Ann Thorac Surg 2000;69:962-966
© 2000 The Society of Thoracic Surgeons
Our Surgical Heritage
Sergei S. Brukhonenko: the development of the first heart-lung machine for total body perfusion
Igor E. Konstantinov, MDa,
Vladimir V. Alexi-Meskishvili, MD, PhDb
a Thoracic and Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
b German Heart Institute, Berlin, Germany
Address reprint requests to Dr Konstantinov, Thoracic and Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55902
e-mail: konstantinov.igor{at}mayo.edu
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Abstract
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Sergei S. Brukhonenko designed and constructed one of the earliest heart-lung machines. He was the first to experimentally perform a total body perfusion with the heart of the animal isolated from the circulation. His work paved the way to the first experimental operations on heart valves. Although Brukhoneko’s pioneering contributions have not received the recognition they deserve, his work represents an important landmark in cardiac surgery.
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Introduction
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"The solution of the problem of the artificial circulation of the whole animal opens the door to the problem of operations on the heart, for example on the valve."
Sergei S. Brukhonenko, 1928
The development of the heart-lung machine by John Heysham Gibbon (1903–1973) is well known and recognized [1, 2]. In 1931, after witnessing the death of a patient from pulmonary embolectomy, Dr Gibbon had an idea for the heart-lung machine. By 1942, he was able to keep cats alive on his experimental devices, with continued survival after bypass. On May 6, 1953, Gibbon performed the world’s first successful open-heart operation using extracorporeal circulation on an 18-year-old woman with a large atrial septal defect. The name Gibbon is well known to cardiac surgeons.
The name of Brukhonenko, however, and his pioneering work on the heart-lung machine is rarely mentioned in the English language surgical literature. In 1997, Fou, in her article entitled "The First 20 Years of the Heart-Lung Machine" and devoted to John H. Gibbon, wrote: "Other names emerging in the field of thoracic surgery included those of ... , and Brukhonenko and his colleagues in Russia" [2]. In 1960, Probert and Melrose, in their article "An Early Russian Heart-Lung Machine," published in the British Medical Journal wrote: "In the development of the heart-lung machine for extracorporeal circulation the contributions of the distinguished Russian scientist, Professor S.S. Brukhonenko, have not hitherto received the recognition they deserve" [3]. Despite thorough literature review, we did not find any biographical material on Professor Brukhonenko published in English, French, or German. Who was this obscure Dr. Brukhonenko? What is his contribution to the development of the heart-lung machine?
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Landmarks in extracorporeal circulation
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It is important to briefly outline the history of artificial circulation to appreciate the work of Brukhonenko and his contributions to the development of modern extracorporeal technology.
The history of the extracorporeal circulation begins in 1813, when LeGallois suggested that vitality of part of the body might be preserved by means of the artificial circulation [4]. In 1858, Brown-Sequard used the limbs of guillotined prisoners and demonstrated that reflex nervous activity could be preserved if perfusion with oxygenated blood was initiated promptly [5]. He achieved blood oxygenation by the whipping of "black" blood, and forced the oxygenated blood through the arteries by means of a syringe. In 1868, Ludwig and Schmidt described an apparatus for arterial blood infusion from a reservoir into an isolated surviving organ [6]. In 1882, von Schroder described a bubble oxygenator with air bubbling through the venous blood from the bottom of the bottle, thereby producing foam [7]. The first heart-lung machine, in which the oxygenation of the blood could be accomplished without the interruption of the blood flow, was devised by von Frey and Gruber in 1885. The blood was spread as a thin film exposed to the oxygen over the inner wall of a rotating cylinder [8]. In 1895, Jacobj used a perfusion apparatus employing dog lungs or the pulmonary lobes of pigs or calves as oxygenators [9]. In 1855, the first roller pump was patented by Porter and Bradley [10].
It can, therefore, be stated that a century ago, three systems were already in use, namely the bubble oxygenator, the film oxygenator, and the lung as an oxygenator. The roller pump was described, and experimental perfusion of isolated organs was successfully performed. However, it was not until Brukhonenko conducted his experiments in 1920s that the feasibility of total body perfusion after heart removal was established [11].
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Biography and work
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Sergei Sergeevich Brukhonenko (1890–1960) (Fig 1) was born on April 30, 1890 in the small Russian town of Kozlov into the family of a civil engineer. While still a teenager, Brukhonenko made his first invention. It was a self-designed and self-constructed bicycle (Fig 2). Brukhonenko received his premedical education in Saratov and then moved to Moscow to study medicine. After graduation from the Medical Faculty of the University of Moscow in 1914, Brukhonenko was assigned to the active army as a junior doctor to an infantry regimen. During World War I, having witnessed many cases of traumatic shock and combat injuries of the lungs, heart, and major vessels, he thought of ways for temporal extracorporeal circulation to support life while injuries are repaired [12]. In Autumn 1917, Brukhonenko returned to Moscow and worked for the Sanitary Council of Sokolniky’s region of Moscow.
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Fig 1. Sergei Sergeevich Brukhonenko (1890–1960). Courtesy of Lutfia Arifulova, Russian Academy of Medical Sciences.
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Fig 2. Sergei Brukhonenko sitting on the self-constructed bicycle with his family. Courtesy of Lutfia Arifulova, Russian Academy of Medical Sciences.
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From 1919 to 1926, he was assistant professor at the Department of Clinical Pathology and Therapy of the Military Hospital in Lefortovo, in the outskirts of Moscow. While working there, he attended many patients with typhus and malaria.
Brukhonenko first approached the problem of the extracorporeal circulation in 1923, when he was studying the trypanocidal drug Suramin (Bayer 205, Germanin, Nagonal) at the State Institute for Chemistry and Pharmacology in Moscow [13, 14]. Finding that this drug was capable of producing an "artificial haemophilia," he began to use it as an anticoagulant in blood transfusions [15]. According to Probert and Melrose, Brukhonenko was using roller pumps in his work on transfusion [3].
In 1926, in collaboration with Dr Tchechulin, he designed an apparatus for the "artificial circulation with blood of warm-blooded animal" [16]. The device was named "autojector" (Fig 3). The apparatus consisted of two mechanically operated diaphragm pumps with a system of valves. The excised lungs of a donor animal acted as an oxygenator. One pump delivered venous blood into the oxygenator; the other pumped the oxygenated blood from the donor lungs into the systemic circulation of the perfused animal. The blood of the donor and the experimental animals was treated with Suramin. In their experiment conducted on November 1, 1926, the heavy ligature was placed around the heart at the atrio-ventricular grove so that the contraction ceased. The dog was kept alive for 2 hours by means of extracorporeal circulation only. Sudden massive bleeding from the internal mammary artery interrupted the experiment [16–18]. This was, apparently, the world’s first experiment of its type. After description of eight experiments, Brukhonenko wrote: "by conducting these experiments we wanted to clarify the principle possibility of surgery on the temporary arrested heart," and concluded that "in principle, the artificial circulation may be used for certain operations on the arrested heart, however, further improvement of the technique is necessary for its practical implementation" [16–18].
In the succeeding years, Brukhoneko pursued a series of research both with isolated organs and with total perfusions [18]. On June 1, 1928, he demonstrated some of the experiments to the international audience at the 3rd Congress of Physiologists of the USSR. Early in the next year, a correspondent of the La Presse Medicale paid a special visit to Moscow; he described this research and published photographs of the apparatus in action [3, 19]. The isolated head reacted briskly to the environment, opened its mouth, and even swallowed a piece of cheese placed in it. The experiment was demonstrated to A. V. Lunacharsky, Russian Minister of Education, and to the international scientists, among them Professor Haldane from the United Kingdom [17]. The news of the head surviving after being cut off from the rest of the body caused a wave of anxiety among laymen in Europe. G. Bernard Shaw wrote a letter on March 12, 1929 and speculated about the input of "Brukhonenko’s most interesting experiments" on preservation of human knowledge [20].
There was also one much more practical application of Brukhonenko’s device. In his article submitted on October 11, 1928 to the French magazine Journal de Physiologie et de Pathologie Generale, Brukhonenko wrote about the artificial circulation: "Would not this method, duly perfected, be useful in clinical medicine: notably in those cases where it would be essential to replace, if only for a time, the work of the failing human heart? Without going more deeply into this question we can state as a result of the present work, that in principle artificial circulation is applicable to man not only clinically, but also for certain operations on the temporarily arrested heart. For its achievement, however, a suitable technique would have to be worked out" [3, 16, 17].
In 1931, Brukhonenko performed experiments with deep hypothermia. Using his autojector device, the dogs were cooled down to 3°C with resulting hypothermic cardiac arrest. After rewarming, the restoration of normal cardiac function and the dogs’ survival were achieved [20]. Brukhonenko applied for a patent on his "Device for Artificial Circulation" in Russia on November 29, 1928. On December 15, 1934, the patent was issued (USSR patent No. 35976). In 1929, the device was patented both in Germany (No. 139825) and in England (No. 30708/28); and in 1930, in France (No. 662878).
From 1929 to 1937, the autojector was successfully used in open heart operations on dogs performed by Terebinski [21–24]. In 1940, Nikolai Terebinski (1880–1959) published a monograph and reported excellent results of more than 260 open heart operations on dogs. Though the device was suitable for experimental open heart operations, it required donor lungs for blood oxygenation, and as such could not be applied clinically.
In 1936, Brukhoneko designed a bubble oxygenator and called it the "artificial lungs," thus completing his heart-lung machine. He applied for a patent on March 31, 1937. It was issued on May 31, 1942 (USSR patent No. 61321). The device consisted of a double-wall glass vessel, with the inner vessel used for the foam-type blood oxygenation, while the outer vessel was filled with an acid and used as an electric heater (Fig 4). The vessel was placed on a scale with a balance occlusion system that occluded the blood outlet when the blood level in the vessel was too low. The oxygen was bubbling through the venous blood from the bottom of the inner vessel, producing foam. The foam was suppressed by alcohol and the oxygenated blood was returned into the body. In 1937, by means of his heart-lung machine, Brukhonenko achieved complete recovery in a dog after 7 minutes of normothermic circulatory arrest. In 1939, 12 out of 13 experimental animals were resuscitated using the heart-lung machine after 10 minutes of circulatory arrest. All dogs recovered completely without any residual neurological damage [24].
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Fig 4. Brukhonenko’s bubble oxygenator: 1, balance; 2, holding stent; 3, glass vessel; 4, electrodes placed in acid for heating with electric current; 5 and 6, thermoregulator system; 7, inner glass vessel; 8 and 9, rubber corks; 10, rubber tube; 11 and 12, occlusion system; 13, oxygenated blood outlet to the body; 25, venous blood inlet; 34, glass vessel filled with water only; 35, glass vessel filled with water and alcohol; 36, thermostat; 37, oxygen inlet. Reprinted from Brukhonenko SS. Device for oxygenation of the blood. USSR Patent No. 61321 issued on May 31, 1942.
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Terebinski and Brukhonenko were eager to apply the heart-lung machine clinically. In 1941, the machine was safe and reliable enough for clinical application. However, World War II interrupted their work.
The war caused enormous cultural, scientific, and economic damage. As many as 27 million of Brukhonenko’s fellow citizens may have died. Material losses are even more difficult to establish, but 30% of the national wealth was destroyed. It took decades for the economy to recover. After the end of World War II and up to 1951, Brukhonenko worked in the Sklifosofsky Emergency Institute in Moscow. Although Terebinski and Brukhonenko resumed their experiments in the early 1950, they simply had no time to implement their ideas into clinical practice. Terebinski died in 1959 at the age of 79. Vita brevis, ars longa! Brukhonenko then attempted to use the heart-lung machine for emergent resuscitation after sudden death. It was a daring idea, original and challenging, and it was also a failure. There were no survivors.
From 1951 to 1958, Brukhonenko headed the physiology laboratory at the Institute of Experimental Surgical Devices and Instruments in Moscow (Figs 5 and 6). Although Brukhonenko was the first to suggest that an extracorporeal circulation could have a place in cardiac surgery [25] and applied his heart-lung machine for clinical resuscitation in the 1950s, the device was never used in clinical open heart surgery. A success of Gibbon’s heart-lung machine in the mid-1950s overshadowed early work of Brukhoneko, and the first heart-lung machine soon fell into oblivion. From 1958 to 1960, Brukhonenko headed the laboratory of Artificial Circulation at the Institute of Experimental Biology and Medicine. Brukhonenko died on April 20, 1960.
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Fig 5. Brukhonenko and associates conducting experiments with the heart-lung machine in 1954. Courtesy of Lutfia Arifulova, Russian Academy of Medical Sciences.
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Fig 6. Brukhonenko with his heart-lung machine in 1954. Courtesy of Lutfia Arifulova, Russian Academy of Medical Sciences.
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Epilogue
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In 1960, the year of his death, Probert and Melrose concluded their article on Brukhonenko’s heart-lung machine as follows: "Brukhonenko’s work demonstrated the difficulties of total perfusion and went a long way towards resolving them. His technique of excluding the heart of the perfused animal from the circulation was crude, but was recognized as a method of achieving planned cardiac arrest. His writings were clear and precise in their prophetic insistence that this early work was applicable to the clinical needs of man" [3].
As we enter a new millennium, a recognition of surgical pioneers of the century is timely and appropriate. Brukhonenko died 40 years ago. His work was left unfinished and time has largely forgotten it. He did not see successful implementation of his heart-lung machine into clinical practice. Yet, what has been accomplished does not die. His work assured immortality for his name and secured its place among the pioneers of cardiac surgery.
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Acknowledgments
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We are grateful to Lutfia Arifulova, Deputy Director, The Scientific Research Center "Medical Museum" of the Russian Academy of Medical Sciences, for providing us with documented information and photographs. We thank Dr Dmitri Tcherkas and Mr Yuri Rost for their kind help and encouragement.
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Abstract
Introduction
