Ann Thorac Surg 2004;77:1870-1873
© 2004 The Society of Thoracic Surgeons
Our surgical heritage
The first successful repair of postinfarction ventricular septal defect: influence of good fortune, team work, and an inquisitive mind
John W. Hammon, MDa*,
Jesse H. Meredith, MDb,
Timothy C. Pennell, MDb,
A. Robert Cordell, MDa
a Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA,
b Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
* Address reprint requests to Dr Hammon, Department of Cardiothoracic Surgery, Medical Center Blvd, Winston-Salem, NC 27157-1096, USA
e-mail: jhammon{at}wfubmc.edu
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Abstract
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Research in our institution identified the first case in which cardiopulmonary bypass was utilized. By happenstance, it turned out to be the presumed first repair of postinfarction ventricular septal defect. The circumstances of this interesting case are presented and discussed in the context of our surgical heritage.
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Introduction
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As we approach the anniversary of the first 50 years of using cardiopulmonary bypass, it was of great interest to me (J.W.H.) to look up the first case in our institution using cardiopulmonary bypass. With the help of one of my coauthors (J.H.M.), we found that the first case using cardiopulmonary bypass was performed on May 23, 1957, and resulted in the successful repair of a postinfarction ventricular septal defect. A search of the literature reveals that this procedure could have been the first successful repair of this particular defect, thus making it worthy of report.
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Case report
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A 59-year old man was diagnosed with an acute anterior myocardial infarction in November of 1956. He was treated in his community hospital in Thomasville, North Carolina, where over the next few weeks he had dyspnea on exertion, ankle edema, and occasional exertional chest pain, and gained 45 pounds. He was transferred to N. C. Baptist Hospital in December of 1956 and was admitted to the cardiology service. He had a history of symptomatic rheumatoid arthritis and psoriasis, having been treated with steroids for some years. He had a family history of heart disease, with both his mother and father dying after myocardial infarctions. The patient had smoked 1 to 2 packs of cigarettes a day for 30 years and got very little physical exercise. He had worked for many years in a furniture factory.
On physical examination, his blood pressure was 90/60 with a pulse rate of 118 beats per minute. His neck veins were distended and filled from below. He had a loud precordial systolic murmur with an obvious enlarged heart. There was a thrill over the precordium and an S3 and S4 gallop. His liver was enlarged with palpable pulsations, and there was marked peripheral edema. He had the clinical stigmata of psoriasis and rheumatoid arthritis.
The patient was admitted to the service of Dr Glenn Sawyer, the Chief of Cardiology, where he was treated with bed rest, fluid restriction, digitalis, and mercurial diuretics. On this regimen, his symptoms improved, he lost 15 pounds, and was discharged home. He was rehospitalized in April 1957 with worsening congestive heart failure, weight gain, and bilateral pleural effusions. Again, he was treated with diuretics and bed rest. Decholin circulation time was suggestive of a central left-to-right shunt. He underwent cardiac catheterization on April 17, 1957. His pulmonary arterial pressure was 65/35 mm Hg, and capillary wedge pressure was markedly elevated at 32 mm Hg. Using a dye-dilution technique, he was found to have a large left-to-right shunt, which was localized to the right ventricle. A diagnosis of postinfarction ventricular septal defect was made, and an attempt was made to transfer the patient to another institution for surgical treatment. It was not possible to transfer the patient, and a surgical consultation was obtained from Dr Frank Johnston, Professor of Surgery at this center, Bowman Gray School of Medicine. Surgical repair was recommended at a high risk. No patient had been operated on with cardiopulmonary bypass at this institution even though the procedure was being evaluated in the surgical laboratory. It was thought that surgical repair using cardiopulmonary bypass was warranted owing to the patient's end-stage heart failure.
After a preoperative course of intense diuresis and nutritional supplementation, the patient was taken to the operating room on May 23, 1957, where he underwent general orotracheal anesthesia and was placed in an ice-filled tub until his esophageal temperature reached 35°C (Fig 1).
He was transferred to the operating table, where his chest and abdomen were prepared as a sterile field. A submammary bilateral thoracotomy incision was made and the heart exposed. The pericardium was opened with a U-shaped incision and 150 mL thin, straw-colored fluid removed. There was a marked thrill over the anterior surface of the right ventricle near the apex of the heart, which was thought to overlay the region of the ventricular septal defect. The patient was given 50 mg of heparin intravenously, and an arterial cannula was inserted into the left subclavian artery. Venous cannulas were then introduced into the inferior and superior vena cavae through the right atrium through purse string sutures.
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Fig 1. An example of the method of care cooling in an ice-filled tub, followed by transfer to the operating table for open heart surgery under general anesthesia, utilized at North Carolina Baptist Hospital in the 1950s.
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The patient was then placed on cardiopulmonary bypass using a modified DeWall oxygenator, which had been primed with 5 U fresh heparinized blood, and a Sigmamotor pump (Sigma Int., Medina, NY). Pump flow was 900 mL/min and mean arterial pressure was 30 mm Hg. A 10-cm ventriculotomy was made on the anterior surface of the right ventricle after 250 mg of acetylcholine had been introduced into the proximal aorta after ascending aorta cross-clamping. This caused cardiac standstill. Inspection of the right ventricle revealed a defect in the apical aspect of the interventricular septum that was approximately 1.5 cm in diameter. The defect was sutured with a continuous suture of 3-0 silk with a 1-cm plug of a synthetic material similar to nylon used for medical patches at that time, which was inserted into the defect and surrounded by the running suture technique. The aortic clamp was removed after 14 minutes, and blood was allowed to enter the coronary circulation. The right ventricle and right atrium were then filled with normal saline solution, and the right ventriculotomy was closed with 3-0 silk running sutures.
Occluding tourniquets on the inferior and superior vena cavae were released, and ventricular contractions began; the extracorporeal pump was discontinued after a pump time of 26 minutes. The caval cannulas and the subclavian cannula were removed, and the defects repaired with fine sutures. Saline, 40°C, was placed in both chest cavities for rewarming, and the core temperature rose from 32°C to 34°C. The pericardium was closed with interrupted sutures of 3-0 silk with the inferior portion left open for drainage. Two no.34 chest catheters were placed in each hemithorax, and the sternum was approximated with two wire sutures of no.16 stainless steel wire. The chest was closed in the routine fashion, and the sponge count was reported as correct. When the drapes were removed, it was noted that the patient's color was considerably improved over the preoperative color. There was no venous distention of the neck, and the blood pressure was obtainable at 74 mm Hg systolic using a blood pressure cuff. The patient remained intubated and was taken to the hospital recovery room for postoperative observation.
In the recovery room, the endotracheal tube was removed after 1 hour of hand mechanical ventilation, and the patient was noted to be quite somnolent for several hours thereafter. The next morning, May 24, 1957, his blood pressure was 100/60 mm Hg by cuff, and he was awake but with a left hemiparesis and right deviating gaze. The remainder of the hospital stay was reasonably stable with mild congestive heart failure requiring a left thoracentesis. He received intense physical therapy for his perioperative stroke and was transferred to his community hospital in Thomasville on June 21, 1957, for continued therapy.
He was rehospitalized at this center on January 31, 1958, for a period of additional physical therapy for his left hemiparesis. At that time, he was noted to have a soft, systolic murmur heard at the left nipple with no evidence of congestive heart failure. He had some difficulty with urination and was treated with a Texas catheter. Physical therapy was continued until his discharge home on February 7, 1958.
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Comment
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The first report of operation for postinfarction ventricular septal defect was by Cooley in 1957 [1]. He reported a case of a posterior ventricular septal defect causing intractable heart failure necessitating operation 1 month after admission for the myocardial infarction. The operation was performed on April 5, 1956, and was deemed successful, but the patient died 6 weeks later from a combination of infection and recurrence of the ventricular septal defect. The manuscript was submitted to Surgery in July 1956, but the article did not appear until June 1957, after Dr Johnston's case.
At the time, Frank R. Johnston, was an academic cardiothoracic surgeon in Winston-Salem (Fig 2).
He graduated from Duke University Medical School in 1943 and came to the Bowman Gray School of Medicine of Wake Forest University in 1944 as an intern serving under Dr Howard Bradshaw. He was called into military medical service in 1945, where he served with the Wake Forest Unit in Europe and received an honorable discharge in 1946. He finished his surgical residency in 1950 at the same institution and immediately joined the faculty. Doctor Johnston was fascinated by the idea of using an artificial heart-lung machine to support patients during cardiac surgery and used the information provided very generously by Dr Richard DeWall at the University of Minnesota to construct a pump oxygenator using commonly available polyvinyl tubing and a Sigmamotor pump (Fig 3).
The construction of this pump oxygenator and its use in 50 patients was reported in 1956 [2]. Doctor Johnston, with the assistance of Dr Jesse Meredith, a surgery resident, and Mr Eddie Parker, a laboratory technician, built a DeWall type pump oxygenator in 1954 and used it for experiments in the surgical laboratories for experimental cardiac operations on dogs.
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Fig 3. A diagram of the DeWall oxygenator that was used to build the device utilized in the repair of a postinfarction ventricular septal defect in 1957.
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Doctor Johnston was a thoughtful, caring surgeon who performed well-planned surgical operations. He was not overly aggressive in adopting cutting edge procedures until he was convinced of their value. His personality was one of self-effacement with sincere interest in patients, colleagues, and friends.
The patient was presented to Dr Johnston by Dr Glenn Sawyer, Chief of Cardiology, after an attempt to refer the patient to another institution was unsuccessful. By April 1956, the patient was in terminal heart failure, and pressure was brought to bear on Dr Johnston to try and repair the defect. By sheer coincidence, Dr Cooley was invited to speak at the County Medical Society in Asheville, North Carolina, in April 1957, accepting the request of Dr Westbrook Murphy, a radiologist, in Asheville, North Carolina, who was one of Dr Cooley's first patients when he arrived in Houston, Texas. One of the authors of this manuscript (T.C.P.) was a medical student at Bowman Gray School of Medicine at the time, and accompanied Dr Johnston to Asheville to hear Dr Cooley's lecture on newer techniques in the surgical treatment of heart disease. After the lecture, Dr Johnston, Dr Pennell, and Dr Cooley gathered on the roof of the Old Battery Park Hotel in Asheville and discussed Dr Johnston's case. Doctor Cooley described the method of repair in his patient and the perfusion techniques utilized.
Of even greater good fortune, the ventricular septal defect in Dr Johnston's patient was located in the anterior septum at the cardiac apex. In Dr Cooley's patient, the ventricular septal defect was located in the posterior septum, and papillary muscles to the tricuspid valve had to be divided because an anterior approach was utilized. In Dr Johnston's case, the defect had a very solid fibrous rim, which held sutures well, permitting a suture technique involving multiple sutures of silk around and including an Ivalon sponge to successfully and permanently close the defect.
One significant difference between the two cases was the inability of the De Wall oxygenator constructed at this center to provide arterial flow more than 1 L per minute. Because the oxygenator was designed to be used on dogs, core cooling in an ice bath was therefore necessary before the bilateral thoracotomy to protect from central hypoxemia. The patient had a postoperative stroke, and it could be surmised that a combination of low perfusion pressure and low blood flow during the 20-minute repair of the defect contributed to cerebral ischemia. More likely, it could be postulated that mural thrombus in the left ventricle embolized during the procedure, as the repair was performed through the right ventricle without any visualization of the interior of the left ventricle. The patient was seen 6 months after the operation, and was found to be free of heart failure with only a slight heart murmur. He was later lost to follow-up, and his ultimate outcome is not known.
Although the DeWall-type oxygenator was used on several more cases at the medical center, rapid conversion to the disk-type oxygenator described by Kay [3] and Cross [4] was made in the late 1950s because of the higher flow rates and superior oxygenating capabilities without the difficulties related to blood trauma, air embolization, and sterilization. Interest in pump oxygenators and the effects of cardiopulmonary bypass on the central nervous system was carried forward by one of the author's of this manuscript (A.R.C.), and provided impetus for the studies of central nervous system outcomes in cardiac surgical patients that exist today.
As befitted his nature, Dr Johnston did not report his surgical success even though operations to repair postinfarction ventricular septal defect were rare, with only 30 cases being reported in the following 12 years [5]. These procedures still represent a major surgical challenge, which makes this successful result all the more remarkable.
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References
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- Cooley DA, Belmonte BA, Zeis LB, Schnur S. Surgical repair of ruptured interventricular septum following acute myocardial infarction. Surgery 1957:930–7
- DeWall R.A., Warden H.E., Read R.C., et al. A simple expendable, artificial oxygenator for open heart surgery. Surg Clin North Am 1956;36:1025-1034.
- Kay E.B., Zimmerman H.A., Berne R.M., et al. Certain clinical aspects in the use of the pump oxygenator. JAMA 1956;162:639-641.[Abstract/Free Full Text]
- Cross F.S., Berne R.M., Hirose Y., et al. Description and evaluation of a rotating disc type reservoir oxygenator. Surg Forum 1956;7:274-278.
- Iben A.B., Pupello D.F., Stinson E.B., Shumway N.E. Surgical treatment of postinfarction ventricular septal defects. Ann Thorac Surg 1969;8:252-262.[Free Full Text]
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Abstract
Introduction
