Origins and Evolution of Extracorporeal Circulation: JACC Historical Breakthroughs in Perspective

Midway through the 20th century, direct open-heart operations were not yet a reality, awaiting safe methods to support the cardiopulmonary circulation during cardiac surgery. The scientific advancements collectively leading to safe cardiopulmonary bypass are considered some of the most impactful advances of modern medicine. Stimulated by the work of physiologists and engineers in the late 19th century, primitive pump and oxygenator designs were the forerunners of major work by DeBakey and others in roller pump design and by Gibbon in oxygenator development. Following Gibbon's historic successful closure of an atrial septal defect in 1953 with his heart-lung machine, it was left to Lillehei and Kirklin to first successfully repair large series of cardiac malformations. The history leading to these historic events and the subsequent evolution of cardiopulmonary bypass machines for short- and longer-term support is filled with engineering and surgical brilliance, daring innovations, and serendipity.

Bernard J. Miller: MD, ScD. (Hon), FACS: Lifelong Surgeon-Scientist and Critical Contributor to the Gibbon Heart-Lung Machine

Bernard J. Miller, MD, ScD. (Hon), FACS, is known as a critical contributor for his work in the John H. Gibbon, MD, laboratory for his work on the heart-lung machine (HLM). In this setting, Dr. Miller developed the fluid control servo system, which was necessary to prevent malfunctioning of the HLM and prevent air emboli. Additionally, Dr. Miller assisted in conceiving and testing the left ventricular vent, the positive-negative pressure ventilator, and the HLM oxygenator; these inventions were all the product of extensive collaboration between the International Business Machines Corporation and the members of Dr. Gibbon's laboratory. Furthermore, Dr. Miller was a surgical assistant and perfusionist in the first successful open-heart surgery. Herein, we seek to describe Dr. Miller's story and his contributions to the HLM, as well as the contributions that were developed by the laboratory at that time. Additionally, we describe critical events leading up to the first successful use of the HLM on May 6, 1953, including a previously unreported use of the HLM for partial bypass of the right heart at Pennsylvania Hospital in 1952. Finally, we present the rest of Dr. Miller's professional and personal successes after his work on the HLM ended.

[Operating upon the Bloodless Heart : A History of Surgical Time between Craft, Machines and Organisms, 1900-1950]

Up until now time has rarely been considered in the historiography of surgery. However, the emergence of modern operating procedures is based significantly on establishing controlled relations of time by adjusting organic, technological and organizational processes. Early cardiac surgery in particular faced a crucial time problem: excluding the heart from the circulatory system long enough to operate inside its bloodless chambers. This problem can be traced back to the early 20th century, when surgeons such as Ludwig Rehn (1849-1930), Friedrich Trendelenburg (1844-1924), and Alexis Carrel (1873-1944) experimented with occlusions of the great vessels. Throughout the first half of the century, various attempts were made to prolong the possible time of circulatory arrest. In this regard, Arthur W. Meyer (1885-1934) in Berlin developed surgical craft procedures, John H. Gibbon Jr. (1903-1973) worked on constructing a heart-lung machine in Boston/Philadelphia, and Wilfred G. Bigelow in Toronto experimented with lowering the temperature of the body. Meticulous scrutiny of these developments illustrates how heterogeneous periods, rhythms, and paces had to be harmonized in order to gain decisive minutes or even seconds. Therefore, major developments on the way to open heart surgery can be described as a history of surgical time.

Making heart-lung machines work in India: Imports, indigenous innovation and the challenge of replicating cardiac surgery in Bombay, 1952-1962

In 1962, surgeons at two hospitals in Bombay used heart-lung machines to perform open-heart surgery. The devices that made this work possible had been developed in Minneapolis in 1955 and commercialized by 1957. However, restrictions on currency exchange and foreign imports made it difficult for surgeons in India to acquire this new technology. The two surgeons, Kersi Dastur and PK Sen, pursued different strategies to acquire the ideas, equipment, and tacit knowledge needed to make open-heart surgery work. While Dastur tapped Parsi networks that linked him to local manufacturing expertise, Sen took advantage of opportunities offered by the Rockefeller Foundation to access international training and medical device companies. Each experienced steep learning curves as they pursued the know-how needed to use the machines successfully in dogs and then patients. The establishment of open-heart surgery in India required the investment of substantial labor and resources. Specific local, national, and transnational interests motivated the efforts. Heart-lung machines, for instance, took on new meanings amid the nationalist politics of independent India: Even as surgeons sought imported machines, they and their allies assigned considerable value to 'indigenous' innovation. The confluence of the many interests that made Sen and Dastur's work possible facilitated the uneasy co-existence of conflicting judgments about the success or failure of this medical innovation.

[Kolff and the artificial kidney]

Willem Kolff (1911-2009), son of a physician, studied medicine in Leiden and specialised in internal medicine in Groningen. It was there that he started attempts to apply the phenomenon of dialysis in patients suffering from renal failure. He built the first prototypes of dialysis machines after his appointment as an internist in the municipal hospital in Kampen, during the Second World War. Indeed, in the first 15 patients he managed to decrease urea levels, resulting in temporary clinical improvement, but eventually they all died. It was not until after the war that dialysis helped a patient survive an episode of acute glomerulonephritis. After 1950 he continued his work on artificial organs in the United States (first in Cleveland and later, after 1967, in Salt Lake City). Although most of his work from then on revolved around the development of an artificial heart, he also contributed to the design of a compact, disposable apparatus for dialysis, the 'twin coil'. Haemodialysis also became feasible for patients with chronic renal failure after the 'Scribner shunt' (1960) provided easy access to the circulation. Peritoneal dialysis is another option. Excess mortality, mainly from cardiovascular disease, is still a largely unsolved problem.

John Heysham Gibbon and the 60th anniversary of the first successful heart-lung machine: brief notes about the development of cardiac surgery in Europe and Slovakia

The development of the heart-lung machine and its first successful clinical application in 1953 was the culmination of Dr. Gibbon's lifetime research project. Despite many technical obstacles, financial problems, and discouragement from colleagues, his goal was achieved after twenty tedious years of tireless work. Posteriorly, his academic contribution established him as a leader and pioneer in the field of cardiac surgery. Parallel to his achievement and Dr. Kirklin's surgical experience, several authors around the world attempted open-heart surgery with the heart-lung machine, particularly in Europe. In Eastern Europe and particularly in the former Czechoslovakia, the lack of access to foreign medical literature forced a group of emerging young physicians from the Second Department of Surgery at Comenius University to furtively collect data on the topic. After building the Simkovic-Bolf heart-lung machine, the first successful open-heart surgery with the new device was performed only 5 years after Dr. Gibbons' experience (Tab. 1, Fig. 4, Ref. 22).

Willem J Kolff (1911-2009): physician, inventor and pioneer: father of artificial organs

Medical pioneer Willem Johan Kolff was an inspirational father, son, physician and inventor. He founded the development of the first kidney dialysis machine, pioneered advances in the heart and lung machine, laid down the foundations for the first mainland blood bank in Europe and successfully implanted the first artificial heart into humans.

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.

John H. Gibbon, Jr., the Inventor of the First Successful Heart-Lung Machine

May 6th, 2003 marked the 50th anniversary of the first successful use of the heart-lung machine. It was an event that would dramatically change the field of cardiac surgery and the approach to the treatment of cardiac disease. It was also the culmination of years of work of Dr. John H. Gibbon, Jr. We take a look at the life of this remarkable man.

Advances in the treatment of coronary artery disease

Initial pioneering efforts of direct coronary artery bypass were all performed on a beating heart. Although originally introduced into cardiac surgery for the repair of intracardiac defects, the ability of John Gibbon's heart-lung machine to create a motionless, bloodless operative field catalyzed coronary artery bypass surgery. During the ensuing decades tens of millions of patients benefited from coronary revascularization on cardiopulmonary bypass. As we celebrate the 50th anniversary of the invention of the heart-lung machine the landscape of interventional treatment of coronary artery disease has shifted dramatically. Although instrumental in the genesis of the field of coronary revascularization, the role of the heart-lung machine has now diminished. Two thirds of all coronary revascularization is now performed by percutaneous approaches and one fourth of all coronary artery bypass grafting procedures are performed without the heart-lung machine. However owing to the complexity of patients now requiring revascularization as well as recently introduced incremental improvements to cardiopulmonary bypass including coated, low prime circuits, closed integrated systems, and pharmacologic adjuncts Gibbon's heart-lung machine will continue to play an integral role in this field.

The Early History of Cardiac Surgery in Stockholm

Cardiac surgery in Stockholm grew on a sound foundation of well-developed general thoracic surgery. The portal figure is Clarence Crafoord (1899-1983) who already in 1927 had succeeded with the Trendelenburg pulmonary embolectomy operation. He went on to develop lung surgery in general. With foresight he stimulated the chemists of Karolinska Institute to purify heparin, first for prophylaxis against venous thromboembolism and later for use with the heart-lung machine. In 1944 he became the first surgeon to successfully operate on patients with coarctation of the aorta. With Viking Olov Bjork and Ake Senning the heart-lung machine was improved, finally allowing its clinical use in a patient operated in 1954 for a myxoma of the left atrium, with long-term survival. This was the first successful use of the heart-lung machine in Sweden and the second in the world. He and his coworkers, first at the Sabbatsberg hospital and from 1957 at the Karolinska hospital made major contributions to cardiology and radiology, apart from the progresses in cardiac surgery. Contributions such as pressure recording from the left atrium by needle puncture in 1950, the Senning operation for transposition of the great arteries and the first use of a totally implantable cardiac pacemaker in 1958 are indeed medical history.

[Fifty years of the heart-lung machine. Report on the pioneers and heroes and about the circumstances that led to the great invention, which allowed the treatment, and in many cases, the cure of heart illnesses]

In 1953 DNA was discovered and the Everest was conquered but also a great invention was developed: the heart-lung machine, which allowed the treatment, and in many cases, the cure of most cardiovascular illnesses. In fact, on May 6, 1953 John Gibbon crowned with success the work of his entire life closing for the first time an atrial septal defect in a young woman using a heart-lung machine of his own invention. Before that, surgeons had explored other roads like hypothermia, cooling the patient in a cold water tub and then rapidly performing the surgical correction of a heart malformation. After his first success, the following 4 patients of Gibbon died, which led him to abandon heart surgery and produced a generalized pessimism about extracorporeal circulation. However, a year later Walton Lillehei reverted this situation with the introduction of controlled cross-circulation in which a patient, usually a child, was connected to a "donor", usually his father or mother, whose heart and lung served as a pump and oxigenator, allowing the performance of open heart surgery. Finally, it was Lillehei again who a year later introduced the bubble oxigenator, simple and inexpensive, opening the doors of open heart surgery to all surgeons around the world. For this, and many other reasons, Walton Lillebei is considered by most surgeons as the "Father of Open Heart Surgery". Lillehei visited Chile in 1963 and operated on a patient in the surgical theaters of the Hospital Clínico de la Universidad Católica and was named an Honorary Member of the School of Medicine of this University. Before that, in 1957 Helmut Jaeger at the Hospital Luis Calvo Mackenna performed the first successful surgical closure of an atrial septal defect with extracorporeal circulation in Chile using a De Wall-Lillebei bubble oxigenator.

History of extracorporeal circulation: the invention and modification of blood pumps

The first roller pump was patented in 1855 by Porter and Bradley and was hand operated. A modification first named "surgical pump", designed and manufactured by E. E. Allen in 1887, was intended for direct blood transfusion. Truax, who also distributed and promoted the Allen pump with one roller, developed the first double roller pump in 1899. In the following decades, several researchers, including Beck, Van Allen, Bayliss and Müller as well as Henry and Jouvelet, refined the apparatus and recommended the use of roller pumps for blood transfusion and other applications. After further modifications made by DeBakey in 1934, and application of this pump in one of the first heart-lung machines constructed by Gibbon, DeBakey's name became inseparably attached to this type of pump. For perfusion experiments, an electrically powered roller pump was first used by Fleisch in 1935. Today, the roller pump is the most frequently used blood pump for cardiopulmonary bypass worldwide, having prevailed against the early pulsatile tube compression pumps and ventricular pumps. In recent years, centrifugal pumps have increasingly competed with roller pumps as systemic blood pumps for cardiopulmonary bypass and have become the preferred arterial pump in a variety of centers. Application of mechanical cardiac assistance has evolved from nonpulsatile roller pump support, followed by an era of pulsatile ventricular pumps to the rediscovery of the nonpulsatile flow mode with modern axial flow pumps.

History of extracorporeal circulation: the conceptional and developmental period

The development of modern techniques in extracorporeal circulation is the result of the combined efforts of physiologists, physicians, and engineers. Early experimental work at the end of the 19th century was accomplished by physiologists, such as von Schröder, von Frey, and Gruber, as well as Jacobj. These scientists laid the foundation for three different artificial oxygenation devices for experimental isolated animal organ perfusion. The developed bubble, film, and isolated lung oxygenation methods developed were later used for the first clinical cardiopulmonary bypass procedures in humans. For continuous perfusion experiments, closed circulation circuits were put into use. In a second step, during the first half of the 20th century, scientists and physicians, such as Brukhonenko, Gibbon, Crafoord, Björk, and Jongbloed were working on the refinement of these methods for intended application during cardiovascular operations in humans. Refined bubble and film oxygenators together with the modern blood pumps in closed circulatory systems were assembled as pump oxygenators, later called heart-lung machines. They were used in the first clinical cases of extracorporeal circulation for heart surgery in the second half of the 20th century by Dennis, Dogliotti and Constantini, and Gibbon.

First steps in membrane oxygenation and prolonged extracorporeal perfusion in Duesseldorf using the Bramson membrane lung

After a shortened history of conventional closed and open heart surgery, including hypothermia by surface cooling and extracorporeal circulation, the first application of a new membrane oxygenator developed by ML Bramson with an integrated temperature exchange system and a heart-lung machine (HLM) was reported in 1972. The aim was to have an efficient oxygenating and gas exchange artificial lung that allowed prolonged perfusions in patients with cardiogenic shock or acute respiratory insufficiency. After in vitro closed recirculation studies comparing different bubble, vertical screen, and the new membrane oxygenators, the Bramson HLM was used in dog experiments before starting clinical cardiac surgery with routine interventions (closure of an atrial septal defect). The first clinically prolonged support for more than three hours after a double valve replacement in a NYHA class IV patient failed. A partial venoarterial prolonged perfusion for 42 hours and 43 minutes in a 10-year-old girl after surgical correction of a partial av canal defect and postoperative development of consistent lung edema caused by myocardial failure after an ischemic time of 43 minutes was the first successful long-term perfusion case in Europe. These first experiences with the Bramson membrane lung formed the basis, in our group, for further investigations of different perfusion routes and cannulations in animal experiments. Also, scanning electron microscopy studies could be performed with experimentally and clinically used membranes. The development of disposable membrane lung devices, for instance, Lande-Edwards, Kolobow Scimed, and General Electric Peirce membrane lungs, ameliorated and improved the use of these devices considerably. Also, BRAMSON had developed a disposable membrane lung device that had proved to be very effective in animal experiments by 1972, but, unfortunately, this device did not become commercially available.

Origin of the helical reservoir bubble oxygenator heart-lung machine

Open-heart surgery was not possible before the early 1950s. Such surgery awaited the development of cardiopulmonary bypass. The development of controlled cross-circulation at the University of Minnesota in 1953 was a major contributing factor towards operating safely on the interior of the heart. Cross-circulation required connecting a donor's arterial and venous blood vessels to those of a smaller recipient whose heart could then be opened for corrective surgery. At that time, no mechanical system was available to serve the role of the donor. The need to replace the donor as soon as possible was recognized. The author has recounted his experience with the development of a bubble oxygenator system, which replaced the donor as was used in cross-circulation open-heart surgery.

Development of Pump-Oxygenator Systems and the Origins of Open-Heart Surgery: A Personal Memoir

Intracardiac surgery requires the use of a pump-oxygenator to maintain life while the heart is taken out of its usual circuit. Open-heart surgery became practical with the introduction of perfusion systems in the early 1950s. Many factors merged at this time to initiate the beginnings of open-heart surgery.