Chapter 1. History of Cardiac Surgery

The development of major surgery was retarded for centuries by a lack of knowledge and technology. Significantly, the general anesthetics ether and chloroform were not developed until the middle of the nineteenth century. These agents made major surgical operations possible, which created an interest in repairing wounds to the heart, leading some investigators in Europe to conduct studies in the animal laboratory on the repair of heart wounds. The first simple operations in humans for heart wounds soon were reported in the medical literature.

On July 10, 1893, Dr. Daniel Hale Williams (Fig. 1-1), a surgeon from Chicago, successfully operated on a 24-year-old man who had been stabbed in the heart during a fight. The stab wound was slightly to the left of the sternum and dead center over the heart. Initially, the wound was thought to be superficial, but during the night the patient experienced persistent bleeding, pain, and pronounced symptoms of shock. Williams opened the patient's chest and tied off an artery and vein that had been injured inside the chest wall, likely causing the blood loss. Then he noticed a tear in the pericardium and a puncture wound to the heart "about one-tenth of an inch in length."1

The wound in the right ventricle was not bleeding, so Williams did not place a stitch through the heart wound. He did, however, stitch closed the hole in the pericardium. Williams reported this case 4 years later.1 This operation, which is referred to frequently, is probably the first successful surgery involving a documented stab wound to the heart. At the time Williams' surgery was considered bold and daring, and although he did not actually place a stitch through the wound in the heart, his treatment seems to have been appropriate. Under the circumstances, he most likely saved the patient's life.

A few years after Williams' case, a couple of other surgeons actually sutured heart wounds, but the patients did not survive. Dr. Ludwig Rehn (Fig. 1-2), a surgeon in Frankfurt, Germany, performed what many consider the first successful heart operation.2 On September 7, 1896, a 22-year-old man was stabbed in the heart and collapsed. The police found him pale, covered with cold sweat, and extremely short of breath. His pulse was irregular and his clothes were soaked with blood. By September 9, his condition was worsening, as shown in Dr. Rehn's case notes:

Pulse weaker, increasing cardiac dullness on percussion, respiration 76, further deterioration during the day, diagnostic tap reveals dark blood. Patient appears moribund. Diagnosis: increasing hemothorax. I decided to operate entering the chest through the left fourth intercostal space, there is massive blood in the pleural cavity. The mammary artery is not injured. There is continuous bleeding from a hole in the pericardium. This opening is enlarged. The heart is exposed. Old blood and clots are emptied. There is a 1.5 cm gaping right ventricular wound. Bleeding is controlled with finger pressure. …

I decided to suture the heart wound. I used a small intestinal needle and silk suture. The suture was tied in diastole. Bleeding diminished remarkably with the third suture, all bleeding was controlled. The pulse improved. The pleural cavity was irrigated. Pleura and pericardium were drained with iodoform gauze. The incision was approximated, heart rate and respiratory rate decreased and pulse improved postoperatively.

… Today the patient is cured. He looks very good. His heart action is regular. I have not allowed him to work physically hard. This proves the feasibility of cardiac suture repair without a doubt! I hope this will lead to more investigation regarding surgery of the heart. This may save many lives.

Ten years after Rehn's initial repair, he had accumulated a series of 124 cases with a mortality of only 60%, quite a feat at that time.3

Dr. Luther Hill was the first American to report the successful repair of a cardiac wound, in a 13-year-old boy who was a victim of multiple stab wounds.4 When the first doctor arrived, the boy was in profound shock. The doctor remembered that Dr. Luther Hill had spoken on the subject of repair of cardiac wounds at a local medical society meeting in Montgomery, Alabama. With the consent of the boy's parents, Dr. Hill was summoned. He arrived sometime after midnight with six other physicians. One was his brother. The surgery took place on the patient's kitchen table in a rundown shack. Lighting was provided by two kerosene lamps borrowed from neighbors. One physician administered chloroform anesthesia. The boy was suffering from cardiac tamponade as a result of a stab wound to the left ventricle. The stab wound to the ventricle was repaired with two catgut sutures. Although the early postoperative course was stormy, the boy made a complete recovery. That patient, Henry Myrick, eventually moved to Chicago, where, in 1942, at the age of 53, he got into a heated argument and was stabbed in the heart again, very close to the original stab wound. This time, Henry was not as lucky and died from the wound.

Another milestone in cardiac surgery for trauma occurred during World War II when Dwight Harken, then a U.S. Army surgeon, removed 134 missiles from the mediastinum, including 55 from the pericardium and 13 from cardiac chambers, without a death.5 It is hard to imagine this type of elective (and semielective) surgery taking place without sophisticated indwelling pulmonary artery catheters, blood banks, and electronic monitoring equipment. Rapid blood infusion consisted of pumping air into glass bottles of blood.

Martin Kirschner reported the first patient who recovered fully after undergoing pulmonary embolectomy in 1924.6 In 1937, John Gibbon estimated that nine of 142 patients who had undergone the procedure worldwide left the hospital alive.7 These dismal results were a stimulus for Gibbon to start work on a pump oxygenator that could maintain the circulation during pulmonary embolectomy. Sharp was the first to perform pulmonary embolectomy using cardiopulmonary bypass, in 1962.8

Pericardial resection was introduced independently by Rehn9 and Sauerbruch.10 Since Rehn's report, there have been few advances in the surgical treatment of constrictive pericarditis. Some operations are now performed with the aid of cardiopulmonary bypass. In certain situations, radical pericardiectomy that removes most of the pericardium posterior to the phrenic nerves is done.

Although cardiac catheterization is not considered heart surgery, it is an invasive procedure, and some catheter procedures have replaced heart operations. Werner Forssmann is credited with the first heart catheterization. He performed the procedure on himself and reported it in Klrinische Wochenschrift.11 In 1956 Forssmann shared the Nobel Prize in Physiology or Medicine with Andre F. Cournand and Dickenson W. Richards, Jr. His 1929 paper states, "One often hesitates to use intercardiac injections promptly, and often, time is wasted with other measures. This is why I kept looking for a different, safer access to the cardiac chambers: the catheterization of the right heart via the venous system."

In this report by Forssmann, a photograph of the x-ray taken of Forssmann with the catheter in his own heart is presented. Forssmann, in that same report, goes on to present the first clinical application of the central venous catheter for a patient in shock with generalized peritonitis. Forssmann concludes his paper by stating, "I also want to mention that this method allows new options for metabolic studies and studies about cardiac physiology."

In a 1951 lecture Forssmann discussed the tremendous resistance he faced during his initial experiments.12 "Such methods are good for a circus, but not for a respected hospital" was the answer to his request to pursue physiologic studies using cardiac catheterization. His progressive ideas pushed him into the position of an outsider with ideas too crazy to give him a clinical position. Klein applied cardiac catheterization for cardiac output determinations using the Fick method a half year after Forssmann's first report.13 In 1930, Forssmann described his experiments with catheter cardiac angiography.14 Further use of this new methodology had to wait until Cournand's work in the 1940s.

The first clinical attempt to open a stenotic valve was carried out by Theodore Tuffier on July 13, 1912.15 Tuffier used his finger to reach the stenotic aortic valve. He was able to dilate the valve supposedly by pushing the invaginated aortic wall through the stenotic valve. The patient recovered, but one must be skeptical as to what was accomplished. Russell Brock attempted to dilate calcified aortic valves in humans in the late 1940s by passing an instrument through the valve from the innominate or another artery.16 His results were poor, and he abandoned the approach. During the next several years, Brock17 and Bailey and colleagues18 used different dilators and various approaches to dilate stenotic aortic valves in patients. Mortality for these procedures, which was often done in conjunction with mitral commissurotomy, was high.

Elliott Cutler worked for 2 years on a mitral valvulotomy procedure in the laboratory. His first patient underwent successful valvulotomy on May 20, 1923, using a tetrasomy knife.19 Unfortunately, most of Cutler's subsequent patients died because he created too much regurgitation with his valvulotome, and he soon gave up the operation.

In Charles Bailey's 1949 paper entitled, "The Surgical Treatment of Mitral Stenosis," he states, "After 1929 no more surgical attempts [on mitral stenosis] were made until 1945. Dr. Dwight Harken, Dr. Horace Smithy, and the author recently made operative attempts to improve mitral stenosis. Our clinical experience with the surgery of the mitral valves has been five cases to date." He then describes his five patients, four of whom died and only one of whom lived a long life.20

A few days after Bailey's success, on June 16 in Boston, Dr. Dwight Harken successfully performed his first valvulotomy for mitral stenosis.21

The first successful pulmonary valvulotomy was performed by Thomas Holmes Sellers on December 4, 1947.22

Charles Hufnagel reported a series of 23 patients starting September 1952 who had this operation for aortic insufficiency.23 There were four deaths among the first 10 patients and two deaths among the next 13. Hufnagel's caged-ball valve, which used multiple-point fixation rings to secure the apparatus to the descending aorta, was the only surgical treatment for aortic valvular incompetence until the advent of cardiopulmonary bypass and the development of heart valves that could be sewn into the aortic annulus position.

Congenital cardiac surgery began when John Streider at Massachusetts General Hospital first successfully interrupted a ductus on March 6, 1937. The patient was septic and died on the fourth postoperative day. At autopsy, vegetations filled the pulmonary artery down to the valve.24 On August 16, 1938, Robert Gross, at Boston Children's Hospital, operated on a 7-year-old girl with dyspnea after moderate exercise.25 The ductus was ligated and the patient made an uneventful recovery.

Modifications of the ductus operation soon followed. In 1944, Dr. Gross reported a technique for dividing the ductus successfully. The next major congenital lesion to be overcome was coarctation of the aorta. Dr. Clarence Crafoord, in Stockholm, Sweden, successfully resected a coarctation of the aorta in a 12-year-old boy on October 19, 1944.26 Twelve days later he successfully resected the coarctation of a 27-year-old patient. Dr. Gross first operated on a 5-year-old boy with this condition on June 28, 1945.27 After he excised the coarctation and rejoined the aorta, the patient's heart stopped suddenly. The patient died in the operating room. One week later, however, Dr. Gross operated on a second patient, a 12-year-old girl. This patient's operation was successful. Dr. Gross had been unaware of Dr. Crafoord's successful surgery several months previously, probably because of World War II.

In 1945, Dr. Gross reported the first successful case of surgical relief for tracheal obstruction from a vascular ring.28 In the 5 years that followed Gross's first successful operation, he reported 40 more cases.

The famous Blalock-Taussig operation also was first reported in 1945. The first patient was a 15-month-old girl with a clinical diagnosis of tetralogy of Fallot with a severe pulmonary stenosis.29 At age 8 months, the baby had her first cyanotic spell, which occurred after eating. Dr. Helen Taussig, the cardiologist, followed the child for 3 months, and during that time, cyanosis increased, and the child failed to gain weight. The operation was performed by Dr. Alfred Blalock at Johns Hopkins University on November 29, 1944. The left subclavian artery was anastomosed to the left pulmonary artery in an end-to-side fashion. The postoperative course was described as stormy; the patient was discharged 2 months postoperatively. Two additional successful cases were done within 3 months of that first patient.

Thus, within a 7-year period, three congenital cardiovascular defects, patent ductus arteriosus, coarctation of the aorta, and vascular ring, were attacked surgically and treated successfully. However, the introduction of the Blalock-Taussig shunt probably was the most powerful stimulus to the development of cardiac surgery because this operation palliated a complex intracardiac lesion and focused attention on the pathophysiology of cardiac disease.

Anomalous coronary artery in which the left coronary artery communicates with the pulmonary artery was the next surgical conquest. The surgery was performed on July 22, 1946, and was reported by Gunnar Biorck and Clarence Crafoord.30 The anomalous coronary artery was identified and doubly ligated. The patient made an uneventful recovery.

Muller31 reported successful surgical treatment of transposition of the pulmonary veins in 1951, but the operation addressed a partial form of the anomaly. Later in the 1950s, Gott, Varco, Lillehei, and Cooley reported successful operative variations for anomalous pulmonary veins.

Another of Gross's pioneering surgical procedures was surgical closure of an aortopulmonary window on May 22, 1948.32 Cooley and colleagues33 were the first to report on the use of cardiopulmonary bypass to repair this defect and converted a difficult and hazardous procedure into a relatively straightforward one.

Glenn34 reported the first successful clinical application of the cavopulmonary anastomosis in the United States in 1958 for what has been termed the Glenn shunt. Similar work was done in Russia during the 1950s by several investigators. On January 3, 1957, Galankin,35 a Russian surgeon, performed a cavopulmonary anastomosis in a 16-year-old patient with tetralogy of Fallot. The patient made a good recovery with significant improvement in exercise tolerance and cyanosis.

The development of the heart-lung machine made repair of intracardiac lesions possible. To bypass the heart, one needs a basic understanding of the physiology of the circulation, a method of preventing the blood from clotting, a mechanism to pump blood, and finally, a method to ventilate the blood.

One of the key requirements of the heart-lung machine was anticoagulation. Heparin was discovered in 1915 by a medical student, Jay McLean, working in the laboratory of Dr. William Howell, a physiologist at Johns Hopkins.36

John Gibbon contributed more to the success of the development of the heart-lung machine than anyone else.

Gibbon's work on the heart-lung machine took place over the next 20 years in laboratories at Massachusetts General Hospital, the University of Pennsylvania, and Thomas Jefferson University. In 1937, Gibbon reported the first successful demonstration that life could be maintained by an artificial heart and lung and that the native heart and lungs could resume function. Unfortunately, only three animals recovered adequate cardiorespiratory function after total pulmonary artery occlusion and bypass, and even they died a few hours later.37 Gibbon's work was interrupted by World War II; afterward, he resumed his work at Thomas Jefferson Medical College in Philadelphia (Table 1-1).

Forest Dodrill and colleagues used the mechanical blood pump they developed with General Motors on a 41-year-old man42 (Fig. 1-3). The machine was used to substitute for the left ventricle for 50 minutes while a surgical procedure was carried out to repair the mitral valve; the patient's own lungs were used to oxygenate the blood. This, the first clinically successful total left-sided heart bypass in a human, was performed on July 3, 1952, and followed from Dodrill's experimental work with a mechanical pump for univentricular, biventricular, or cardiopulmonary bypass. Although Dodrill and colleagues had used their pump with an oxygenator for total heart bypass in animals,53 they felt that left-sided heart bypass was the most practical method for their first clinical case.

Later, on October 21, 1952, Dodrill and colleagues used their machine in a 16-year-old boy with congenital pulmonary stenosis to perform a pulmonary valvuloplasty under direct vision; this was the first successful right-sided heart bypass.44 Between July 1952 and December 1954, Dodrill performed approximately 13 clinical operations on the heart and thoracic aorta using the Dodrill–General Motors machine, with at least five hospital survivors.54 Although he used this machine with an oxygenator in the animal laboratory, he did not start using an oxygenator with the Dodrill–General Motors mechanical heart clinically until early 1955.

Hypothermia was another method to stop the heart and allow it to be opened. 91–93

John Lewis closed an atrial septal defect in a 5-year-old girl on September 2, 1952 using a hypothermic technique.43

However, the use of systemic hypothermia for open intracardiac surgery was relatively short lived; after the heart-lung machine was introduced clinically, it appeared that deep hypothermia was obsolete. However, during the 1960s it became apparent that operative results in infants under 1 year of age using cardiopulmonary bypass were poor. In 1967, Hikasa and colleagues,55 from Kyoto, Japan, published an article that reintroduced profound hypothermia for cardiac surgery in infants and used the heart-lung machine for rewarming. Their technique involved surface cooling to 20°C, cardiac surgery during circulatory arrest for 15 to 75 minutes, and rewarming with cardiopulmonary bypass. At the same time, other groups reported using profound hypothermia with circulatory arrest in infants with the heart-lung machine for cooling and rewarming. Results were much improved, and subsequently the technique also was applied for resection of aortic arch aneurysms.

After World War II, John Gibbon resumed his research. He eventually met Thomas Watson, chairman of the board of the International Business Machines (IBM) Corporation. Watson was fascinated by Gibbon's research and promised help. Soon afterward, six IBM engineers arrived and built a machine that was similar to Gibbon's earlier machine, which contained a rotating vertical cylinder oxygenator and a modified DeBakey rotary pump. Gibbon operated on a 15-month-old girl with severe congestive heart failure (CHF). The preoperative diagnosis was atrial septal defect (ASD), but at operation, none was found. She died, and a huge patent ductus was found at autopsy. The next patient was an 18-year-old girl with CHF owing to an ASD. This defect was closed successfully on May 6, 1953, with the Gibbon-IBM heart-lung machine. The patient recovered, and several months later the defect was confirmed closed at cardiac catheterization.56 Unfortunately, Gibbon's next two patients did not survive intracardiac procedures when the heart-lung machine was used. These failures distressed Dr. Gibbon, who declared a 1-year moratorium for the heart-lung machine until more work could be done to solve the problems causing the deaths.

During this period, C. Walton Lillehei and colleagues at the University of Minnesota studied a technique called controlled cross-circulation.57 With this technique, the circulation of one dog was used temporarily to support that of a second dog while the second dog's heart was stopped temporarily and opened. After a simulated repair in the second dog, the animals were disconnected and allowed to recover.

Lillehei and colleagues57 used their technique at the University of Minnesota to correct a VSD in a 12-month-old infant on March 26, 1954 (Fig. 1-4). Either a parent or a close relative with the same blood type was connected to the child's circulation. In Lillehei's first clinical case, the patient made an uneventful recovery until death on the eleventh postoperative day from a rapidly progressing tracheal bronchitis. At autopsy, the VSD was closed, and the respiratory infection was confirmed as the cause of death. Two weeks later, the second and third patients had VSDs closed by the same technique 3 days apart. Both remained long-term survivors with normal hemodynamics confirmed by cardiac catheterization.

In 1955, Lillehei and colleagues58 published a report of 32 patients that included repairs of VSDs, tetralogy of Fallot, and atrioventricularis communis defects. By May of 1955, the blood pump used for systemic cross-circulation by Lillehei and colleagues was coupled with a bubble oxygenator developed by Drs. DeWall and Lillehei, and cross-circulation was soon abandoned after use in 45 patients during 1954 and 1955. Although its clinical use was short-lived, cross-circulation was an important steppingstone in the development of cardiac surgery.

Meanwhile, at the Mayo Clinic only 90 miles away, John W. Kirklin and colleagues launched their open-heart program on March 5, 1955.49 They used a heart-lung machine based on the Gibbon-IBM machine but with their own modifications. Kirklin wrote:59

We investigated and visited the groups working intensively with the mechanical pump oxygenators. We visited Dr. Gibbon in his laboratories in Philadelphia, and Dr. Forest Dodrill in Detroit, among others. The Gibbon pump oxygenator had been developed and made by the International Business Machine Corporation and looked quite a bit like a computer. Dr. Dodrill's heart-lung machine had been developed and built for him by General Motors and it looked a great deal like a car engine. We came home, reflected and decided to try to persuade the Mayo Clinic to let us build a pump oxygenator similar to the Gibbon machine, but somewhat different. We already had had about a year's experience in the animal laboratory with David Donald using a simple pump and bubble oxygenator when we set about very early in 1953, the laborious task of building a Mayo-Gibbon pump oxygenator and continuing the laboratory research.

Most people were very discouraged with the laboratory progress. The American Heart Association and the National Institutes of Health had stopped funding any projects for the study of heart-lung machines, because it was felt that the problem was physiologically insurmountable. David Donald and I undertook a series of laboratory experiments lasting about 1½ years during which time the engineering shops at the Mayo Clinic constructed a pump oxygenator based on the Gibbon model.

… In the winter of 1954 and 1955 we had nine surviving dogs out of 10 cardiopulmonary bypass runs. With my wonderful colleague and pediatric cardiologist, Jim DuShane, we had earlier selected eight patients for intracardiac repair. Two had to be put off because two babies with very serious congenital heart disease came along and we decided to fit them into the schedule. We had determined to do all eight patients even if the first seven died. All of this was planned with the knowledge and approval of the governance of the Mayo Clinic. Our plan was then to return to the laboratory and spend the next 6 to 12 months solving the problems that had arisen in the first planned clinical trial of a pump oxygenator. … We did our first open-heart operation on a Tuesday in March 1955.

Kirklin continued:59

Four of our first eight patients survived, but the press of the clinical work prevented our ever being able to return to the laboratory with the force that we had planned. By now, Walt Lillehei and I were on parallel, but intertwined paths.

By the end of 1956, many university groups around the world had launched into open-heart programs. Currently, it is estimated that more than 1 million cardiac operations are performed each year worldwide with use of the heart-lung machine. In most cases, the operative mortality is quite low, approaching 1% for some operations. Little thought is given to the courageous pioneers in the 1950s whose monumental contributions made all this possible.

Extracorporeal Life Support

Extracorporeal life support is an extension of cardiopulmonary bypass. Cardiopulmonary bypass was limited initially to no more than 6 hours. The development of membrane oxygenators in the 1960s permitted longer support. Donald Hill and colleagues in 1972 treated a 24-year-old man who developed shock lung after blunt trauma.60 The patient was supported for 75 hours using a heart-lung machine with a membrane oxygenator, cannulated via the femoral vein and artery. The patient was weaned and recovered. Hill's second patient was supported for 5 days and recovered. This led to a randomized trial supported by the National Institutes of Health to determine the efficacy of this therapy for adults with respiratory failure. The study was conducted from 1972 to 1975 and showed no significant difference in survival between patients managed by extracorporeal life support (9.5%) and those who received conventional ventilatory therapy (8.3%).61 Because of these results, most U.S. centers abandoned efforts to support adult patients using extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO).

One participant in the adult trial decided to study neonates. The usual causes of neonatal respiratory failure have in common abnormal postnatal blood shunts known as persistent fetal circulation (PFC). This is a temporary, reversible phenomenon. In 1976, Bartlett and colleagues at the University of Michigan were the first to treat a neonate successfully using ECLS. More than 8000 neonatal patients have been treated using ECLS worldwide, with a survival rate of 82% (ELSO registry data).

Melrose and colleagues62 in 1955 presented the first experimental study describing induced arrest by potassium-based cardioplegia. Blood cardioplegia was used "to preserve myocardial energy stores at the onset of cardiac ischemia." Unfortunately, the Melrose solution proved to be toxic to the myocardium, and as a result cardioplegia was not used widely for several years.

Gay and Ebert63 and Tyres and colleagues64 demonstrated that cardioplegia with lower potassium concentrations was safe. Studies by Kirsch and colleagues,65 Bretschneider and colleagues,66 and Hearse and colleagues67 demonstrated the effectiveness of cardioplegia with other constituents and renewed interest in this technique. Gay and Ebert in 1973 demonstrated a significant reduction in myocardial oxygen consumption during potassium-induced arrest when compared with that of the fibrillating heart.63 They also showed that the problems in the use of the Melrose solution in the early days of cardiac surgery probably were caused by its hyperosmolar properties and perhaps not the high potassium concentration.

In a 1978 publication by Follette and colleagues,68 the technique of blood cardioplegia was reintroduced. In experimental and clinical studies, these authors demonstrated that hypothermic, intermittent blood cardioplegia provided better myocardial protection than normothermic, continuous coronary perfusion and/or hypothermic, intermittent blood perfusion without cardioplegia solution. The composition of the best cardioplegia solution remains controversial, and new formulations, methods of delivery, and recommended temperatures continue to evolve.

With the advent of cardiopulmonary bypass using either the cross-circulation technique of Lillehei and colleagues or the version of the mechanical heart-lung machine used by Kirklin and colleagues, the two groups led the way for intracardiac repairs for many of the commonly occurring congenital heart defects. Because of the morbidity associated with the heart-lung machine, palliative operations also were developed to improve circulatory physiology without directly addressing the anatomic pathology. These palliative operations included the Blalock-Taussig subclavian–pulmonary arterial shunt28 with modifications by Potts and colleagues69 and Waterston,70 the Blalock-Hanlon operation to create an atrial septal defect,71 and the Galankin-Glenn superior vena cava–right pulmonary arterial shunt.34,35

As the safety of cardiopulmonary bypass improved steadily, surgeons addressed more and more complex abnormalities of the heart in younger and younger patients. Some of the milestones in the development of operations to correct congenital heart defects using cardiopulmonary bypass appear in Table 1-2.

Cardiac valve repair or replacement under direct vision awaited the development of the heart-lung machine. The first successful aortic valve replacement (AVR) in the subcoronary position was performed by Dr. Dwight Harken and associates.89 A caged-ball valve was used. Many of the techniques described in Harken's 1960 report are similar to those used today for AVR.

That same year, Starr and Edwards90 successfully replaced the mitral valve using a caged-ball valve of their own design.

By 1967, nearly 2000 Starr-Edwards valves had been implanted, and the caged-ball-valve prosthesis was established as the standard against which all other mechanical prostheses would be compared.

In 1964, Starr and colleagues reported 13 patients who had undergone multiple valve replacement.91 One patient had the aortic, mitral, and tricuspid valves replaced on February 21, 1963. Cartwright and colleagues, however, on November 1, 1961, were the first to replace both the aortic and mitral valves successfully with ball-valve prostheses that they had developed.92 Knott-Craig and colleagues,93 from the Mayo Clinic, successfully replaced all four heart valves in a patient with carcinoid involvement.

In 1961, Andrew Morrow and Edwin Brockenbrough94 reported a treatment for idiopathic hypertrophic subaortic stenosis by resecting a portion of the thickened ventricular septum. They referred to this as subaortic ventriculomyotomy. They gave credit to William Cleland and H.H. Bentall in London, who had encountered this condition unexpectedly at operation and resected a small portion of the ventricular mass. The patient improved, but no postoperative hemodynamic studies had been reported. The subaortic ventriculomyotomy became the standard surgical treatment for this cardiac anomaly, although in some patients systolic anterior motion (SAM) of the anterior leaflet of the mitral valve necessitates mitral valve replacement with a low-profile mechanical valve.

An aortic homograft valve was used clinically for the first time by Heimbecker and colleagues in Toronto for replacement of the mitral valve in one patient and an aortic valve in another.95 Survival was short, 1 day in one patient and 1 month in the other. Donald Ross reported on the first successful aortic valve placement with an aortic valve homograft.96 He used a technique of subcoronary implantation developed in the laboratory by Carlos Duran and Alfred Gunning in Oxford.

The technique of AVR with a pulmonary autograft described initially by Ross in 1967 is advocated by some groups for younger patients who require AVR.97 An aortic or pulmonary valve homograft is used to replace the pulmonary valve that has been transferred to the aortic position.

Other autogenous materials that have been used to manufacture valve prostheses include pericardium, fasciae latae, and dura mater. In the 1960s, Binet and colleagues98 began to develop and test tissue valves. In 1964, Duran and Gunning in England replaced an aortic valve in a patient using a xenograft porcine aortic valve. Early results with formaldehyde-fixed xenografts were good,98 but in a few years these valves began to fail because of tissue degeneration and calcification.99 Carpentier and colleagues revitalized interest in xenograft valves by fixating porcine valves with glutaraldehyde. Carpentier also mounted his valves on a stent to produce a bioprosthesis. Carpentier-Edwards porcine valves and Hancock and Angell-Shiley bioprostheses became popular and were implanted in large numbers of patients.100,101

With the development of cardiopulmonary bypass, valves could be approached under direct vision, and for the first time, mitral insufficiency could be attacked by reparative techniques. Techniques for mitral annuloplasty were described by Wooler and colleagues,102 Reed and colleagues,103 and Kay and colleagues.104 The next step forward was development of annuloplasty rings by Carpentier and Duran. In the 1970s, few groups were involved in valve repairs. Slowly, techniques evolved, were tested clinically, and were followed over the years. Carpentier led the field by establishing the importance of careful analysis of valve pathology, describing in detail several techniques of valve repair, and reporting good results after early and late follow-up, especially with concomitant use of annuloplasty rings.105

From 1966 to 1968, a small epidemic of infective endocarditis in Detroit among heroin addicts broke out. Patients were dying of intractable gram-negative tricuspid valve endocarditis, often caused by Pseudomonas aeruginosa. Long-term antibiotic administration in combination with tricuspid valve replacement was 100% fatal. Starting in 1970, Arbulu operated on 55 patients; in 53, the tricuspid valve was removed without replacing it.106,107 At 25 years, the actuarial survival is 61%.

Selective coronary angiography was developed by Sones and Shirey at the Cleveland Clinic and reported in their 1962 classic paper entitled, "Cine Coronary Arteriography."108 They used a catheter to inject contrast material directly into the coronary artery ostia. This technique gave a major impetus to direct revascularization of obstructed coronary arteries.

From 1960 to 1967, several sporadic instances of coronary grafting were reported. All were isolated cases and, for uncertain reasons, were not reproduced. None had an impact on the development of coronary surgery. Dr. Robert H. Goetz performed what appears to be the first clearly documented coronary artery bypass operation in a human, which was successful. The surgery took place at Van Etten Hospital in New York City on May 2, 1960.109 He operated on a 38-year-old man who was severely symptomatic and used a nonsuture technique to connect the right internal mammary artery to a right coronary artery. It took him 17 seconds to join the two arteries using a hollow metal tube. The right internal mammary artery–coronary artery connection was confirmed patent by angiography performed on the 14th postoperative day. The patient remained asymptomatic for about a year and then developed recurrent angina and died of a myocardial infarction on June 23, 1961. Goetz was severely criticized by his medical and surgical colleagues for this procedure, although he had performed it successfully many times in the animal laboratory. He never attempted another coronary bypass operation in a human.

Another example involved a case of autogenous saphenous vein bypass grafting performed on November 23, 1964, in a 42-year-old man who was scheduled to have endarterectomy of his left coronary artery.110 Because the lesion involved the entire bifurcation, endarterectomy with venous patch graft was abandoned as too hazardous. The authors, Garrett, Dennis, and DeBakey, however, did not report this case until 1973. The patient was alive at that time, and angiograms showed the vein graft to be patent.

Shumaker111 credits Longmire with the first internal mammary–coronary artery anastomosis. "It was almost surely Longmire, long-time chairman at UCLA, and his associate, Jack Cannon, who first performed an anastomosis between the internal mammary artery and a coronary branch, probably in early 1958."

The reference that Shumaker gives for this quotation from Longmire is a personal communication to Shumaker in 1990, which was 32 years after the fact!

As early as 1952, Vladimir Demikhov, the renowned Soviet surgeon, was anastomosing the internal mammary artery to the left coronary artery in dogs.112 In 1967, at the height of the Cold War, a Soviet surgeon from Leningrad, V.I. Kolessov, reported his experience with mammary artery–coronary artery anastomoses for the treatment of angina pectoris in six patients in an American surgical journal.113 The first patient in that series was done in 1964. Operations were performed through a left thoracotomy without extracorporeal circulation or preoperative coronary angiography. The following year, Green and colleagues114 and Bailey and Hirose115 separately published reports in which the internal mammary artery was used for coronary artery bypass in patients.

Rene Favalaro from the Cleveland Clinic used saphenous vein for bypassing coronary obstructions.116 Favalaro's 1968 article focused on 15 patients, who were part of a larger series of 180 patients who had undergone the Vineberg procedure. In these 15 patients with occlusion of the proximal right coronary artery, an interpositional graft of saphenous vein also was placed between the ascending aorta and the right coronary artery distal to the blockage. The right coronary artery was divided, and the vein graft was anastomosed end to end. Favalaro states that this procedure was done because of the unfavorable results with pericardial patch reconstruction of the coronary artery. In an addendum to that paper, 55 patients were added, 52 for segmental occlusion of the right coronary and 3 others for circumflex disease.

The contributions by Favalaro, Kolessov, Green and colleagues, and Bailey and Hirose all were important, but arguably the official start of coronary bypass surgery as we know it today happened in 1969 when W. Dudley Johnson and coworkers from Milwaukee reported their series of 301 patients who had undergone various operations for coronary artery disease (CAD) since February of 1967.117 In that report, the authors presented their results with direct coronary artery surgery during a 19-month period. They state:

After two initial and successful patch grafts, the vein bypass technique has been used exclusively. Early results were so encouraging that last summer the vein graft technique was expanded and used to all major branches. Vein grafts to the left side of the arteries run from the aorta over the pulmonary artery and down to the appropriate coronary vessel. Right-sided grafts run along the atrioventricular groove and also attach directly to the aorta. There is almost no limit of potential (coronary) arteries to use. Veins can be sutured to the distal anterior descending or even to posterior marginal branches. Double vein grafts are now used in more than 40% of patients and can be used to any combination of arteries.

Johnson goes on to say:

Our experience indicates that five factors are important to direct surgery. One: Do not limit grafts to proximal portions of large arteries. … Two: Do not work with diseased arteries. Vein grafts can be made as long as necessary and should be inserted into distal normal arteries. Three: Always do end-to-side anastomoses. … Four: Always work on a dry, quiet field. Consistently successful fine vessel anastomoses cannot be done on a moving, bloody target. … Five: Do not allow the hematocrit to fall below 35.

In discussing Dr. Johnson's presentation, Dr. Frank Spencer commented:

I would like to congratulate Dr. Johnson very heartily. We may have heard a milestone in cardiac surgery today. Because for years, pathologists, cardiologists, and many surgeons have repeatedly stated that the pattern of coronary artery disease is so extensive that direct anastomosis can be done in only 5 to 7% of patients. If the exciting data by Dr. Johnson remain valid and the grafts remain patent over a long period of time, a total revision of thinking will be required regarding the feasibility of direct arterial surgery for CAD.117

The direct anastomosis between the internal mammary artery and the coronary artery was not as popular initially as the vein-graft technique; however, owing to the persistence of Drs. Green, Loop, Grondin, and others, internal mammary artery grafts eventually became the conduit of choice when their superior long-term patency became known.118

Denton Cooley and colleagues made two important contributions to the surgery for ischemic heart disease.119 In 1956, with the use of cardiopulmonary bypass, they were the first to repair a ruptured interventricular septum following acute myocardial infarction. The patient did well initially but died of complications 6 weeks after the operation. Cooley and colleagues also were the first to report the resection of a left ventricular aneurysm with the use of cardiopulmonary bypass.120

Cobb and colleagues at Duke University developed the first successful surgical treatment for cardiac arrhythmias.121 A 32-year-old fisherman was referred for symptomatic episodes of atrial tachycardia that caused CHF. On May 2, 1968, after epicardial mapping, a 5- to 6-cm cut was made extending from the base of the right atrial appendage to the right border of the right atrium during cardiopulmonary bypass. The incision transected the conduction pathway between the atrium and ventricle. Subsequent epicardial mapping indicated eradication of the pathway. Six weeks after the operation, heart size had decreased and lung fields had cleared. The patient eventually returned to work.

A year earlier, Dr. Dwight McGoon at the Mayo Clinic closed an ASD in a patient who also had Wolff-Parkinson-White (WPW) syndrome.122 At operation, Dr. Birchell mapped the epicardium of the heart and localized the accessory pathway to the right atrioventricular groove. Lidocaine was injected into the site, and the delta wave disappeared immediately. Unfortunately, conduction across the pathway reappeared a few hours later. This probably was the first attempt to treat the WPW syndrome surgically. As a result of knowledge gained from the surgical treatment for WPW syndrome, more than 95% of all refractory clinical cases now are treated successfully by nonsurgical means.122

Ross and colleagues123 in Sydney, Australia, and Cox and colleagues124 in St. Louis, Missouri, used cryosurgical treatment of atrial ventricular node re-entry tachycardia. Subsequently, James L. Cox, after years of laboratory research, developed the Maze operation for atrial fibrillation.125 That technique, with his subsequent modifications, is now known as the Cox Maze procedure and has become the world standard with which other techniques used to treat atrial fibrillation, either surgically or with catheters, are compared.125

Guiraudon and colleagues126 from Paris, reported their results with an encircling endomyocardial ventriculotomy for the treatment of malignant ventricular arrhythmias. The following year, in 1979, Josephson and colleagues127 described a more specific procedure for treatment of malignant ventricular arrhythmias. After endocardial mapping, the endocardial source of the arrhythmia was excised. Although the Guiraudon technique usually isolated the source of the arrhythmia, the incision also devascularized healthy myocardium and was associated with high mortality. Endocardial resection was safer and more efficacious and became the basis of all approaches for the treatment of ischemic ventricular tachycardia.122

Stimulated by the death of a close personal friend from ventricular arrhythmias, Dr. Mirowski developed a prototype defibrillator over a 3-month period in 1969. In 1980, Mirowski and colleagues described three successful cases using their implantable myocardial stimulator at Johns Hopkins.128

In 1952 Paul Zoll applied electric shocks 2 ms in duration that were transmitted through the chest wall at frequencies from 25 to 60 per minute and increased the intensity of the shock until ventricular responses were observed. However, after 25 minutes of intermittent stimulation the patient died, although many subsequent patients recovered.129 The next step came when Lillehei and colleagues reported a series of patients who had external pacing after open-heart surgery during the 1950s.130 The field of open-heart surgery gave a major impetus to the development of pacemakers because there was a high incidence of heart block following many intracardiac repairs. The major difference between Zoll's pacing and that of Lillehei and colleagues was that Zoll used external electrodes placed on the chest wall, whereas Lillehei and colleagues attached electrodes directly to the heart at operation. Lillehei and colleagues used a relatively small external pacemaker to stimulate the heart and much less electric current. This form of heart pacing was better tolerated by the patient and was a more efficient way to stimulate the heart. The survival rate of Lillehei's patients with surgically induced heart block was improved significantly.

During this period, progress was made toward a totally implantable pacemaker. Elmquist and Senning131 developed a pacer battery that was small enough for an epigastric pocket with electrodes connected to the heart. They implanted the unit in a patient with atrioventricular block in 1958. Just before implantation, the patient had 20 to 30 cardiac arrests a day. The first pacemaker that was implanted functioned only 8 hours; the second pacemaker implanted in the same patient had better success. The patient survived until January 2002 and had many additional pacemakers. Chardack and colleagues are perhaps better known for their development of the totally implantable pacemaker.132 In 1961 they reported a series of 15 patients who had pacemakers that they had developed implanted.

Early implantable pacemakers were fixed-rate, asynchronous devices that delivered an impulse independent of the underlying cardiac rhythm. During the past 40 years, enormous progress has been made in the field of pacing technology. The number of individuals with artificial pacemakers is unknown; however, estimates indicate that approximately 500,000 Americans are living with a pacemaker and that each year another 100,000 or more patients require permanent pacemakers in the United States.

Alexis Carrel and Charles Guthrie reported transplantation of the heart and lungs while at the University of Chicago in 1905.133 The heart of a small dog was transplanted into the neck of a larger one by anastomosing the caudad ends of the jugular vein and carotid artery to the aorta and pulmonary artery. The animal was not anticoagulated, and the experiment ended about 2 hours after circulation was established because of blood clot in the cavities of the transplanted heart.

Vladimir Demikhov, from Russia, described more than 20 different techniques for heart transplantation in 1950.134 He also published various techniques for heart and lung transplantation. He was even able to perform an orthotopic heart transplant in a dog before the heart-lung machine was developed. This was accomplished by placing the donor heart above the dog's own heart, and then with a series of tubes and connections, he rerouted the blood from one heart to the other until he had the donor heart functioning in the appropriate position and the native heart removed. One of his dogs climbed the steps of the Kremlin on the sixth postoperative day but died shortly afterward of rejection.

Richard Lower and Norman Shumway established the technique for heart transplantation as it is performed today.135 Preservation of the cuff of recipient left and right atria with part of the atrial septum was described earlier by Brock136 in England and Demikhov112 in Russia,137 but it became popular only after Shumway and Lower reported it in their 1960 paper.

The first attempt at human heart transplantation was made by Hardy and colleagues138 at the University of Mississippi. Because no human donor organ was available at the time, a large chimpanzee's heart was used; however, it was unable to support the circulation because of hyperacute rejection.

The first human-to-human heart transplant occurred December 3, 1967, in Capetown, South Africa.139 The surgical team, headed by Christiaan Barnard, transplanted the heart of a donor who had been certified dead after the electrocardiogram showed no activity for 5 minutes into a 54-year-old man whose heart was irreparably damaged by repeated myocardial infarctions. The second human heart transplant using a human donor was performed on a child 3 days after the first on December 6, 1967, by Adrian Kantrowitz in Brooklyn, New York. Dr. Kantrowitz's patient died of a bleeding complication within the first 24 hours.140 Barnard's patient, Lewis Washkansky, died on the 18th postoperative day. At autopsy, the heart appeared normal, and there was no evidence of chronic liver congestion, but bilateral pneumonia was present, possibly owing to severe myeloid depression from immunosuppression.141

On January 2, 1968, Barnard performed a second heart transplant on Phillip Blaiberg, 12 days after Washkansky's death.142 Blaiberg was discharged from the hospital and became a celebrity during the several months he lived after the transplant. Blaiberg's procedure indicated that a heart transplant was an option for humans suffering from end-stage heart disease. Within a year of Barnard's first heart transplant, 99 heart transplants had been performed by cardiac surgeons around the world. However, by the end of 1968, most groups abandoned heart transplantation because of the extremely high mortality related to rejection. Shumway and Lower, Barnard, and a few others persevered both clinically and in the laboratory. Their efforts in discovering better drugs for immunosuppression eventually established heart transplantation as we know it today.

A clinical trial of heart-lung transplantation was commenced at Stanford University in 1981 by Reitz and colleagues.143 Their first patient was treated with a combination of cyclosporine and azathioprine. The patient was discharged from the hospital in good condition and was well more than 5 years after the transplant.

The current success with heart, heart-lung, and lung transplantation is related in part to the discovery of cyclosporine by workers at the Sandoz Laboratory in Basel, Switzerland, in 1970. In December of 1980, cyclosporine was introduced at Stanford for cardiac transplantation. The incidence of rejection was not reduced, nor was the incidence of infection. However, these two major complications of cardiac transplantation were less severe when cyclosporine was used. Availability of cyclosporine stimulated many new programs across the United States in the mid-1980s.

The first human lung transplant was performed by Hardy and colleagues144 at the University of Mississippi on June 11, 1964. The patient died on the 17th postoperative day. In 1971, a Belgian surgeon, Fritz Derom, achieved a 10-month survival in a patient with pulmonary silicosis.145

Much of the credit, however, for the success of lung transplantation belongs to the Toronto group, whose efforts were headed by Joel Cooper. Their successes were based on laboratory experimentation and the discovery of cyclosporine. After losing an early patient to bronchial anastomotic dehiscence in 1978, the group substituted cyclosporine for cortisone and wrapped the bronchial suture line with a pedicle of omentum. They also developed a comprehensive preoperative preparation program that increased the strength and nutritional status of the recipients. In 1986, Cooper and associates presented their first two successful patients, who had returned to normal activities and were alive 14 and 26 months after operation.146

In 1963, Kantrowitz and colleagues reported the first use of the intra-aortic balloon pump (IABP) in three patients.147 All were in cardiogenic shock but improved during balloon pumping. One survived to leave the hospital.

In 1963, Liotta and colleagues reported a 42-year-old man who had a stenotic aortic valve replaced but suffered a cardiac arrest the following morning.148 The patient was resuscitated but developed severe ventricular failure. An artificial intrathoracic circulatory pump was implanted. The patient's pulmonary edema cleared, but he died 4 days later with the pump working continuously. In 1966, the same group used a newer intrathoracic pump to support another patient who could not be weaned from cardiopulmonary bypass. This pump maintained the circulation. The patient eventually died before the pump could be removed.149 Later that year, the same group used a left ventricular assist device (LVAD) in a woman who could not be weaned from cardiopulmonary bypass after double valve replacement.150 After 10 days of circulatory assistance, the patient was weaned successfully from the device and recovered. This woman was probably the first patient to be weaned from an assist device and leave the hospital.

The first human application of a totally artificial heart was by Denton Cooley and colleagues as a "bridge" to transplantation.151 They implanted a totally artificial heart in a patient who could not be weaned from cardiopulmonary bypass. After 64 hours of artificial heart support, heart transplantation was performed, but the patient died of Pseudomonas pneumonia 32 hours after transplantation. The first two patients bridged successfully to transplantation were reported at almost the same time and in the same location by different groups. On September 5, 1984, in San Francisco,152 Donald Hill implanted a Pierce-Donachy LVAD in a patient in cardiogenic shock. The patient received a successful transplant 2 days later and was discharged subsequently. The assist device used by Hill was developed at Pennsylvania State University by Pierce and Donachy. Phillip Oyer and colleagues at Stanford University placed an electrically driven Novacor LVAD in a patient in cardiogenic shock on September 7, 1984.153 The patient was transplanted successfully and survived beyond 3 years. The device used by the Stanford group was developed by Peer Portner.

The first implantation of a permanent totally artificial heart (Jarvik-7) was performed by DeVries and colleagues at the University of Utah in 1982.154 By 1985, they had implanted the Jarvik in four patients, and one survived for 620 days after implantation. This initial clinical experience was based heavily on the work of Kolff and colleagues.

Alexis Carrel was responsible for one of the great surgical advances of the twentieth century: techniques for suturing and transplanting blood vessels.155 Although Carrel initially developed his methods of blood vessel anastomosis in Lyon, France, his work with Charles Guthrie in Chicago led to many major advances in vascular, cardiac, and transplantation surgery. In a short period of time, these investigators perfected techniques for blood vessel anastomoses and transposition of arterial and venous segments using both fresh and frozen grafts. After leaving Chicago, Carrel continued to expand his work on blood vessels and organ transplantation and in 1912 received the Nobel Prize. Interestingly, Carrel's work did not receive immediate clinical application.

Rudolph Matas pioneered clinical vascular surgery. Matas' work took place before drugs were available to prevent blood clotting, before antibiotics, and without reliable blood vessel substitutes.156 Matas performed 620 vascular operations between 1888 and 1940. Only 101 of these were attempts to repair arteries; most involved ligation. Matas developed three variations of his well-known endoaneurysmorrhaphy procedure. The most advanced was to reconstruct the wall of the blood vessel from within while using a rubber tube as a stent.

Vascular surgery advanced tentatively during World War II as traumatic injuries to major blood vessels were repaired in some soldiers with results significantly better than with the standard treatment of ligation.157 The successful treatment of coarctation of the aorta by Crafoord and Gross added a major boost to the reconstructive surgery of arteries.

Shumaker reported the excision of a small descending thoracic aortic aneurysm with reanastomosis of the aorta in 1948.158 Swan and colleagues159 repaired a complex aneurysmal coarctation and used aortic homograft for reconstruction in 1950. Gross160 reported a series of similar cases using homograft replacement. In 1951, DuBost and colleagues161 in Paris resected an intra-abdominal aortic aneurysm with homograft replacement.

In 1953, Henry Bahnson,162 from Johns Hopkins, successfully resected six saccular aneurysms of the aorta in eight patients. In the same year, DeBakey and Cooley163 reported a 46-year-old man who had resection of a huge aneurysm of the descending thoracic aorta that measured approximately 20 cm in length and in greatest diameter. The aneurysm was resected and replaced with an aortic homograft approximately 15 cm in length.

During the Korean War, the arterial homograft and autogenous vein graft were used to reconstruct battlefield arterial injuries and reduce the overall amputation rate to 11.1%164 compared with the rate of 49.6% reported in World War II. Although the vein autograft remains the first-choice peripheral vascular conduit today, the arterial homograft was superseded by the development of synthetic vascular grafts by Arthur Voorhees at Columbia University in 1952. Voorhees and colleagues developed Vinyon-N cloth tubes to substitute for diseased arterial segments.165

Another advance in aortic surgery appeared in 1955 when DeBakey and colleagues166 reported six cases of aortic dissection treated by aggressive surgery. Because mortality of operation for acute dissections remained high, Myron Wheat Jr introduced medical therapy for the disease.167

During the late 1950s, the Houston group, consisting of Michael DeBakey, Denton Cooley, Stanley Crawford, and their other associates, systematically developed operations for resection and graft replacement of the ascending aorta,168 descending aorta, and thoracoabdominal aorta.169 Cardiopulmonary bypass was used for the ascending aortic resections. The high risk of paraplegia highlighted a major complication of thoracoabdominal aortic resections. The Houston group was the first to resect an aortic arch with the use of cardiopulmonary bypass in 1957 and replace the arch with a reconstituted aortic arch homograph.170 More interesting is that Cooley and colleagues, using great ingenuity, resected a large aortic arch aneurysm that also involved a portion of the descending aorta in a 49-year-old patient on June 24, 1955. The surgery was done, without the use of cardiopulmonary bypass, by first sewing in a temporary graft from the ascending aorta to the distal descending aorta and sewing in two more temporary limbs off that graft, which were anastomosed to the left and right carotid arteries, while the aneurysm was resected and a permanent graft was placed.171

In 1968, Bentall and De Bono172 introduced replacement of the ascending aorta and aortic valve with reanastomoses of the coronary ostia to the replacement graft. They described the composite-graft technique for replacement of the ascending aorta with reimplantation of the coronary arteries into the composite Dacron graft containing the prosthetic aortic valve. As mentioned, Cooley and DeBakey were first to replace the supracoronary ascending aorta in 1956. In 1963, Starr and colleagues173 reported replacing the supracoronary ascending aorta and the aortic valve at the same sitting. The technique of fashioning "buttons" of aortic tissue adjacent to the coronary ostia and then incorporating these buttons into the aortic graft along with the aortic valve replacement was described by Wheat and colleagues174 in 1964. Bentall and De Bono incorporated the aortic prosthesis into the tube graft and used the Wheat technique for implanting the coronary arteries into the composite graft.

Since the early 1990s, stents also have been used for the treatment of aneurysms in both the descending aorta and abdominal aorta.175,176 The progress in this field is moving rapidly.

The history of adult cardiac surgery continues to be written and will continue to evolve as long as acquired heart disease shortens lives. In the early days after the introduction of cardiopulmonary bypass, the pace of advance was torrid but, in a way, narrowly focused. Now hundreds of thousands of clinicians, scientists, and engineers are involved in a broad and deep effort to develop new and safer operations and procedures, new valves, new revascularization techniques, new biomaterials, new heart substitutes, new life-support systems, and new methods to control cardiac arrhythmias and ventricular remodeling after injury. This research and development is supported by a vigorous infrastructure of basic science in biology and medicine, chemistry and pharmacology, and engineering and computer technology. The history of cardiac surgery is only a prelude; the moving finger writes and having writ moves on to a bright, exciting future.