Ann Thorac Surg 2009;88:1044-1046. doi:10.1016/j.athoracsur.2009.05.077
© 2009 The Society of Thoracic Surgeons
Our Surgical Heritage
The First Open-Heart Repairs Using Extracorporeal Circulation by Cross-Circulation: A 53-Year Follow-Up
James H. Moller, MDa,*,
Sara J. Shumway, MDb,
Vincent L. Gott, MDc
a Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
b Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
c Johns Hopkins University School of Medicine, Baltimore, Maryland
* Address correspondence to Dr Moller, MMC 288, 420 Delaware St SE, Minneapolis, MN 55455 (Email: molle002{at}umn.edu).
Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
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Abstract
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Between March 26, 1954 and July 19, 1955, C. Walton Lillehei and colleagues operated upon 45 infants and children with previously uncorrectable cardiac anomalies using cross-circulation with a human donor. Late follow-up was obtained in all of the 28 patients discharged after the operation. All of the 20 currently living patients were personally interviewed with regard to their cardiac status. Eight early survivors have died. Three died after repair of a residual cardiac anomaly. Another died 4 months postoperatively from heart failure. The other 4 died 13 to 47 years later: 2 of unknown causes, 1 of pneumonia, and 1 was an accident. Eleven late cardiac operations were performed. Seven were done to correct a residual anomaly. More than 40 years later, 2 patients underwent procedures to correct tricuspid regurgitation. One had a mitral valve procedure, and another underwent coronary artery bypass grafting. Of the current 20 survivors, none is limited from cardiac causes. Considering that these 45 patients represent "the dawn of open-heart surgery," the long-term results are quite remarkable.
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Introduction
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From March 26, 1954, through July 19, 1955, 45 children with previously uncorrectable cardiac anomalies were operated upon at the University of Minnesota. Cardiopulmonary bypass was established by cross-circulation with a relative or donor [1, 2]. Among the 45 high-risk children, there were 17 postoperative deaths. A 30-year follow-up of survivors was carried out previously [3].
Our current study describes the further follow-up experience with the 28 survivors, focusing on the past 23 years.
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Material and Methods
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The original medical records were reviewed to extract information about the patients' conditions, diagnostic studies, details of the operation, and postoperative courses. The previously reported 30-year follow-up data were reviewed. Various methods were used to locate the 28 survivors. Once located, the survivors were interviewed for information concerning their cardiac status, subsequent operations, overall health, activity level, and presence of noncardiac conditions. The study was reviewed and approved by the Institutional Review Board of the University of Minnesota Medical School.
Cross-Circulation and Operative Procedure
The cross-circulation technique is depicted in Figure 1. A donor (relative or volunteer) served as the oxygenator, and blood flow between the patient and donor was achieved with a SigmaMotor "finger-pump" (SigmaMotor Inc, Middleport, NY). Flow rates were 25 to 30 mL · kg–1 · min–1. Pump times ranged from 6 to 40.5 minutes. In 31 patients, pump times were less than 15 minutes. The duration of the cardiotomy ranged from 4 to 14 minutes (mean 8). Operations were carried out without hypothermia or cardiac arrest. Reusable cardiac suction was not available. No prosthetic patch material was used to either close a septal defect or widen the right ventricular outflow tract in patients with tetralogy of Fallot. Defects were closed with interrupted 3-0 silk sutures. Infundibular stenosis was primarily removed with a rongeur.
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Fig 1. Cross-circulation circuit. Arterial blood flows from donor (on right) through Sigmamotor pump to patient's subclavian artery (on left). Venous flow returns from patient's vena cavae through pump to donor's saphenous vein. (A = artery; I.V.C. = inferior vena cava; Jug. = jugular; V = vein.)
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Results
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Table 1
shows the critical data for the 45 patients. The 45 patients ranged in age from 4 months to 14 years. Six of them were less than 6 months of age. Nine were between 6 and 12 months. Seven were between 1 and 2 years. The remaining 23 patients were between 2 and 14 years of age.
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Table 1 Critical Data of 45 Patients Grouped According to Cardiac Anomaly, With Important Postoperative Data Shown
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There were 17 operative deaths. Twelve occurred either in the operating room or on the first postoperative day. Four died on postoperative days 2 to 4. The remaining patient died on postoperative day 11 of pneumonia. He was the initial patient to be operated upon using this technique.
Ventricular septal defect (27 patients), tetralogy of Fallot (10), and atrioventricular canal (5) were the most frequent cardiac anomalies. These three conditions accounted for 16 of the 17 postoperative deaths.
Among the 28 survivors, there were 8 late deaths. Three followed an operation for a residual anomaly. Two deaths were from an unknown cause. The 3 remaining deaths resulted from congestive heart failure, probable pulmonary vascular disease, and an automobile accident, respectively. A survival curve (Fig 2) illustrates the timing of the late deaths.
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Fig 2. Survival curve with 95% confidence levels shown. Sharp drop in initial part of curve reflects operative deaths. Over the ensuing 53 years, an additional 8 deaths occurred. Dashed lines are the 95% confidence interval of survival function.
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There were 11 late cardiac operations in 8 patients. Seven of these operations were to correct a residual anomaly. Four others were performed more than 40 years after the original cardiac operation. Two of these late operations were performed for tricuspid regurgitation, which occurred because of damage to the septal leaflet at the time of closure of a perimembranous ventricular septal defect. The third patient was operated for mitral regurgitation, and the fourth required coronary artery bypass grafting.
The functional status in 19 survivors was New York Heart Association class I or II. The remaining patient was limited by fibromyalgia. No other major noncardiac conditions have occurred in the other 19. Atrial fibrillation has occurred in 3 late survivors.
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Comment
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In the early 1950s, the number of cardiac anomalies that could be corrected or palliated was limited. Ligation of a patent ductus arteriosus or resection of a coarctation of the aorta treated the condition directly. Children with tetralogy of Fallot could be palliated with a Blalock-Taussig shunt. Also, a few patients with pulmonary stenosis were being treated with valvotomy.
Intracardiac anomalies, such as ventricular septal defect or tetralogy of Fallot, presented a challenge; cardiopulmonary bypass would be required to enter the cardiac chambers. In 1951, Clarence Dennis, at the University of Minnesota, carried out two unsuccessful attempts at closing an atrial septal defect using a pump-oxygentor of his design [4]. In 1953, John Gibbon [5], at Jefferson Medical College, successfully closed an atrial septal defect in an 18-year-old girl using the screen oxygenator that he had developed. Despite this extremely important achievement, Gibbon was unsuccessful in 5 other patients with a preoperative diagnosis of atrial septal defect. Gibbon was so discouraged with his early clinical results, he discontinued further attempts at open heart repair of atrial septal defects using cardiopulmonary bypass equipment with a membrane oxygenator.
From 1952 to 1955, F. John Lewis and colleagues [6] at the University of Minnesota operated upon 60 patients with an atrial septal defect. Using hypothermia and inflow occlusion, they were able to close the defect by sutures in 5 minutes or less [6]. Fifty-four patients survived. The experience learned from these procedures provided background for other intracardiac operations.
While an atrial septal defect was a fairly simple defect that could be repaired in a short period of time, the challenge was far greater for ventricular septal defect. Anomalies in the ventricular septum and outflow tract were far more complicated and required a transventricular approach. These anatomical factors and early lack of success with the screen oxygenators required unique techniques.
Lillehei and coworkers [7] took a bold approach by utilizing the "perfect oxygenator," the human lung. Their approach resembled the support of a fetus by a pregnant mother. Using extracorporeal circulation with a donor, they were able to correct a range of serious cardiac anomalies for the first time. Of the 45 children operated on by Lillehei and colleagues, 15 were under 1 year of age. Remarkably, 28 (62%) were discharged from the hospital. With these exceptional early results using cross-circulation, Lillehei then very successfully switched to the DeWall bubble oxygenator in May 1955 [8].
The operative and early postoperative mortality rate of 38% (17 of 45 patients) must be considered in light of the techniques and intraoperative and postoperative support that was available in that era. In addition to operating on a beating heart with normothermic bypass, there were no methods for recording intraoperative arterial pressure and blood gases. Despite these barriers, the pump times and duration of the cardiotomy were amazingly short. Postoperative care was given in a general surgical recovery room and then on a hospital ward. This was a time before intensive care units existed. In addition, these operations were performed before the availability of cardiac pacing for patients with heart block.
Despite the early mortality rate, this approach demonstrated that with cardiopulmonary bypass, intraventricular anomalies could be corrected successfully. Furthermore, it dispelled the myth that children with a cardiac anomaly had an additional intrinsic myocardial problem that was potentially lethal [7]. In the years that followed, newer bypass methods evolved and more centers began operating on children with a ventricular septal defect or tetralogy of Fallot, and overall worldwide results improved remarkably.
In conclusion, it is generally agreed that C. Walton Lillehei's use of cross-circulation in 1954 and 1955 provided the dawn of open heart repair for complicated cardiac anomalies. Forty-five infants and children were operated on during a 14 month period; remarkably, 28 patients—19 with a ventricular septal defect, 5 with tetralogy of Fallot, and 1 with atrioventricular canal—were successfully repaired and discharged from the hospital. A 30-year follow-up was presented by C. Walton Lillehei at the 1985 Society for Thoracic Surgeons meeting. During this 30-year interval, 6 late deaths had occurred. Our current 53-year follow-up reveals that there have been only 2 subsequent deaths and that 20 of the original cross-circulation patients are living with no problems and no significant limitations related to their original operations.
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Acknowledgments
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We appreciate the assistance of Beverly June Lewis, Mary Jo Antinozzi, and Ceeya Patton in locating the patients and maintaining contact with them.
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References
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- Lillehei CW, Cohen M, Warden HE, Varco RL. The direct-vision intracardiac correction of congenital anomalies by controlled cross circulation: results in 32 patients with ventricular septal defects, tetralogy of Fallot, and atrioventricular communis defects Surgery 1955;38:11-29.[Medline]
- Lillehei CW, Cohen M, Warden HE, Read RC, Aust JB, DeWall RA. Direct vision intracardiac surgical correction of the tetralogy of Fallot, pentalogy of Fallot, and pulmonary atresia defects: report of first ten cases Ann Surg 1955;142:418-445.[Medline]
- Lillehei CW, Varco RL, Cohen M, Warden HE, Patton C, Moller JH. The first open-heart repairs of ventricular septal defect, atrioventricular communis, and tetralogy of Fallot using extracorporeal circulation by cross-circulation: a 30-year follow-up Ann Thorac Surg 1986;41:4-21.[Abstract/Free Full Text]
- Dennis C, Spreng DS, Nelson GE, et al. Development of a pump-oxygenator to replace the heart and lungs: an apparatus applicable to human patients and application to one case Ann Surg 1951;134:709-721.[Medline]
- Gibbon JH. Application of a mechanical heart and lung apparatus to cardiac surgery Minn Med 1954;37:171-185.[Medline]
- Lewis FJ, Taufic M. Closure of atrial septal defects with the aid of hypothermia; experimental accomplishments and the report of one successful case Surgery 1953;33:52-59.[Medline]
- Lillehei CW. A personalized history of extracorporeal circulation Am Soc Artif Intern Organs (Transactions) 1982;28:5-16.
- DeWall RA, Warden HE, Read RC, et al. A simple, expendable, artificial oxygenator for open heart surgery Surg Clin North Am 1956;36:1025-1034.
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Abstract
Introduction
