Ann Thorac Surg 2003;76:2147-2155
© 2003 The Society of Thoracic Surgeons
Our surgical heritage
The evolution of cardiovascular surgery in China
Song Wan, MD, PhDa*,
Anthony P. C. Yim, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, People's Republic of China
* Address reprint requests to Dr Wan, Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, People's Republic of China
e-mail: swan{at}cuhk.edu.hk
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Abstract
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The history of the development of cardiovascular surgery in China was little known to the West not only because the majority of the earlier reports were published almost exclusively in the Chinese language but also because China was essentially closed to the West before the 1980s. We present here an account of how some Chinese surgeons struggled to establish a new specialty in a country that makes up more than one fifth of the world population.
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Introduction
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Things present are judged by things past. Chinese idiom (1945, Chongqing, China)
lthough the Chinese were the first to discover the concept of blood circulation some two thousand years before William Harvey [1], cardiovascular surgery did not exist in China until the time of World War II. The first successful cardiac operation ever recorded in China—a direct repair of a right ventricular stab wound—was carried out in October 1940 by Dr Zhang Chao-Mei [2]. (Please note, in Chinese, the family name always appears before the given name, as has been done throughout this article.) Similar to the United States and Europe, subsequent development in cardiovascular surgery started with extracardiac anomalies. A leading Chinese thoracic surgeon, Dr Wu Ying-Kai [3], performed the first ligation of patent ductus arteriosus at Central Hospital of Chongqing in 1944 (6 years after the groundbreaking operation of Robert Gross) [4] and the first successful pericardectomy for constrictive pericarditis in 1948 [5] after the hospital was relocated in Tianjin.
In early 1940s, the city of Chongqing (previously known as Chungking) was the wartime capital of China. Several famous Chinese universities were forced to move from the other major cities just before their occupation by Japanese troops to Chongqing and Chengdu, two large cities in Sichuan Province, China. Many Chinese physicians and surgeons who were to become leaders in their fields received their medical or surgical training there during this time of turmoil. Among them was Dr Shih Mei-Hsin (Fig 1),
one of the foremost pioneers in cardiac surgery in China.
Shih's pursuit of cardiac surgery was stimulated interestingly by a talk in 1945 in Chongqing. As a second-year surgical resident at the Teaching Hospital of National Shanghai Medical College (which was later moved back to Shanghai in 1946), Shih was among the audience one day for a special lecture by Dr Leo Eloesser from Stanford University who visited China under the United Nations' Relief and Rehabilitation Administration [6]. With great enthusiasm Eloesser introduced to the Chinese surgeons the Blalock-Taussig operation, which was first performed only months previously at the John Hopkins Hospital on November 29, 1944. The combination of a brilliant concept and its technical success brought hope for those "blue babies" who were formerly considered incurable. "If anyone of you can perform such an operation," Eloesser teased the audience at the end of his talk, "I will cut my head off." Probably trying to enliven the atmosphere, he even made a gesture to imitate cutting his head. Without his realizing it, this condescending remark became a powerful stimulus to the budding surgeons in the audience. Decades later Shih could still recall the exact words.
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Rise to the challenge (1953 to 1958, Shanghai)
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Shih Mei-Hsin performed the first Blalock-Taussig shunt in China at Zhong-Shan Hospital of the Shanghai First Medical College on March 2, 1953. Few of us today could even come close to imagine the hardship facing Shih at that time. He returned to Shanghai shortly after the Korean War and under the political and socioeconomic circumstances then, it was impossible for Shih to acquire any Western-made surgical materials or instruments. This however did not deter Shih from pursuing his goal. He spent all his spare time in the week before surgery converting some ordinary sewing needles (the smallest he could find) into curved surgical needles to improvise. These "homemade" needles turned out to be quite satisfactory during the operation on a 13-year-old boy with tetralogy of Fallot (Fig 2;
the picture was taken 38 years after the operation when the grateful patient returned to visit the surgeon who saved his life).
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Fig 2. The patient who underwent the first Blalock-Taussig procedure in China visited Dr Shih at Zhong-Shan Hospital in Shanghai 38 years later. (Courtesy of Dr Shih Mei-Hsin.)
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Over the next few years Shanghai as the largest city in China witnessed many breakthroughs in cardiovascular surgery (Table 1). Lan Xi-Chun (previously spelled as Lan Hsi-Ch'un) and his team at the Shanghai Second Medical College performed the first closed mitral commissurotomy (using the index finger through the left atrial appendage) in February 1954, which marked the beginning of intracardiac surgery in China. Within a year they were able to report their experience in 32 patients with only 1 death (secondary to cerebral embolism) [7].
In the meantime Fu Pei-Bing and associates [8] at Guang-Ci Hospital of the Shanghai Second Medical College excised a huge syphilitic aneurysm of the innominate artery (with a diameter of 15 cm) on October 13, 1955. To connect the right internal carotid artery to the left subclavian artery they had to implant two pieces of arterial homografts as no single available graft was adequate in length. The operation lasted more than 13 hours. The 49-year-old patient was able to sit up and talk comfortably within a day after surgery. However the patient died suddenly on postoperative day 15 while he was having dinner. The autopsy showed rupture at the anastomosis of the homograft to the left subclavian artery [8]. Seven months later this group of surgeons performed another operation on a 38-year-old man with a similar pathology. They waited more than a month for the suitable arterial homografts, which had been stored in the modified "Tyrode" solution for 3 days before the operation. The surgeons certainly had learned from their experience as this operation went uneventfully and was 4 hours shorter than the previous one. The patient was successfully discharged home weeks later after having finished a full course of antisyphilitic therapy [8].
In January 1957 Liang Qi-Chen and Wang Yi-Shan at Ren-Ji Hospital of the Shanghai Second Medical College did the first two cases in China of pulmonary valvotomy for stenosis under direct vision using hypothermia (28 to 30°C) without extracorporeal circulation [9]. One of the patients underwent a closed pulmonary valve dilatation (through the right ventricle using the Brock valve knife) 2 and a half years earlier by the same group of surgeons. However her pulmonary valve became stenotic again within months. The patient had sustained relief of symptoms after the second operation [9].
On April 10, 1958, Shih and colleagues closed an atrial septal defect (ASD) under moderate hypothermia at 30°C on a 21-year-old student. This first direct repair of ASD in China lasted 7 minutes and 15 seconds, without the use of cardiopulmonary bypass (CPB). By the end of 1959 Shih's group had collected a series of 20 patients who underwent this operation. All patients except 1 survived the operation and remained in excellent condition on follow-up [10].
Although one of the ASD repairs in Shih's series [10] was eventually done with the use of heart-lung machine, the first successful open heart operation under CPB in China was performed a few months earlier by another group of surgeons in Xi'an.
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First cardiopulmonary bypass procedure in China (1958, Xi'an)
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Doctor Su Hong-Xi (Fig 3)
was born in 1915. He graduated from the Medical College of National Nanjing Central University in 1943 (the same year as Shih Mei-Hsin) in Chengdu, the neighbor city of Chongqing. He served more than a year in the war before returning to his university to complete his surgical training. After his chief residency year, Su was sent to the United States in 1949 for further training in thoracic and cardiovascular surgery. He spent the next 7 years in Chicago at Northwestern University and the University of Illinois. During this period Su not only personally experienced the rapid development of cardiac surgery but also met Jane H. McDonald, who was to become his wife.
During his visit to the University of Illinois Su had a chance to participate in the experimental studies on extracorporeal circulation. This experience had a tremendous impact on his future career and life. He used up his own savings to buy the expensive heart-lung machine and shipped it back to China in January 1957 for his use upon returning home [11]. Under the political circumstances at the time the return journey to China for the young couple was not straightforward. Pretending to be a tourist, Jane flew through Canada to England. Meanwhile Su spent a week on a British ship crossing the Atlantic Ocean. The couple met again in Liverpool and finally arrived together in Beijing 5 weeks later at the end of February 1957. Mrs Jane Su (known to many Chinese friends as "Su Jane") spent the next few decades in China with her husband and played a strong supporting role in his career.
Su became the chief of cardiovascular surgery at the Fourth Military Medical University (former Medical College of National Nanjing Central University) in Xi'an, where the animal research project on extracorporeal circulation began in July 1957. In total Su and his colleagues performed various procedures under CPB in 168 dogs with an overall survival rate of 76%. This preceded the clinical application of a newly learned technique.
On June 26, 1958, 5 years after John Gibbon's landmark operation, Su and his team set out to close a VSD on a 6-year-old boy (Fig 4, A) under CPB [12]. However an unexpected event happened. Convulsions suddenly developed in the patient just when the cannulas were inserted into his right atrium. As such an unforeseen convulsion was considered due to fever resulted from high room temperature and heavy surgical drapes (air-conditioning did not exist then) the decision was made not to abandon the procedure. The convulsion subsided as soon as the patient went on CPB. Naturally the success of this operation (Fig 4, B) hit the headlines in more than 40 newspapers across China.
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Fig 4. (A) The patient who underwent the first cardiopulmonary bypass procedure in China in 1958 (inset) and in 1998 (with his wife and daughter). (B) Doctor Su (second from left) and colleagues at the operation, including Dr Liu Wei-Yong (third from left). (Courtesy of Dr Liu Wei-Yong.)
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Within a month Gu Kai-Shi and his associates [13] at Shanghai Chest Hospital also performed a surgical correction of congenital right ventricular outflow tract obstruction under CPB. This operation marked the first clinical use of an entirely Chinese made heart-lung machine. Their extracorporeal circuit consisted of a roller pump and a bubble oxygenator (Fig 5),
which was designed by the surgeons at the Shanghai Chest Hospital and produced by the Shanghai Medical Equipment Factory [13]. The continued collaboration between these two teams soon led to another important accomplishment—a Chinese-made mitral valve dilator. This device was first used clinically in December 1960 by Gu Kai-Shi and colleagues to perform the closed mitral commissurotomy through the left ventricle for the first time. This novel approach rapidly gained wide popularity in China [14].
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Fig 5. The first Chinese made heart-lung machine used at Shanghai Chest Hospital in July 1958. (Courtesy of Shanghai Chest Hospital.)
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In the ascendant (1959 to 1966, Shanghai and Beijing)
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By the end of 1959 hundreds of direct vision intracardiac operations under hypothermia without the use of CPB had been performed at 30 hospitals in 13 provinces across China, although the majority of such cases (with a small number of CPB procedures) were carried out in Shanghai and Beijing [15].
Several milestones in the history of cardiovascular surgery in China were linked with Shanghai over this period (Table 1). From August 1957 through February 1960, Gu Kai-Shi and his team [16] performed different types of aortic aneurysm repair in 17 patients (ascending 4, arch 7, descending 5, and abdominal 1), remarkably with 14 survivors. Using temporary left heart bypass followed by a temporary shunt of synthetic vascular prosthesis between the ascending and descending aorta (Fig 6),
Shih Mei-Hsin and colleagues [17] did two cases of complete resection of the syphilitic aortic arch aneurysm with homograft replacement in July and September of 1959. Both aortic arch homografts were stored in liquid nitrogen and supplied by the surgical colleagues at Guang-Ci Hospital in Shanghai. Unfortunately the first patient died 3 days later owing to respiratory failure (ventilators were not widely available then) [17].
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Fig 6. A temporary shunt of vascular prosthesis between the ascending and descending aorta for resection of an aortic arch aneurysm with homograft replacement in 1959. (Reprinted from Shih MH, et al, Chin Med J 1960;8:505–13 [17], [16]with permission.)
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Meanwhile another locally made heart-lung machine was applied clinically in 1959, once again the result of the collaboration between six hospitals and six factories in Shanghai. A vertical screen oxygenator was developed (Fig 7)
in combination with the use of a roller pump. After more than a year and in total 191 animal experiments, the first case was carried out at Zhong-Shan Hospital in Shanghai on September 21, 1959. In the next 10 weeks, 9 of 11 patients with congenital cardiac defects survived direct intracardiac repairs under CPB [18]. Using this device Shih and associates performed complete correction of tetralogy of Fallot in December 1959 and repair of ruptured sinus of Valsalva in January 1960 [19].
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Fig 7. The heart-lung machine used in 1959 at Zhong-Shan Hospital in Shanghai. (Courtesy of Dr Shih Mei-Hsin.)
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Two years later Feng Zhuo-Rong and colleagues at Shanghai Chest Hospital excised a left atrial myxoma from a patient under CPB [20], about 7 years after a similar operation was first described by Crafoord and others. This 48-year-old man was initially diagnosed to have mitral stenosis and underwent a closed mitral commissurotomy through a left thoracotomy on November 27, 1961. However a mobile soft tissue mass was felt as soon as the surgeon's index finger entered the left atrium, while the patient's mitral valve appeared normal on palpation. Realizing it was a left atrial myxoma, the operation was then abandoned as no CPB device was prepared. A redo operation was later performed on January 24, 1962. A 5 x 4 x 3 cm myxoma was successfully excised under CPB through a right hemiclam shell incision (the left pleural cavity was not entered this time) [20].
Another important breakthrough occurred in June 1965 when Cai Yong-Zhi and associates at the Second Military Medical University in Shanghai performed the first successful mitral valve replacement with a locally made ball and cage mechanical prosthesis [21], 5 years after the world's first mechanical heart valve implantation. This event marked the beginning of the era of valvular replacement in China.
Over the same period of time a relatively new hospital in Beijing started to attract attention. Founded in 1956 [3], Fu-Wai Hospital grew to become the biggest cardiovascular center in China. Intracardiac operations under hypothermia without CPB (Fig 8)
such as repairs for atrial and ventricular septal defects and pulmonary commissurotomy had been conducted since early 1958 at Fu-Wai [22]. Using this hypothermic approach Hou You-Lin (Fig 9)
and colleagues performed the first direct mitral valve repair for regurgitation in China in September 1958 and aortic valve commissurotomy in March 1959 [22, 23]. They also successfully repaired a ruptured sinus of Valsalva under hypothermia before their "homemade" CPB device became available [22, 23]. The CPB pump initially used in Fu-Wai Hospital (Fig 10)
was designed by a group of investigators at the Chinese Academy of Medical Sciences, with a modified Dewall-Lillehei bubble oxygenator made in the same hospital by the anesthetists and the technicians. After experimentation on more than 100 animals the device was first utilized clinically in late 1959. However, they soon switched to use the Shanghai heart-lung machine in the 1960s. A total of 3,021 CPB cases had been performed at Fu-Wai Hospital using only this type of device (which was later modified) until 1980, when the more sophisticated CPB equipments from the United States or Europe then became available [24].
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Fig 8. Whole-body cooling during a hypothermic open-heart operation at Fu-Wai Hospital in 1958. (Courtesy of the Chinese Academy of Medical Sciences.)
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Fig 9. Doctor Hou You-Lin (first from right), the founding Chairman of the Department of Cardiac Surgery, Fu-Wai Hospital, Beijing.
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Fig 10. The heart-lung machine used in late 1959 at Fu-Wai Hospital, Beijing. (Courtesy of Dr Xiao Ming-Di.)
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Striving against the stream (1967 to 1980)
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During the first few years of the "cultural revolution" period (1967 to 1976), cardiovascular surgery in China came to a complete halt. However, by the early 1970s cardiac surgery reemerged in a few major centers in Beijing, Shanghai, Xi'an, Guangzhou, and Shenyang [25].
At Fu-Wai Hospital in Beijing, Guo Jia-Qiang and colleagues performed the first resection of postinfarction ventricular aneurysm in 1972 and the first coronary artery bypass operation using saphenous vein as graft conduits in October 1974 [22]. After more than 4 years of experimental study, Zhu Xiao-Dong and Guo Jia-Qiang performed the first aortic valve replacement with a bovine pericardial prosthesis made in Fu-Wai in May 1976, which marked the use of tissue valve in China [23]. Over the following year Luo Zheng-Xiang and his team from Guangzhou also reported their clinical experience of porcine valve implantations [25]. Soon after, Cai Yong-Zhi and coworkers from Shanghai and Lanzhou successfully developed the first entirely Chinese made single-leaflet disk prosthesis (the "C-L valve") in 1978 [14]. As valvular replacement operation gained momentum there were 2,051 documented valves implanted (439 mechanical and 1,612 biological prostheses) between 1978 and 1982 in China [25].
For complex congenital heart surgery like the surgical correction of tetralogy of Fallot, however, the learning curve was steep. Between 1959 and 1979 the mortality rate at Fu-Wai Hospital was prohibitively high by today's standard at 32%, which later dropped to 11% between 1980 and 1988, 5% from 1989 to 1990, and less than 3% from 1991 to 1995, in a total of 2,896 cases [23]. The best published result of this procedure before 1979 in China came from Wang Zeng-Wei and his colleagues at the Army General Hospital in Shenyang. They reported 150 cases with a mortality rate of 6% in 1979 (for the 82 patients who underwent surgery in 1978, the mortality rate was only 2.4%) [25].
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The dawn of a new era (1981 onward)
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A total of 6,444 open-heart operations were recorded in China for the year of 1982. The number increased to about 15,000 cases a year by 1990 [26]. In 1999 cardiac surgical programs were available in more than 600 centers in China. Among them more than 50 centers have a workload of more than 250 cases a year. The number of annual open-heart operations is more than 500 in some 20 centers in China and the highest workload remains at the Fu-Wai Hospital in Beijing. For example, in the year 1997 there were 3,856 cardiac operations performed at this institution [26].
Although by now valvular replacement is theoretically available at every hospital with a cardiac surgical program in China, this procedure is concentrated in centers from the major cities. For instance, large series of valvular replacements were reported in 1997 in 3,656 patients at Chang-Hai Hospital of the Second Military Medical University in Shanghai and in 4,960 patients at Fu-Wai Hospital in Beijing (the overall mortality was less than 6% in both series) [14]. Owing to the high incidence of chronic rheumatic heart disease in China, about 30% of the patients received multiple valvular replacements [14]. However, more complex operations such as the Ross procedure or homograft implantations are only available in a few centers. New types of tissue valves or mechanical prostheses are under development in Beijing, Xi'an, Shanghai, Guangzhou, and Chengdu.
The development of coronary surgery in China was somewhat slow until recent years. According to a survey conducted by the Chinese Society for Thoracic and Cardiovascular Surgery, only five centers in 1998 had annual numbers of coronary artery bypass graft (CABG) operations greater than 50 while there were about 1,000 CABG operations performed that year [27]. From 1996 through 2000, Wu Qing-Yu and Hu Sheng-Shou and their colleagues at Fu-Wai Hospital performed the largest series of CABG operations in China (n = 2,315) with an early success rate of 98.7% [27, 28]. In 2002 this team did 1,034 CABG operations with an overall mortality rate of 0.97% [29]. With the maturation of the younger generation of Chinese cardiac surgeons, complete arterial grafting and off-pump beating heart CABG have also rapidly gained their popularity in China.
Open-heart surgery for children younger than 2 years of age was first conducted by Ding Wen-Xiang and colleagues at Xin-Hua Hospital of the Shanghai Second Medical College in 1974 [25, 26]. In early 1990s they summarized their experience in surgical correction of transposition of great arteries using either the Senning operation [30] or the arterial switch operation [31]. From 1973 through 1988 Wang Zeng-Wei and his associates at Army General Hospital in Shenyang performed 1895 complex congenital cardiac operations in 1880 patients with tetralogy of Fallot, Ebstein malformation, double-outlet right ventricle, univentricle and tricuspid atresia, transposition of great arteries, and so forth [32]. The overall surgical mortality in this group of patients was 4.0% [32]. They also reported the first series (n = 14) in China of total cavopulmonary connection for complex Fontan operations [33]. In 1977 Liu Wei-Yong and colleagues at Xi-Jing Hospital of the Fourth Military Medical University in Xi'an (the previous unit of Su Hong-Xi) developed a prosthetic conduit containing a locally made porcine valve. They first used this conduit in the surgical correction of double-outlet right ventricle and transposition of great arteries in early 1979 [34]. This group of surgeons also successfully operated on two patients with left ventricular outflow tract obstruction in March 1983 using a similar apicoaortic valved composite conduit [35].
In October 1977, long before cyclosporin A was widely available, Zhang Shi-Ze and associates at Rui-Jin Hospital of the Shanghai Second Medical College were preparing to begin a new adventure. A total of 30 orthotopic and six heterotopic heart transplantations were done in animals by this group of surgeons over a 6-month period. Subsequently they performed the first clinical orthotopic heart transplantation in China on April 21, 1978 [36]. The donor was a 23-year-old victim of road traffic accident who arrived in the same hospital with irreversible brain injury. The 38-year-old recipient who had end-stage heart failure due to chronic rheumatic valvular disease survived 109 days [36]. In the following decade at least five additional cardiac transplant procedures were carried out in China and none of these recipients had a longer survival. Despite this setback, others were not deterred. In 1992 Chen Bao-Tian and colleagues at An-Zhen Hospital in Beijing, Xia Qiu-Ming and associates at the Harbin University Hospital, and Liu Xiao-Cheng's team at Mudanjiang Cardiovascular Institute independently restarted their heart transplantation program with much improved results [37, 38]. In December 1992 Liu Xiao-Cheng and colleagues also performed the first heart-lung transplantation in China [39]. By the end of 1999 approximately 130 heart and nine heart-lung transplantations had been accomplished in more than 35 centers in China [37]. Among the heart transplantation recipients, the longest survivor has remained well for 10 years [37]. On a separate note, the first clinical implantation of a heterotopic heart with long-term survival in China, as well as in Asia, was carried out in Taiwan by Chu Shu-Hsun and coworkers in 1988 [40].
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Concluding remarks
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The trend of time makes one a hero. Chinese idiom
The great difficulty in establishing a new surgical subspecialty has been universally recognized and cardiovascular surgery was no exception. On top of various technical obstacles, socioeconomic factors could also significantly influence the whole process. The development of cardiovascular surgery in Europe was slowed down by the tragedy of World War II [41]. Compared with the United States and Europe, the growth of cardiovascular surgery was even more difficult in China over the first few decades after World War II under the ever-changing political and harsh socioeconomic conditions. This article presents a few interesting frames from a movie of the unique history of cardiovascular surgery in China. In view of the rising incidence of cardiovascular diseases worldwide, the struggle to establish our specialty in a country with more than one fifth of the world population is certainly one of the most important challenges in the last century. Through the continued perseverance, dedication, and hard work of many individuals working together the evolution of cardiovascular surgery is still ongoing in China with the expectation that this progress will accelerate with improvement in the country's economy. However, we should never forget it was the bold ventures of those pioneers that brought us to where we are today.
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Acknowledgments
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We are sincerely grateful to Professor Shih Mei-Hsin (Shanghai Medical University, Shanghai), Professor Liu Wei-Yong (Fourth Military Medical University, Xi-Jing Hospital, Xi'an), Professor Yu Yi-Fei (301 PLA General Hospital, Beijing), Professor Xiao Ming-Di (Shanghai First People's Hospital, Shanghai), and Dr Long Cun (Cardiovascular Institute of Chinese Academy of Medical Sciences, Fu-Wai Hospital, Beijing) for their valuable advice and generous help in providing some of the photographs used in this article.
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Abstract
Introduction
