Ann Thorac Surg 2003;76:S2188-S2194
© 2003 The Society of Thoracic Surgeons
Supplement: Gibbon & His Heart-Lung Machine
John Gibbon and the heart-lung machine: a personal encounter and his import for cardiovascular surgery
Michael E. DeBakey, MDa*
a Chancellor Emeritus, Olga Keith Wiess and Distinguished Service Professor, Michael E. DeBakey Department of Surgery, Director, DeBakey Heart Center, Baylor College of Medicine, Houston, Texas, USA
* Address reprint requests to Dr DeBakey, Baylor College of Medicine, One Baylor Plaza, 6565 Fannin St, Houston, TX 77030, USA
e-mail: mdebakey{at}bcm.tmc.edu
Presented at the symposium, "Gibbon & His Heart-Lung Machine: 50 Years & Beyond," Philadelphia, PA, May 2, 2003.
I am privileged to have been invited to participate in this Golden Anniversary of the development and first successful clinical use of the heart-lung machine, and I am especially touched to be able to honor Dr Gibbon's memory. He was not only a friend but also an inspiration to me.
I had the pleasure of meeting Dr Gibbon for the first time in the 1930s at a medical meeting, and he later invited me to his laboratory to discuss the experimental work he was then doing on the heart-lung machine using cats. He noted that one of the mechanical problems he encountered was the pump; he was dissatisfied with the one he was using. He had devised a pump himself and had used the Dale Schuster pump for perfusion, but these were simply not adequate for his purposes. When I was a medical student at Tulane University School of Medicine, I had the privilege of working as a technician in a research laboratory. The faculty member under whom I was working was interested in a pump that he could use to study the pulse wave, and he asked me to find such a pump. As a medical student, I had no knowledge of pumps, but I felt a responsibility to fulfill my assignment. I went to the medical library in search of existing knowledge about pumps, but I felt I needed more information. Then I remembered that one of my freshman classmates in the Tulane College of Arts and Sciences decided to study engineering. We had become good friends during college, and when he went into engineering and I went to medical school, we continued to see each other at lunch or dinner about once every week or two. Shortly after my assignment to find a pump, I met him and mentioned my frustration. He pointed out that I had gone to the wrong library and directed me to the one in the engineering school, where, he said, I would find a great deal about pumps. I immediately went to that library and found that people had been working on pumps for more than 2,000 years, dating back to Archimedes, who developed a pump for irrigation purposes (similar in principle to an axial flow pump, to which I will refer later).
As a consequence of my library experience, I developed the roller pump. When I became a resident at the Charity Hospital in New Orleans, we used direct blood transfusions (there were no blood banks at the time), and I used this pump quite successfully for that purpose [1]. And so when I met Dr Gibbon, I suggested that he might try this pump. I then sent him a model of my roller pump, which he subsequently incorporated into his heart-lung machine. In some of his articles, he graciously referred to obtaining the roller pump from me [2]. And that is how it became an integral component of the heart-lung machine.
I would like to comment on some other aspects of Dr Gibbon's contribution because it had a much more profound effect than the mere construction of a mechanical pump for temporary replacement of the function of the heart and lungs. Once he showed successfully that it could be used for that purpose, that success had a profound impact on the medical community, particularly on researchers who were interested in the cardiovascular field. In a way, he blasted open the door that had been locked for centuries against any medical therapeutic intrusion into the cardiovascular field, and he thus helped greatly to stimulate the developments in the past half century that have provided us the satisfying experience we have today in dealing with cardiovascular problems. Not that we have completed that process by any measure. After all, we still do not know the real cause of arteriosclerosis, although we do know a great deal more about how to deal with it and with other forms of cardiovascular disease because of the door he opened. That, I think, is the most important aspect of his contribution. The mechanical part was, of course, also important, but he stimulated the imagination of other researchers, and his contribution certainly had a great impact on me. In this connection, it is of interest that Dr Gibbon, in his Presidential Address before the Society for Vascular Surgery in 1965, recognized some aspects of this impact by choosing with admirable insightfulness to discuss the artificial intracorporeal heart [3], a device that has since received increasingly intensive investigation.
I have selected a series of illustrations to show Dr Gibbon's impact from my standpoint, because it also illustrates the impact on many others. Figure 1
is an autographed photograph he kindly gave me. This quotation from one of his early articles projects a vision that led to the event of half a century ago that we are celebrating today—one of the truly great sagas of medical research in the history of medicine: "Our objective was to determine whether the circulation could be temporarily aided by mechanical means in the presence of an obstruction of the pulmonary artery" [4]. The idea of this young resident watching the patient die and thinking about what could be done and then dedicating the rest of his life to achieving that objective—that is unarguably one of the great stories of inspiration in the history of medical research.
Figure 2
shows an early version of Dr Gibbon's heart-lung apparatus before incorporating the roller pump. The roller pump that I developed consisted of a half-circle metal housing incorporating a flanged rubber tube with two rollers for compression (Fig 3) [1]. The pump I provided to the Tulane faculty member when I was a medical student was not as elegant as this one, which I gave Dr Gibbon for the heart-lung machine, but it proved useful in transporting blood at a time when we did not have effective anticoagulant agents, and the blood therefore had to be transported rapidly. With this pump, I could easily transfuse 5 or 6 L per minute, if necessary. It usually took me about 2 or 3 minutes to transfer 500 mL from a donor to a patient. In response to physicians' requests, I used to go to several hospitals in New Orleans to perform transfusions because I was the only one who had this pump. Before that, there were a number of other devices [5]. Percy [6], in 1915, for example, had created a device that he used as a glass vessel and that was lined with paraffin, to diminish clot formation. Of course, once we had blood banks, we no longer needed the pump. It served its purpose, however, for the heart-lung machine, even though at the time I developed it, I had no idea that it would one day be used for that purpose.
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Fig 2. Photograph taken in Dr Gibbon's laboratory, showing an early version of his heart-lung machine. (Courtesy of J. H. Gibbon, Jr. Reprinted with permission from Gibbon JH et al. Arch Surg 1937; 34:1109.)
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The autographed photograph of the operation 50 years ago, which we are now celebrating, shows the kind of friendship Dr Gibbon extended to me (Fig 4).
He wrote the inscription to me on this photograph himself and signed it: "Dear Mike, A picture of the first successful open-heart operation with complete bypass of heart and lungs May 6, 1953, Jefferson Hospital, Best wishes, Jack." It expresses the admirable character of this man, a true gentleman, his dedication and his unrelenting efforts to achieve his objective. The remarkable combination of all these qualities with his astute intellect is a constant source of inspiration to anyone who was privileged to know him.
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Fig 4. Autographed photograph of operating room scene during first successful use of the Gibbon heart-lung machine.
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In this connection, I would like to relate another example of my high esteem and warm friendship for Dr Gibbon. Some 3 decades ago, friends, colleagues, and former students of Dr Gibbon established the John H. Gibbon, Jr, Lecture at the annual meeting of the American College of Surgeons. I was invited, at the recommendation of Dr Gibbon, to give the first lecture, which I stated at that time was—and still is—considered a great honor. The following quotation from that lecture evinces my assessment of his contributions as an impressive sage in the field of cardiovascular endeavor: "One of the most impressive evidences of the role of investigative surgery in the history of medicine is the persevering efforts of Dr Gibbon for more than 20 years, which finally culminated in a practical heart-lung machine" [7].
When Dr Gibbon came to Baylor College of Medicine as our Visiting Professor, he was given a plaque (Fig 5).
His charismatic personality had a tremendous impact on our residents. Another illustration of my relationship with him, which I truly treasure, can be seen in Figure 6.
I was Chairman of the Lasker Jury that selected him for the Lasker Award for Clinical Research, one of the most prized awards for American medical researchers, often referred to as the American Nobel Prize. The photograph shows Mary Lasker, who founded the Award, and I also had the pleasure of being with him when he received this Award in 1968. The citation used for this award is worth noting: "The vast impact of Dr Gibbon's discovery on medical sciences 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 and cure of human disease."
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Fig 5. Photograph showing plaque given to Dr Gibbon on the occasion of his Baylor Visiting Professorship.
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Fig 6. Photograph during presentation of 1968 Albert Lasker Award showing Michael E. DeBakey, Lasker Jury Chairman, Mary Lasker, and John Gibbon, Lasker Awardee in 1968.
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During the early period of the use of the heart-lung machine, a number of important and instructive observations were made that had significant consequences. This is illustrated by a patient in heart failure from severe aortic valve disease in whom I replaced the aortic valve with the use of the heart-lung machine [8]. As the illustration shows, after completing the operation, we began trying to wean the patient off the heart-lung machine (Fig 7).
Our first attempt was a failure because the arterial pressure fell and the left atrial pressure rose, which indicated that the heart function was inadequate. It was therefore necessary to put the patient back on the heart-lung machine, after which her arterial pressure rose and the left atrial pressure fell. On our second attempt to wean the patient off the heart-lung machine, the same sequence of events occurred, necessitating re-use, of the heart-lung machine. On the final occasion, the patient was much more slowly weaned off the heart-lung machine over a period of about 90 minutes, and that proved successful as the heart was able to maintain adequate output. That was an experience that many cardiac surgeons had in the early clinical use of the heart-lung machine, and we still do to some extent, although we have better methods today to deal with it.
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Fig 7. Drawing showing use of heart-lung machine to assist patient's failing heart following aortic valve replacement.
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Unfortunately, not all patients who have this experience survive. That led to the search for other methods of more prolonged support of the failing heart for days or weeks in order to give the heart more time to recover, culminating in the concept of the ventricular assist device (VAD). In the 1960s, in collaboration with the School of Engineering of Rice University, we began working on that concept, using various experimental models that we developed in the laboratory (Fig 8).
After several years of experimental studies with this device (Fig 9),
establishing its efficacy and safety in calves, we used it successfully in a patient for the first time in 1966 [8]. This patient had developed heart failure from severe aortic and mitral valve disease. After surgical replacement of both valves with use of the heart-lung machine and despite prolonged support with that device, it was not possible to wean the patient off it. We then used our ventricular assist device, whose supplemental use provided adequate cardiac output and permitted removal of the heart-lung machine (Fig 10). We used the ventricular assist device to support the patient's heart for a little more than 10 days. Since this was our first clinical experience with use of this pump, there were times when we were trying to get the patient off the pump as quickly as we could, but she would develop heart failure, and we would have to put her back on the pump. It was indeed interesting and impressive how quickly, after putting her back on the pump, the left atrial pressure and her blood pressure stabilized. She was able to get out of bed several days after operation (Fig 11).
Finally, after 10 days we were able to take her off the pump. We discontinued the pump function for about 6 hours, and when she remained stabilized, we removed the pump. She resumed normal activity, and when I saw her 1 year later, her heart function was relatively normal (Fig 12).
Tragically, she was killed in an automobile accident 6 years postoperatively, but she had led a perfectly normal life after the operation.
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Fig 8. Drawing showing experimental model of ventricular assist device, consisting of an outer rigid structure with two chambers, a blood chamber and an air chamber, with a diaphragm separating the two that could be compressed to force the blood out with valves that allowed for unidirectional flow so oxygenated blood came from the left atrium and was then pumped into the aorta by connection of the outflow graft to the left axillary artery.
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Fig 9. Photograph of a calf showing the extracorporeal ventricular assist device attached to the left thorax in the experimental laboratory.
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Fig 10. Drawing showing method of connecting left ventricular bypass pump to left atrium for in-flow and to right axillary artery for out-flow.
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Fig 11. Photograph showing patient out of bed on fourth postoperative day with the extracorporeal ventricular assist device. (Reprinted from DeBakey ME, Left ventricular bypass pump for cardiac assistance, Am J Cardiol 1971;27:5. Used with permission of Excerpta Medica, Inc.)
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The success of this procedure was extremely encouraging in much the same manner as the impressive success of the heart-lung machine used by Dr Gibbon a half century ago. That is a direct result of the impact John Gibbon had on us, as well as on other investigators interested in this kind of research.
In 1984, I had an opportunity to do a heart transplant on an engineer from the NASA Johnson Space Center (JSC) in Houston, Texas, who became interested in our experimental work on the artificial heart. Because of my earlier experience with the engineering community, I suggested that he and some of his associates might be interested in helping us in our research. He found some hydraulic engineers at the NASA Johnson Space Center in Houston who were also interested in working with us on their own time. I showed them some of the ventricular assist models we had developed in the laboratory, and I explained to them that we needed something much smaller than the bulky devices we had that would have similar output of 5 to 10 L per minute. As a result, they helped us develop a ventricular assist device, using the axial flow principle (Fig 13).
The pump consists of a flow tube measuring 68 mm long and 24 mm wide, within which there is an inducer-impellor, the only moving part, with a brushless motor stator set around the middle of the flow tube where the impellor is located [9]. Rare earth magnets, imbedded in the blades of the impellor, act as the rotor of the brushless motor and make the impellor spin in a magnetic field. The pump is capable of producing a flow of 5 L/min against 100 mm Hg pressure, with the inducer-impellor spinning at about 10,000 rpm, requiring less than 10 W of input power (Fig 14)
[9]. The licensing for the industrial production of this pump was obtained by MicroMed Technology, Inc, of Houston, Texas, which provided additional technologic development for its clinical application.
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Fig 13. Drawing showing the structure of the axial flow ventricular assist device developed with the collaboration of NASA engineers at the Johnson Space Center.
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Fig 14. Photograph of the MicroMed DeBakey Ventricular Assist Device showing inflow tube on right and outflow Dacron graft with flow meter on left.
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The efficacy and safety of this pump were demonstrated in calves with implant VADs for up to 6 months, and its clinical application, investigated first in European cardiovascular centers, provided data for its clinical approval in Europe. After surgical implantation of the VAD in the patient, the electrical connection is brought out subcutaneously through a small incision in the lower right abdominal wall to be connected to the controller and batteries, which the patient may carry in a shoulder bag or by attachment to a belt (Fig 15).
At present, it is being used as a bridge-to-transplant in this country under Food and Drug Administration guidelines (Fig 16).
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Fig 15. Drawing showing method of implantation of pump with connection to extracorporeal controller and batteries supported on belt or carried on shoulder pack.
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Fig 16. Roentgenogram of the chest of a 32-year-old woman with dilated cardiomyopathy showing the position of the ventricular assist device with the inflow tube in the left ventricle and the outflow graft to the ascending aorta. This patient later had a successful heart transplant.
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Two patients in Berlin who have been on the pump for between 1 year and 2 years have asked to be taken off the heart transplant list. They are perfectly happy, leading a normal life with the implanted pump. It has been impressive to observe the restoration of physical activity in these bedridden patients after installation of the ventricular assist devise. That is exemplified by a young patient with cardiomyopathy in Vienna who was on the heart transplant list and could not get out of bed before the VAD was implanted. Not long after its implantation, the patient was able to climb the steps to the top of the St. Stephen Cathedral (Fig 17).
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Fig 17. Photograph showing patient with the MicroMed DeBakey Ventricular Assist Device after climbing the 346 steps to the top of the St. Stephen's Cathedral in Vienna. This patient has since had a successful heart transplant.
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The recently published report of the data from the Rematch Study clearly indicates that patients with irreversible heart failure may be greatly improved by implantation of a ventricular assist device [10]. I have previously stated, and am now more strongly convinced, that such a ventricular assist device has great clinical potential in the therapeutic regimen of patients with irreversible heart failure [9].
Finally, of interest is this quotation from an article written by the late Lewis Thomas, who was obviously not very apt at prophecy. He virtually denied that the artificial heart would ever have any useful purpose: "The artificial heart could, with better science and a lot of luck, turn out to be, one day or other, an interesting kind of antique, similar in its historical significance to the artificial lung and the other motor-driven prosthetic devices that were in the planning stage just before the development of the Salk vaccine and the virtual elimination of poliomyelitis" [11].
In closing, I would like to express my great pleasure again to be here to pay tribute to a man who, I think, has placed himself among the noblest contributors to the advancement of medicine, one we can be proud of, and one who will remain an inspiration to all of us and to all those who come after us in medicine and in medical research.
References
- DeBakey M.E. A simple continuous flow transfusion instrument. New Orleans Med Surg J 1934;87:386.
- Miller B.J., Gibbon J.H., Gibbon M.H. Recent advances in the development of a mechanical heart and lung apparatus. Ann Surg 1951;134:694.[Medline]
- Gibbon J.H. The artificial intracorporeal heart. Surgery 1966;59:1-5.[Medline]
- Gibbon J.H. Artificial maintenance of circulation during experimental occlusion of the pulmonary artery. Arch Surg 1937;34:1105-1137.
- Kilduffe R.A., DeBakey M.E. The blood bank and the technique and therapeutics of transfusions. . St. Louis: CV Mosby, 1942.
- Percy N.M. A simplified method of blood transfusion with report of 6 cases of pernicious anemia treated by massive blood transfusion and splenectomy. Surg Gynecol Obstet 1915;21:1360.
- DeBakey ME. Presentation of John H. Gibbon, Jr., Lecture. The impact of the development of the heart-lung machine in medicine. American College of Surgeons, 1971
- DeBakey M.E. Left ventricular bypass pump for cardiac assistance: clinical experience. Am J Cardiol 1971;27:3-11.[Medline]
- DeBakey M.E. Development of a ventricular assist device. Artif Organs 1997;21:1149.[Medline]
- Rose E, et al. Rematch study group: long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435
- Thomas L. Late night thoughts on listening to Mahler’s ninth symphony. New York: The Viking Press, 1983.
This article has been cited by other articles:
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M. E. DeBakey
Development of Mechanical Heart Devices
Ann. Thorac. Surg.,
June 1, 2005;
79(6):
S2228 - S2231.
[Abstract]
[Full Text]
[PDF]
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