Arteriovenous Fistula: The Backstory of the Birth of Cardiovascular Surgery

The foundation for the celebrated operation on patent ductus arteriosus (PDA) in 1938 was the work on arteriovenous fistula (AVF) during the preceding half century. Galen and Osler wrote about it, and AVF was a major interest of leading surgeons of the late 19th and early 20th centuries, such as William Halsted, Rudolph Matas, Mont Reid, and Emile Holman. Nearly all AVFs of the era developed because of penetrating injury to major vessels. Survivors suffered gradual debilitation and faced death from gangrene or rupture. Development of an operation with a reasonable chance for success came only after the development of the cornerstones of modern surgery: suture, needles, anesthesia, and antiseptic and aseptic surgery. The only durable solution was quadruple ligation, ligation of both the vein and artery above and below the site of the fistula, and a technically demanding operation that risked ischemia and gangrene. Techniques pioneered by Alexis Carrel and Bernard Bertheim allowed strategies of early vascular reconstruction that reestablished normal circulation. Seeing patients with AVF with heart failure, Halsted recognized PDA as a naturally occurring AVF. Other surgeons proposed that ligation of PDA would be lifesaving. The struggles to understand and devise operative strategies to deal with AVF were the first steps toward the spectacular advances in cardiovascular surgery that followed.

[The world's fist successful closure of the wound of the ascending aorta. Russian priority]

The year of 1896 became the starting point in the development of cardiovascular surgery, since it was just then that Ludwig Rhen was the first in the world to have performed a successful closure of a right-ventricle wound, thus opening up the era of active surgical policy in heart wounds. However, tangible progress in surgical management of intrathoracic vessels was made later on. One of the important stages of this trend was a successful closure of an ascending-aorta wound performed by I.I. Dzhanelidze in 1913. It was not only the world's first successful operation performed in a traumatic lesion of the ascending aorta but also apf intervention giving rise to further development of surgery in this field. The present-day notions concerning surgical policy in traumatic lesions of intrathoracic vessels are based on the experience of prominent and outstanding surgeons of the 20th century. The material for this publication was I.I. Dzhanelidze's article entitled "A case of ascending- aorta wound closure" and published in 1916.

Heart surgeon Miro Košak (1919-2010) and his contribution to the development of cardiovascular surgery in slovenia

Heart surgeon Miro Košak was a pioneer of modern cardiovascular surgery in Slovenia; in 1958, he performed the first open-heart surgery with extracorporeal circulation, in 1965, the first implantation of heart valve and pacemaker, and in 1971, the first bypass on coronary arteries. He also paved the way for heart transplantations that followed.

C Walton Lillehei (1918-99): the versatile pioneer of open-heart surgery

Walton Lillehei can be truly regarded as the 'Father of Open-Heart Surgery'. His career demonstrates the virtues of tenacity and the ability to overcome adversity and opposition in the taking forward of significant innovation.

[Cardiovascular surgery in a hospital]

The problem of effectuating of a specialized aid to the patients with damages of vessels, enlargement of the patients with cardio- and vessel-diseases, a high lethality and invalidization formed a need for organization of specialized units. The first staff unit of vessel-surgery in the Armed Forces was created in 1968 in CMCH of Vishnevsky A.A. Since 1981 hospital became the main base of preparing vessel-surgeons. The author showed the role of prime specialists in elaborating and development of a new direction in treatment of the patients with cardio- and vessel-damages.

[Michael Ellis DeBakey (1908-2008): a short biography]

On July 11, 2008, expired in Houston, Texas, Michael Ellis DeBakey, who was a legendary figure of Medicine of the XX century and of cardiovascular surgery in particular, due to the enormous contributions he gave to the progress and development of contemporary cardiac and vascular surgery. Michael Ellis DeBakey can be remembered as well as a distinguished investigator, educator, academician and medical statesman, recognized and admired in his country and all over the world, including Portugal. The course of his life and major achievements are described and remembered, as a single tribute payed by a former disciple, bringing to the new generations of physicians the example of a fully active, criative and laborious life committed and devoted to the fight against disease and promotion of mankind welfare.

[History of rhythm surgery with focus on surgical ablation procedures to treate atrial fibrillation]

Rhythm surgery, which was initiated many years ago, has fundamentally changed by the development of sparing interventional treatment procedures and the successful introduction of the implantable defibrillator.A cornerstone in the history was the first successful treatment of a patient with Wolff-Parkinson-White-Syndrome separating accessory conduction lines between atrium and ventricle in 1968. The experience and knowledge of the surgical therapy of the 70ies has promoted the implementation of successful interventional ablation procedures in the early 80ies.Further steps in the rapidly developing area of rhythm surgery were the left and right atrial isolation procedures for the treatment of automatically atrial tachycardia's, the use of cryo-surgery for AV-node ablation in patients with AV-re-entry tachycardia's in the 80ies and finally the procedures for the treatment of atrial fibrillation like the transsection procedure, the corridor operation and the Maze procedure. Special methods for the therapy of ventricular arrhythmias should be mentioned for the sake of completeness, but are not extensively discussed. These are the right ventricular disconnection procedure, endocardial and subendocardial resections, endocardial cryo-ablation, the Jatene- and Dor-operation for the treatment of ischemic ventricular arrhythmias. Out of the original indications, today the therapy of atrial fibrillation has become more and more important and represents a booming part of rhythm surgery in the last decade. The unsatisfactory results of medical treatment, new understanding of the pathophysiology of atrial fibrillation and the introduction of simplified ablation procedures have led to a markable increase of rhythm surgery procedures. One reason is the increasing life expectancy of the population leading to a higher incidence of atrial fibrillation, which makes this arrhythmia to the most common rhythm disturbance. This growing number of patients is a challenge for cardiac surgery today and leads the focus on this special part.

Cardiology at Westmead Hospital from 1990 to 2007

Professor John Uther was the Director of Cardiology at Westmead Hospital from 1979 to 1990. Professor David Ross and Dr Pramesh Kovoor followed in this capacity subsequently. Networking between Westmead and metropolitan hospitals was established by conjoint appointment of cardiologists across the facilities. Westmead has maintained its excellence in electrophysiology with leadership in operative/catheter ablation of atrial fibrillation, development of catheter for mapping tricuspid annulus, multi-electrode mapping and intramural ablation of ventricular tachycardia and paediatric electrophysiology. Dr. Hugh Paterson became the Director of Cardiothoracic Surgery in 2006. The previous Directors were Dr. David Johnson, Dr. Graham Nunn and Associate Professor Richard Chard. Westmead established an area-wide acute infarct angioplasty service for all patients presenting to any facility in Western Sydney along with triage of chest pain in the ambulance in 2004. Collaborative sessions with vascular surgeons for non-coronary interventions commenced in 2005. In the future, Westmead will continue its excellence in vascular and electrophysiological interventions. Imaging (echocardiography, computerised tomography and magnetic resonance imaging) will be a major part of the service. Innovation in basic science is likely. Overall, it will be an exciting time to be a cardiologist, vascular surgeon or cardiothoracic surgeon at Westmead.

History of surgical treatment of ischemic heart disease--pre-'coronary bypass grafting' era

BACKGROUND AND AIM

To review the various concepts, surgical experiments, and actual procedures performed for the treatment of ischemic heart disease, which eventually led to the evolution of direct coronary artery bypass surgery.

METHODS

References were collected from original articles and through pubmed search.

RESULTS

Various concepts and procedures were introduced, all with the aim of increasing myocardial blood flow and relief of angina. These included creation of vascular adhesions, denervation, thyroidectomies, using other organs for providing blood supply, and intramyocardial implantation of bleeding systemic arteries.

CONCLUSION

Historically various innovative concepts existed and a variety of procedures were performed for treating ischemic myocardium, with variable results. These procedures continued till the evolution of direct coronary artery bypass grafting.

[To the history of organisation and development of cardiac anesthesiology in the A. N. Bakulev Research Center of Cardiovascular Surgery of the Russian Academy of Medical Sciences: the start of activities (1956-1965)]

The authors present data on the development and introduction of anesthetic techniques during cardiac surgery at the Institute of Thoracic Surgery, USSR Academy of Medical Sciences, in 1956-1960 and after its reorganization to the Institute of Cardiovascular Surgery, USSR Academy of Medical Sciences, in 1961-1965. It is shown that in the years of introduction of closed operations on the heart, the methods of one- and many component inhalational anesthesia were mastered, its techniques were developed, anesthesia apparatuses and an anesthesia schedule were designed, cardiac anesthesiological studies were conducted, training of physicians from the country's regions was initiated, and the first guidelines for general anesthesia were published. In these years, the firm foundation was laid for the development of cardiac anesthesia. Later on the Institute developed and introduces all basic types of inhalational anesthesia during operations on the open heart under both extracorporeal circulation and hypothermia. The gained experience allowed the laboratory staff to defend several dissertations, to issue two monographs, and to analyze errors and risks of general anesthesia in patients with cardiovascular diseases at surgery.

Congenital Heart Disease: A Surgical-Historical Perspective

Pediatric cardiac surgery began with Dr Gross's first successful ligation of a patent ductus arteriosus on August 8, 1938, at the Children's Hospital in Boston. The beginnings of open-heart surgery for repair of congenital malformations, aside from Gibbon's first successful closure in Philadelphia of an atrial septal defect using an artificial heart-lung machine, can be traced to members of the Department of Surgery at the University of Minnesota during the fifties and sixties of the 20th century. This story will be told, and other advances will be discussed, some of which also carry the imprint of the Minnesota surgical training program, with its heavy emphasis on research.

Lillehei, Lewis, and Wangensteen: The Right Mix for Giant Achievements in Cardiac Surgery

The dawn of open-heart surgery occurred at the University of Minnesota on September 2, 1952, when Dr John Lewis and his surgical team closed an atrial septal defect using total-body hypothermia and inflow stasis. Eighteen months later on March 26, 1954, Dr C. Walton Lillehei and his surgical team used a parent as a biologic oxygenator to repair a ventricular septal defect in a 1-year-old boy. This technique of cross circulation was then used in a total of 45 children during the next 16 months to successfully repair tetralogy of Fallot, atrioventricular canal, and ventricular septal defect. Remarkably, two thirds of these children were discharged from the hospital. Thirty years later, Dr Lillehei reported that 17 of his 27 patients with repair of a ventricular septal defect had survived and were all New York Heart Association class I. These landmark operations in the open heart could not have been achieved by Drs Lewis and Lillehei without the remarkable support that they received from their surgical chief, Dr Owen Wangensteen. Doctor Wangensteen would later state in his book, The Rise of Surgery, that: "The outstanding contribution to the advancement of surgery in the 20th century has been the development of open-heart surgery."

Challenges of cardiology and cardiovascular surgery in 1958

The Cardiology Foundation supported by the perspicacious Princess Lilian was created in 1958. As an introduction to this symposium, the challenges that the cardiologist and surgeon encountered in 1958, are recalled as well as the essential problems requiring solutions in that era of evolving cardiac surgery.

The evolution of cardiovascular surgery in China

The history of the development of cardiovascular surgery in China was little known to the West not only because the majority of the earlier reports were published almost exclusively in the Chinese language but also because China was essentially closed to the West before the 1980s. We present here an account of how some Chinese surgeons struggled to establish a new specialty in a country that makes up more than one fifth of the world population.

[Pierre Marion, 1914-2000. Past president of the National Academy of Surgery. An illustrious figure in the city of Lyons]

The surgical work of Pierre Marion extends over a period of 40 years. It takes part in the history of portal hypertension surgery. Pierre Marion has been in France one of the major craftsmen of heart surgery with Paul Santy. In 1952, he performed the first pulmonary-embolectomy with success and later devoted his time to the development of valves and of an artificial heart. The second part of his life was dedicated to the direction of the Bullukian Foundation, founded in 1983, with the goal of helping medical research, supporting the armenian community in our country and promoting literary, artistic and theatrical creation in Lyons and its surroundings. Pierre Marion has written two remarquable books "Afin que batte le coeur", a history of the cardiac surgery epic and "Le génial bonhomme Ampère", consecrated to the life of this great scholar.

Profulla Kumar Sen: his contributions to cardiovascular surgery

One of the most eminent cardiothoracic surgeons of India, Profulla Kumar Sen (1915-1982) had a keen interest in research and in the subsequent clinical application of knowledge gained in the laboratory. His most significant contributions are his pioneering work on a transmyocardial acupuncture technique for treatment of ischemic myocardium, on heart transplantation in canine models and later in human beings, and on a new technique for aortic arch replacement. Transmyocardial laser revascularization of the 1990s was but an extension of his mechanical myocardial acupuncture for the treatment of ischemic heart disease, which he introduced 30 years earlier. On 16 February 1968, after many years of preparation through work with animal models, P.K. Sen and his team performed the 1st cardiac transplantation in India and the 6th in the world.

Cardiology's 10 greatest discoveries of the 20th century

We present a brief summary of the 10 greatest cardiologic developments and discoveries of the 20th century Described are electrocardiography; preventive cardiology and the Framingham Study; "lipid hypotheses" and atherosclerosis; coronary care units; echocardiography; thrombolytic therapy; cardiac catheterization and coronary angiography; open-heart surgery; automatic implantable cardiac defibrillators; and coronary angioplasty. These topics are the personal choices of the authors.

[The path taken by surgery in the treatment of coronary disease. Posthumous tribute to Dr. René Favaloro]

The first surgical procedure for the treatment of coronary artery disease, in 1933, was total thyroidectomy. Some years later, procedures to increase heart irrigation such as pectoral or great epiplon grafting and cardiopeumopexy were attempted. In 1940, the ligation of great cardiac vein or coronary sinus were introduced. Five years later, pericoronary neurectomy was used. In 1945, Beck used an arteriovenous fistula between the descending aorta and the coronary sinus and, from 1954, be used the erosion of heart surface with asbestos application, complemented with the occlusion of the coronary sinus and the application of parietal pericardium. In 1958, Glover introduced the bilateral ligation of mammary arteries and Vineberg, developed the internal mammary artery implant, that consisted in the tunneling of the free portion of such artery in the myocardium. En 1956, Lillehei and Bailey introduced coronary endarterectomy and finally in 1967, Favaloro introduced systematically the aortocoronary bypass using saphenous vein, that became the definitive surgical treatment for coronary artery disease. In Chile the first coronary surgery was done by Torwall and Uribe in 1950 and modern coronary surgery was initiated by Salvestrini in 1970.