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Ann Thorac Surg 2003;76:S2197-S2198
© 2003 The Society of Thoracic Surgeons
* Address reprint requests to Ms Fraser, 2984 Tusket Ave, North Port, FL, USA 34386.
Presented at the symposium, "Gibbon & His Heart-Lung Machine: 50 Years & Beyond," Philadelphia, PA, May 2, 2003.
May 6, 1953 could very well be one of the most significant dates in medical history. On this day 50 years ago, Dr John H. Gibbon, Jr, performed surgery at Philadelphia's Jefferson Hospital on a young woman in what was the world's first successful open heart operation using a mechanical heart-lung device on a human being.
In 1953 this patient was a 17-year-old college student in Wilkes-Barre, Pennsylvania, who had a congenital heart defect: a hole the size of a half dollar in the wall between the two upper chambers of the heart. She came in for regular follow-up for years and I had the chance to meet her during those visits as a nurse/perfusionist here at Jefferson. In 1978, about 25 years after her surgery, I lost track of her but up until that time she was living a healthy life working as a secretary in Philadelphia. At about this time I remember an article in the Philadelphia Bulletin, which was the evening paper at that time, in which she was quoted as saying she always had a youthful hunch or teenager's intuition that her surgery would be a success. She felt it would go her way with Dr Gibbon, his machine, and prayers.
In 1956–1957 I attended Hood College in Frederick, Maryland. From there I came to Jefferson Medical College School of Nursing from 1957–1960. While studying I met Sylvia Shopp, the head nurse of the cardiac operating room and I spent some time working in the dog laboratory where I met Dr Gibbon. Doctor Gibbon said to me one day, "What's a nice young girl from Friends Central [he had attended our sister school Penn Charter] doing cleaning out cages? You should study hard instead." In fact he often called me, "Hey, Friends Central!" So I did study hard and my fascination with the machinery continued for another 30 years.
After graduation from nursing school I went straight to the cardiac operating room. While working as a nurse at Jefferson I was also training with Drs Templeton and Bacharach in operating the heart-lung machine. I also learned a great deal about cardiac surgery and nursing from Sylvia. When Sylvia left to get married I became the head nurse/pumpist.
From 1960–1975 I had the honor of working with Dr Gibbon and his young associate, Dr John Young Templeton, first in the operating room as a scrub/circulating nurse, then as head nurse of that operating room, and finally from 1962 on as a nurse "pumpist" as we were then called. While the work was challenging, historical, and life changing for our patients, I also remember great times on such a close team, especially Christmas parties at Dr Gibbon's farm in Media.
The first Gibbon machine was a film oxygenator using a series of vertical screens. It was made to Dr Gibbon's specifications working with IBM. It required a large prime of whole fresh heparinized blood, which was donated from many donors (some 25 of them), mostly sleepy medical students who would line up in the hallway to donate the morning of surgery or some local donors and perhaps even the Red Cross. Those were the days when students really did have to bleed for their profession. The pump was primed and the oxygenator recirculated using the whole fresh blood. The machine was the size of a grand piano and there were hoses and lines everywhere. The water supply for the heat exchanger was behind the autoclaves in a room between operating rooms 3 and 4 in the Pavilion Building. As you can imagine people were walking and tripping over the lines and hoses constantly.
By the time I first used the Gibbon machine in the 1960s, there were many changes. The screens had been replaced by mylar coated aluminum sheets and the artificial lung was tailored to the patients surface area the night before. The larger the patient, the more sheets in the lung case and then of course it was all sterilized. Most of the reservoirs including the lung case were Lexan. The tubing connectors were highly polished stainless steel with very sharp edges. Some things remained the same however, as there were still hoses everywhere.
At the conclusion of bypass the machine had to be dismantled and cleaned. This process took several hours, even over night. Before a solution called Hemosol came along, each piece had to be soaked separately in plastic trays in order to avoid any harm to the highly polished surfaces that could cause blood aggregates to be delivered to the next patient. Some parts had to be first cleaned with large pipe cleaners. The lung required two men to lift it in and out of the sterilizer. The Lexan parts could not be autoclaved and had to be ethylene oxide sterilized, which was a large improvement for those times, however we didn't have any venting for the gas at the end of sterilization. This would hardly be acceptable to OSHA today. We were not yet in the age of disposables.
Others like Dr DeWall and Dr Lillihei were demonstrating that a simple bubble diffusion oxygenator could be effective for temporary cardiopulmonary byass. The first one of these that I saw clinically was the 3-L Travenol bag. It was a heavy duty plastic heat sealed helical device that we tied to a square shaped metal mast and taped to an intravenous pole. The venous blood came in the bottom of a long plastic sleeve. In the bottom of this sleeve were two nipples and an oxygen hose attached to an aquarium stone that made tiny bubbles in the venous blood. These tiny bubbles traveled up the sleeve and poured over stainless steel "tuffy" sponges covered with Dow-Corning antifoam. This mesh quite effectively debubbled the then oxygenated blood, and it flowed out into the arterial helix and was delivered to the patient through a bubble trap and double armature roller pump. If the patient had a large body surface area and one needed more than 3 L of flow, one simply hooked up two 3-L bags and used a parallel Y in the arterial and venous lines. The beauty of this oxygenator's concept was that it was mostly disposable, it didn't need a blood prime (it didn't need much prime at all if you tied it on the mast tight enough), drainage from the patient was by gravity not suction, and it could be set up and ready for use in an emergency. We had come a long, long way.
The next generation of oxygenators were also bubble oxygenators but they employed a hard shell and included a large surface area and an in-line heat exchanger. Often a sharp blow had to be given to the base of this oxygenator to remove the air lock and improve oxygenation.
At about this time the space program was developing a 20- to 40-micron filter to filter rocket fuel. Soon we had particulate matter filters and bubble filters in our pre-bypass set-ups, arterial lines, cardiotomy reservoirs, transfusion lines, and gas filters. That was one of the many benefits of the early space program.
In the late 1960s and early 1970s came the acceptance of the aortocoronary bypass graft procedure. It was this procedure's acceptance that greatly increased the number of open heart procedures. It also influenced a number of trends and innovations during this period. There was a growing emphasis on myocardial protection from ischemic damage and cardioplegia techniques began evolving using crystalline and blood perfusates and hypothermia to arrest the heart and decrease its need for oxygen.
Also there were some mechanical methods for circulatory support being used preoperatively and postoperatively. The intraaortic balloon pump began to be used frequently for patients with even marginally functioning left ventricles. Perfusionists then became very involved with intraoperative monitoring of biochemical changes during bypass. Blood gas monitoring ensured better surgical results as did heparin-protamine titration.
In the 1980s, 1990s, and today, the problems that remain are more complex ones related to prolonged perfusions. The physiologic and biochemical changes inherent in temporary cardiopulmonary bypass could be reduced but not eliminated entirely. The introduction of the new generation of disposable membrane oxygenators and centrifugal pumps that provide low indices of hemolysis have made left ventricular assist devices (LVADs) and extracorporeal membrane oxygenation (ECMO) procedures possible.
Extracorporeal perfusion has had its successes and failures since it was first proposed as isolated organ perfusion in 1813. Doctor Gibbon changed the emphasis in 1939 with his report to the American Association of Thoracic Surgery meeting when he described the survival of cats after they had undergone pulmonary artery occlusion and total cardiopulmonary bypass [1]. However the spectacular growth of cardiac surgery during the last 50 years is due primarily to the development of a reliable heart-lung machine that was capable of supporting total cardiopulmonary bypass. It was Dr Gibbon's spectacular machine that started this dynamic process.
References
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