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Pioneers of Heart Surgery
For most of        [World War II surgery tent]
history, the human
heart has been
regarded as a forbidden organ too delicate to
tamper with. It might have remained so, were it
not for World War II. Military doctors, facing
injury and suffering on a massive scale,
pioneered advances in antibiotics, anesthesia
and blood transfusions -- advances that would
usher in the age of modern surgery.
One of the first surgeons to use these improved
techniques to gain access to the heart was Dr.
Dwight Harken, a young U.S. Army surgeon. Many
of Harken's patients were young soldiers
[Dr. Dwight Harken]  evacuated from the
European front with shell
fragments and bullets
lodged inside their hearts. To leave the
shrapnel in was dangerous, but removing it was
almost surely fatal. Harken began operating on
animals, trying to develop a technique that
would allow him to cut into the wall of a still
beating heart, insert a finger, locate the
shrapnel and remove it. All of his first 14
animals subjects died. Of the second group of
14, half died. Of the third group of 14, only 2
died. Harken felt ready to try the technique on
humans. All of his patients survived, proving
that the human heart could be operated upon.
It wasn't long before surgeons began wondering
if Harken's technique might be applied to
defective heart valves. In 1948, within days of
each other, Harken and a Philadelphia surgeon,
Dr. Charles Bailey, independently reported on a
daring procedure to correct mitral stenosis: a
condition where the mitral valve (see Hot
Science) is narrowed and won't open properly.
Just as with the soldiers, a small hole was cut
in the side of a beating heart and a finger was
inserted to find and very carefully widen the
narrowed valve. Early results were disastrous,
with the majority of patients dying. Gradually,
though, surgeons improved their technique and
the procedure became quite safe. This kind of
blind surgery -- or closed heart surgery --
spread to hospitals around the world.
Impressive as the technique was, it made little
difference to patients suffering from more
serious heart defects -- children born with
congenital heart disorders, breathless and blue
and condemned to  [child with rheumatic fever]
an early death --
or victims of
rheumatic fever whose heart valves were
narrowed or stuck. If surgeons couldn't work on
the heart from the inside, nothing could be
done. But how could surgeons open up the heart
without their patients bleeding to death?
Temporarily stopping a patient's circulation
only gave doctors about four minutes to work
before brain damage from oxygen deprivation
took place.
At the University of Minnesota, a young
Canadian surgeon named Dr. Bill Bigelow came up
with the first workable, if highly bizarre,
answer. He had noticed how hibernating animals,
like ground hogs, survived the bitterly cold
Canadian winters. Their hearts beat slower,
allowing them to survive for months without
food. Wondering if cold might be the key to
operating inside the heart, Bigelow began
animal experiments and found that when dogs
were cooled, open heart surgery could be done
for long periods -- much longer than four
minutes -- and they didn't die. He showed that
at lower temperatures, the tissues of the body
and brain didn't need as much oxygen, and could
survive without oxygenated blood for longer.
On September 2, 1952, two University of
Minnesota surgeons, Dr. Walton Lillehei and Dr.
John Lewis, attempted the first open heart
surgery on a five-year-old girl who had been
born with a hole in her heart. Anaesthetized to
stop her shivering, the girl was cooled by a
special blanket until her body temperature
reached 81 degrees F. At this temperature, she
could survive without a pumping heart for ten
minutes, not four. Clamping the inflow to her
heart so that it emptied of blood, Lillehei and
[Surgeons performing open heart surgery]  Lewis

cut open her heart, which was still slowly beating, and
quickly sewed up the hole. With the repaired
heart working properly for the first time in
her life, the girl was then immersed in a bath
of warm water to bring her body temperature
back to normal. The operation was a success.
The "hypothermic approach" became very
successful in treating small heart defects. But
all too often, surgeons opened hearts to find
more complex defects -- defects that couldn't
be repaired in 10 minutes. With the clock
ticking away, they did what they could, but it
was clear that a better approach needed to be
found.

The dream of building a machine to take over
the function of the heart and lungs during
surgery had existed before World War II. Early
prototypes, built by pioneers like Dr. John
Gibbon in      [patient in heart/lung machine]
Great Britain,
were
cumbersome and dangerous -- often leaking
blood, damaging blood cells and causing air
embolisms. It wasn't until 1958, when a system
that involved bubbling blood was perfected,
that "heart-lung" machines came of age. Dr.
Dennis Melrose of London further increased
chances for success when he pioneered an
injection that stopped the heart from beating
during surgery.
Now surgeons had time to work on a heart that
was not only empty of blood, but which wasn't
moving. And they had time to correct the most
serious abnormalities. Holes which were too big
to be sewn up were patched. Where valves were
damaged beyond repair, artificial valves were
put in. Blocked arteries were bypassed.
Weakened arteries were replaced altogether.
Modern heart surgery seemed unstoppable.
But a major problem still remained -- what to
do for patients whose very heart muscle was
diseased beyond repair? Could these patients be
given new hearts? By 1966, heart surgeons were
ready to take on the challenge. Most, like Dr.
Michael De Bakey of Houston, thought the answer
lay in artificial hearts. But the future would
lie in a different direction: heart
transplants. Kidneys had been transplanted
successfully as early as 1963, after the
complexities of tissue rejection were solved
with drugs that suppressed the immune response.
If the barrier had been breached for the
kidney, why not for the heart?
In December of 1967, a South African surgeon,
Dr. Christiaan Barnard, transplanted the heart
of a 23-year-old woman killed in a motor
vehicle accident into the chest of a
middle-aged man. He lived for eighteen days,
until the powerful drugs used to suppress
rejection weakened him and he died of
pneumonia. The second patient to receive a
heart transplant, at the hands of Dr. Adrian
Kantrowitz in the United States, lived only six
hours. But Dr. Barnard's next heart-transplant
patient lived for 18 months and became a symbol
of hope for victims of heart disease. All over
the world patients were asking and receiving
the new miracle operation.
But these surgical triumphs proved short-lived.
Patients began dying of either rejection or
infection. By 1971, 146 of the first 170 heart
transplant recipients were dead. What first
looked like another surgical miracle had turned
into a disaster. Heart surgeons who had
promoted the operation admitted defeat.
Only one American surgeon would continue -- Dr.
Norman Shumway. Throughout the 1970's, he built
a team of scientists and doctors to tackle the
complex biological problem of tissue rejection
in a careful, scientific manner. His team
[Dr. Norman Shumway]  devised a way of spotting
rejection attacks, by
feeding a catheter into
the heart and removing a piece of heart muscle
for examination. Only when signs of rejection
were seen were doses of the dangerous
immuno-suppressive drugs increased. And Shumway
benefited from a chance discovery made in
another part of the world.
In the soil of Norway's Hardaanger fjord, a
fungus was found which contained a compound
that would revolutionize transplant surgery.
The substance, called cyclosporin, appeared to
have exquisite immuno-suppressant properties --
controlling organ rejection without knocking
out all resistance to infection. In the hands
of Dr. Shumway, cyclosporin transformed the
picture for heart transplant recipients.
Hospitals around the world began to re-open
their heart transplant units and their patients
began to survive and prosper.
But this breakthrough has come with
limitations, too. The problem with heart
transplants now has become finding enough
hearts. Today in the United States alone, 2
million people suffer from congestive heart
failure. When drug treatments fail, transplants
are the best hope. But less than 2,500 donor
hearts are available each year, leaving
thousands of patients desperate for an
alternative.
In 1994, Dr. Randas       [Dr. Randas Batista]
Batista of Brazil devised
a radical new surgical
technique to treat a common form of heart
failure for people with enlarged hearts.
Normally, oxygen-rich blood flows into the left
side of the heart from the lungs (see Hot
Science). The left ventricle is responsible for
pumping the blood out to the rest of the body.
When the heart becomes diseased, it sometimes
dilates or swells. The contractions become
sluggish and the left ventricle is unable to
squeeze out enough blood. Blood backs up in the
heart and the lungs, resulting in congestive
heart failure.
[Batista procedure - cutting into the heart]  Batista's
idea
was
to cut a swath out of the left ventricle and
sew the chamber back together, thereby reducing
its size and increasing its efficiency.
Gradually, news of Batista's radical approach
spread and, currently, a small number of
surgeons around the world are experimenting
with the procedure. Their results, so far, have
been mixed. More time and innovation are needed
before it's known whether this technique will
be the next milestone in the history of heart
surgery.
Photos: (1) © NARA; (2) © Fabian Bachrach; (3,
5) © WHO; (4) © NIH;
(6) © N. Shumway; (7-8) WGBH Educational
Foundation.

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