 1970s. Mason Sones [29] in fact proved the merits of the Vineberg procedure in 1962 when he demonstrated angiographically the connections between the mammary artery implant and myocardial vessels in humans. Sones' advancement of the technique of coronary angiography was a key to transforming myocardial revascularization from a laboratory to a clinical procedure.
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In the 1950s numerous advances in cardiopulmonary bypass paved the way for the more precise, and more complete, techniques of coronary artery operations that could be performed on the nonbeating heart. Working at Johns Hopkins, Alfred Blalock, a pioneer best known for his landmark "blue baby" shunt procedure (codeveloped with cardiologist Helen Taussig), introduced in 1945, espoused a physiologically based approach to cardiac operations that inspired a generation of other pioneers in ischemic heart disease operations. Bigelow and associates [31] reported their successful surgical procedures on the open dog heart, in which general body hypothermia was used to allow the body to tolerate circulatory arrest; no cardiopulmonary bypass was used. In 1951 Dogliotti performed right heart bypass in a human during resection of a mediastinal tumor and Dennis [32] became the first to use a heart-lung machine for total cardiopulmonary bypass in 2 patients; all 3 of these patients died intraoperatively, however. In 1952 Dodrill used right and left heart partial cardiopulmonary bypass pumps to perform experimental and clinical cardiac surgery.
In 1953 Gibbon [33] perfected the first effective heart-lung bypass machine, using a screen oxygenator. This paved the way for an explosion of previously impossible procedures that could now be performed on the nonworking heart during bypass. However, although his report of the successful case was well received in the lay press, it aroused surprisingly little interest among cardiologists or cardiac surgeons at the time. Gibbon himself became so discouraged by his unsuccessful cases that he abandoned open heart surgery entirely, which had a chilling effect on the field's future in the minds of many investigators.
After a series of ingenious but desperate operations utilizing hypothermia and inflow occlusion, as well as cross-circulation between the patient and the "donor" to bypass the patient's circulation and enable the arrest of her heart, Jones and Donald, of the Mayo Clinic, each reported first experimental and then clinical success using a modified Gibbon-type pump oxygenator during open-heart operations. Effective heart-lung bypass would become available by the mid-1950s, but it would not be used routinely in operations for ischemic heart disease until the late 1960s.
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The Third Era (1954–1966): Early Forms of Direct Coronary Artery Surgical Procedures |
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TopFootnotesAbstractIntroductionThe First Era (1880-1934):...The Second Era (1935-1953):...The Third Era (1954-1966):...The Fourth Era (1967-Present):...References |
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). Building on Carrel's pioneering efforts using arterial conduits for coronary bypass, Murray was the first to employ the internal mammary artery. Although Battezzati and colleagues rekindled interest in mammary artery ligation in 1955, the following year several workers launched a new chapter in direct coronary artery operations. Specifically, May [34] performed the first experimental closed, retrograde endarterectomies on dog and cadaver coronary arteries using a special catheter to extract atheroma. In addition, Charles Bailey soon performed the first closed coronary endarterectomy on a human subject on October 29, 1956, at Hahnemann Hospital in Philadelphia, using a retrograde, distal, blind technique without heart-lung bypass. Further, Kline and associates [19], expanding on Vineberg's work, reported the experimental myocardial implantation of the bronchial artery. In 1956, Absolon performed endarterectomies as well as end-to-end or end-to-side arterial–coronary artery grafting (using carotid, subclavian, or mammary arteries, with or without Ivalon prostheses) in dogs and cadavers, while Thal performed experimental mammary artery grafting onto coronary arteries, carried out on a beating heart using a suture technique. Finally, Goldman and associates [35] described a new approach to myocardial revascularization, which involved channeling left ventricular blood through a carotid homograft into the myocardium.
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The year 1958 saw continued progress. In that year Senning [39] reported his experimental use of coronary endarterotomy with direct-vision excision of plaque followed by patch grafting of the defect in the vessel with a split segment of autologous mammary artery. In addition, Carter and Roth [40] reported a nonsuture, metal ring technique for grafting the mammary artery to coronary arteries in the beating dog heart and Longmire and colleagues [41] reported an antegrade, open coronary endarterectomy procedure, performed on humans without cardiopulmonary bypass. Vineberg-type procedures were still popular at this time, as evidenced by Fuquay and associates' [42] report on experimental subclavian artery myocardial implantation.
In 1959 Dubost and colleagues [43] became the first to perform a coronary artery operation in a human using cardiopulmonary bypass when they performed coronary ostial reconstruction on a patient with syphilitic aortitis. In 1961 Robert Goetz and his co-workers [44] extended Carter's earlier work by reporting mammary artery–coronary artery bypass grafting using an innovative nonsuture tantalum ring technique on the beating heart in dogs. Almost as an aside, it was noted in an addendum to the paper that on May 2, 1960, at Van Etten Hospital, in Bronx, New York, a right mammary artery–right coronary artery bypass was performed on a 38-year-old patient. This marked the first time mammary artery–coronary artery bypass grafting was performed in a human subject. In 1961 Senning [45] reported carrying out coronary endarterotomy and lesion excision followed by the first strip grafting procedure to be performed in patients. The operation was performed using hypothermia but not cardiopulmonary bypass and involved the use of split autogenous saphenous vein segments as patches. Amazingly, his patient was the first to undergo a coronary artery operation after undergoing diagnostic coronary arteriography; previously, the diagnosis of coronary disease was made on the basis of the history, electrocardiography, and surgical palpation findings!
On April 4, 1962, David Sabiston, Jr, performed the first saphenous vein–coronary artery bypass grafting procedure in the world (Fig 5). Working at Johns Hopkins in 1961, he had performed a then standard endarterectomy on the right coronary artery of a 41-year-old patient, but within a year the artery had reoccluded. He then performed a vein bypass on the patient using an end-to-end distal anastomosis without using cardiopulmonary bypass (the cut proximal end of the native vessel was tied off). The patient died 3 days later of a stroke, however, and autopsy revealed a thrombus at the graft's proximal anastomosis, which he presumed had embolized. Sabiston was discouraged enough by this experience that he did not try vein bypass again until 1968 and did not report this landmark event until 1974, well after the rise of vein bypass surgery.
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The world's second human vein bypass graft operation, and the first successful one, was performed by Garrett, Dennis, and DeBakey at Methodist Hospital in Houston on November 23, 1964, on a 42-year-old man. As with Sabiston's patient, a routine endarterectomy with patch grafting was scheduled and cardiopulmonary bypass was not employed. However, the native vessel proved to be unsuitable because its lesion involved the left main artery bifurcation, so Garrett uneventfully bypassed the left anterior descending artery with an autologous saphenous vein segment, using an end-to-side distal anastomosis. Angiography performed 7 years later revealed a patent vein graft and occluded native vessel. Like Sabiston and the first vein bypass operation, Garrett inexplicably did not bother to report his historic operation until 1973. The patient died 1 year after this report as the result of occlusion of the grafted vessel distal to the insertion of the still-patent vein graft.
Work on direct myocardial implants continued even in 1965: Vineberg and Diethrich each reported implantating free omentum, and Sewell implanted a pedicle containing artery, vein, muscle, pleura, and fascia. The same year, Donald Effler and his associates at The Cleveland Clinic reported their modification of Senning's strip graft technique in which they used pericardial patches on endarterotomy sites instead of mammary artery or saphenous vein patches. This group performed the operation using hypothermia and cardiopulmonary bypass. This technique, developed in 1962 when a vein patch was dropped on the operating room floor, causing the surgeons to use the pericardium instead, was employed as the coronary revascularization procedure of choice at The Cleveland Clinic until Favaloro pioneered the use of saphenous vein bypass techniques. Sen and colleagues [47] reported the application of myocardial acupuncture, or the use of needles to create channels between ventricular blood into the myocardium, to humans in 1965.
In 1966 Bailey implanted a gastroepiploic artery into the myocardium and Pearce implanted an intercostal artery. The following year Braunwald used carotid sinus nerve stimulation in angina patients in an effort to reduce sympathetic tone, a high-technology throwback to the days of Paul Dudley White. Meanwhile, Sawyer developed a new technique for coronary endarterectomy involving the use of CO2 to dissect plaque from the normal vessel wall. Finally, in 1966 Wakabayashi and colleagues began the only published animal studies of the era on aortocoronary saphenous vein bypass grafting, which had already been performed in human subjects by Sabiston and by Garrett. Their work used cardiopulmonary bypass, and their findings were published beginning in 1968 [48]. The full exploitation of this technique would await the team at The Cleveland Clinic.
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The Fourth Era (1967–Present): Coronary Artery Bypass Grafting Comes of Age |
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TopFootnotesAbstractIntroductionThe First Era (1880-1934):...The Second Era (1935-1953):...The Third Era (1954-1966):...The Fourth Era (1967-Present):...References |
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Soon after Favaloro and colleagues at The Cleveland Clinic began to use autologous saphenous vein segments as bypass grafts, initially to the right coronary artery and initially employing an end-to-end distal anastomosis, with the proximal end of the right coronary artery tied off (Fig 6A). Favaloro and Effler did not originally plan to utilize aortocoronary vein bypass but quickly found that vein interpositions required two anastomoses and were of no use for ostial or very proximal lesions. It was for such lesions that they eschewed vein interposition and modified it into the bypass technique; the native vessel was still transected and the distal anastomosis was still made end to end with the distal right coronary. However, instead of making the proximal anastomosis with the other cut end of the native vessel, they moved more proximally by creating an anastomosis with the ascending aorta; the cut end of the proximal coronary was then ligated. At first these surgeons often grafted the right coronary artery with the heart beating, but they and others later routinely used cardiopulmonary bypass, especially when they then ventured into bypassing the left coronary artery system. Favaloro then settled on performing vein bypass grafting with an end-to-side distal anastomosis, which quickly became the standard operation throughout the world (Fig 6B). Though not the first or even the second to employ vein bypass grafting in human subjects, it was the broad clinical application of the technique by Favaloro and others in 1967 and 1968 that revolutionized the treatment of ischemic heart disease. Initially Favaloro and colleagues often combined saphenous vein grafting of the right coronary artery with single or double internal mammary artery myocardial implantation. It was because of their tendency to combine the Vineberg procedure with theirs that Favaloro's team initially avoided performing internal mammary artery–coronary artery anastomoses.
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Despite the great and nearly simultaneous enthusiasm for the saphenous vein bypass technique, many experts in the field were not ready to abandon prior procedures. As late as 1970, cardiac surgery pioneer Charles Bailey had the following comments for one of Favaloro's series: "You know, we have a 24-year follow-up on human implant arteries, and I do not agree with some people who are now saying that the direct procedures should completely supplant the indirect procedures. I think we would be well advised in properly indicated cases to stick to those procedures that we know will work." Favaloro responded to this by conceding that "We are in complete agreement that the Vineberg operation still has a definite place in myocardial revascularization." In fact, when patients began to be enrolled in 1970 in the landmark Veterans Administration Cooperative Study of medical therapy versus surgical therapy for coronary artery disease, the protocol called for the surgical patients to undergo mammary artery implantation. Later, saphenous vein grafting would be added to mammary implantation, and still later, all surgical patients underwent vein bypass only [1].
The major advance of 1968 was the implementation of internal mammary grafting by several groups. Though Goetz and Kolesov had performed the first such human operations, it was only in 1968 that broad use of the procedure began. Bailey was the first to perform the procedure that year, followed soon by Reed, who became the first to perform the operation using cardiopulmonary bypass and fibrillation, the first to perform it on the left anterior descending artery, and only the second to bypass that vessel by any means. Further application of the mammary graft occurred with the work Spencer and Green, of the group at New York University, which included Reed. In 1973 Carpentier reported the use of free radial artery autografts for bypass procedures, and in 1975 Bulkley used bovine arterial xenografts in human subjects. Neither technique became popular, however, because results were poor, though radial artery and other arterial grafts are even today being rediscovered as conduit material.
Thus, the long and fascinating history of the surgical treatment of coronary artery disease and its sequelae, spanning a century of innovative surgeons and their ideas, has yielded tools of protean importance, and ingenious advances continue to occur in the still dynamic field of myocardial revascularization. The future of the field appears especially promising and dramatic as current and future workers climb onto the shoulders of these past giants.
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Footnotes |
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TopFootnotesAbstractIntroductionThe First Era (1880-1934):...The Second Era (1935-1953):...The Third Era (1954-1966):...The Fourth Era (1967-Present):...References |
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References |
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TopFootnotesAbstractIntroductionThe First Era (1880-1934):...The Second Era (1935-1953):...The Third Era (1954-1966):...The Fourth Era (1967-Present):...References |
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