Surgery's New Frontier
"Surgery of the heart has probably reached the limits set by Nature to all surgery: no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart." So in 1896 wrote eminent British Surgeon Stephen Paget. A few weeks ago at Philadelphia's Hahnemann Hospital, eminent U.S. Surgeon Charles Philamore Bailey walked into a cluttered, unpretentious operating room which has attracted visiting medical men from all over the world. Dr. Bailey, at 46 one of the most daring innovators in heart surgery, was ready once again to push "the limits set by Nature" far beyond what was considered possible only five years ago.
The anesthetized patient on the operating table was a man of 50 whose heart had been seriously damaged by rheumatic fever. Electrodes taped to his ankles and wrists led to an electrocardiograph screen. He had a blood pressure cuff on the left arm, and the usual tube down the wind pipe, hooked up to an oxygen cylinder. Surgeon Bailey--scrubbed and all but mummified in sterile gear--stepped up to the table. He drew a scalpel lightly across the patient's chest, barely breaking the skin in a thin red line, to show where he wanted the incision. Then he stood by, relaxed, while an assistant cut deeper. To the surgical nurse standing on a low stool at the foot of the operating table, surrounded by trays of sterile instruments, went a running fire of orders:
"Mosquito" (a small blood-vessel clamp).
"Four-O" (a thread size).
"Peanut" (a little pledget of gauze).
Three dozen or more minor blood vessels had to be tied off to stanch the bleeding. One surgeon would hold a clamp on a blood vessel while another passed the suture silk around it, deftly tying knots. With ribs and breastbone now lying bare, Bailey chose which bones to cut, called "rib shears." A scrub nurse handed him a device like fowl shears with offset handles. With firm pressure of powerful hands. Bailey himself snipped the breastbone.
"Rib spreaders." A bridgelike gadget was clamped in place; with a few turns of the screw it spread the ribs six inches apart. The assistants cut deeper through the chest. "Lung retractors." The heaving lungs were pushed aside. Many more blood vessels were tied off. Bailey slit the heart sac almost from top to bottom, took quick stitches in it, left long threads which were clamped to the rib spreaders to hold the sac open.
At last the heart lay bare, red and purple with a greyish cast, glistening under the strong lights, squirming and rippling with life--a life Dr. Bailey and his team were fighting to save.
Plastic Lung. To the surgeon the heart is the center of a familiar but complex machine (see diagram). Used blood, from which all the body's tissues have removed nourishing oxygen, returns through the two great veins (superior and inferior vena cava) to the right upper chamber (auricle). It empties from there through the tricuspid valve into the right ventricle. This muscular chamber contracts and pushes the blood through the pulmonary valve and pulmonary artery to the lungs to pick up fresh oxygen. Reddened blood returns to the left auricle, passes through the mitral valve into the left ventricle. This most muscular of the heart's chambers sends it pulsing through the aortic valve into the aorta, the great artery trunk of which all other arteries are but branches. In the case of Surgeon Bailey's patient, this smooth mechanism was dangerously out of kilter.
To open the way for Bailey, assistants now passed tourniquets like cotton shoelaces around both great veins but did not yet draw them tight. Another tourniquet went around the right subclavian artery. With a needle holder like a long, slender pair of pliers, Bailey dipped his needle lightly in and out of the wall of the right auricle, drawing only a few drops of blood as he made two circular (purse-string) sutures. "Suction." An assistant dipped a glass-tipped rubber tube, attached to a vacuum pump, into the heart bed, drew out the spilled blood. With fine team coordination, Bailey made a small cut in the auricle wall; one assistant slid a plastic tube through it into the lower great vein, and another drew the purse string tight to check bleeding. Another cut, another tube, for the upper great vein. A third tube, through the side of the subclavian artery into the aorta.
For most heart operations these would have been enough. But in this case Surgeon Bailey wanted to keep up a gentle blood flow through the heart muscle while he operated. So he lifted the heart and turned it, exposing the coronary sinus through which most of the blood is drained from the heart. In a ring of stitches he made a cut and slipped in a fourth tube.
Meanwhile, three members of the surgical staff had been standing by an odd-looking device--a heart-lung machine. On the front edge of its table was an electric motor flanked by pumps. Behind was the oxygenator--an arrangement of plastic cylinders and tubing. "Ready?" asked Bailey. The moment had come to bypass the heart and lungs to give the surgeon a dry field and to let the machine take over. As the first pump was switched on, the surgeons tightened the tourniquets around the great veins so that the blood, shut off from the heart, was forced out of the body along tubes leading to the machine. In the artificial lung, the blood picked up fresh oxygen. As the tourniquet on the subclavian was tightened, the machine forced the blood back into the patient: the major inflow went to the aorta to supply blood to the head, arms and lower body; a small additional pump sent blood through the small tube into the coronary sinus, from which it nourished the heart muscle by reverse flow into the veins--some flowing to the capillaries and some through a subsidiary vein system into the right auricle. The anesthesiologist and his assistant relaxed. The patient's lungs went limp; the oxygenator was doing their work, as the pumps were doing that of the heart.
Fixing the Valve. When the heart was almost emptied of blood, its walls relaxed, though it continued to beat. Bailey reached for the aorta where it emerges from the left ventricle. The patient's aortic valve, scarred by rheumatic fever, would not open wide enough to pass more than a little jet of blood, so that he became winded, had fainting spells, and his heart began to pound on the slightest exertion. (Even with a sedentary job as a brokerage clerk, he could no longer work.) Bailey clamped and then slit the aorta for almost two inches, down to the valve and nearly to the ventricle wall. With the aorta held open, Bailey could look directly at the heart's outlet. The valve leaflets were thickened, stiff and almost immovable, and partly crusted with chalky deposits. The opening, Bailey saw, was only the size of a pencil, whereas it should have admitted two fingers easily. With scissors he carefully snipped the leaflets apart along the lines of their earlier, natural opening until he could put two fingers through the valve and into the heart. He was careful not to dislodge any of the chalky deposits (in operations where valves are opened "blind" by feel, this material may become dislodged and travel through the bloodstream to the brain, causing paralysis or death).
Surgeon Bailey filled the flaccid aorta with warm saline solution (to make sure that no air was trapped in it), then sewed it up with a double row of stitches. Assisting surgeons loosened the tourniquets on the great veins so that the heart filled with blood. They took the tube out of the coronary sinus and drew tight the stitches around the wound in that delicate vessel. As the heartbeat strengthened, the pump operators cut down the flow of blood into the subclavian. When Anesthesiologist Kenneth Keown reported pulse and blood pressure back to normal, they shut off the machine. It had done the work of the patient's heart and lungs for 13 minutes.
The entire operation from opening the chest to putting the last stitches in it--"skin to skin," as surgeons call it--had taken 3 1/2 hours. After five weeks the patient went back to work. His heart no longer pounds unbearably; he can be as active as most men his age.
Operations like this--sometimes on damaged valves, often to correct defects inside the heart itself--are being duplicated a hundred times or more each week in a dozen or so U.S. medical centers where heart surgery has become an everyday affair. Many surgeons use heart-lung machines more or less similar to Bailey's. Some chill their patients to a body temperature 10DEG or more below normal. Others may plunge a needle into a patient's heart and deliberately stop its beat for as long as they need to work inside it. Generally, they cut, stitch, stretch, graft, rebuild and insert gadgets in the heart with ever-growing success--although the death rate inevitably is high in heroic operations on patients already in poor condition.
What Can Go Wrong. An alarming number of things can be wrong with the heart to require surgery. Some defects may be present in a child's heart or great vessels at birth (estimated annual U.S. incidence: 30,000 to 80,000 births). The great vessels (pulmonary artery and aorta) may be transposed, not harmful during fetal life but usually fatal soon after birth. Often there is a hole in the wall (septum) between the auricles or between the ventricles; there may be a hole permitting all four heart chambers to communicate. The aorta may override (straddle) both right and left ventricles. The neck (infundibulum) of the right ventricle may be narrowed, retarding movement of blood to the lungs. In the most famed of all congenital defects, Pallet's tetralogy, the blue baby has an amazingly consistent pattern of four anomalies combined: overriding aorta, a hole between the ventricles, narrowing of the pulmonary valve or infundibulum (or both), and a greatly enlarged right ventricle.
Other defects may be acquired later in life, notably scarring and narrowing of the valves (especially the mitral) as the result of rheumatic fever. Following this or other diseases, these same valves instead of being "sticky" and tight may be too wide open and leaky (regurgitant).
Most frequent of acquired heart defects but so far relatively neglected by surgeons are the blockages resulting from coronary artery disease. This causes 500,000 U.S. deaths a year; it probably strikes new victims at least as often. Surgery aimed at correcting it is still the subject of the hottest debate in a widely debated field.
Closing the Ring. The surgeon's dogged efforts to conquer these defects turned into one of the great campaigns in medical history. Despite revolutionary progress in all surgery during the '30s--thanks to improved anesthesia and transfusion techniques plus antibacterial drugs--older surgeons still recoiled from the heart. Younger men braved its defenses; with rare exceptions heart surgery is still dominated by young men. After the first premature frontal attacks--nearly all patients died --the pioneers began to close the ring around the heart by working on the nearby great vessels: as one of them puts it, "circling for a landing."
In 1938 Boston's Dr. Robert Edward Gross, then 33, operated successfully to eliminate a patent ductus arteriosus--a tubular connection between pulmonary artery and aorta that normally closes soon after birth. Falling back on Alexis Carrel's brilliant experiments in the early 1900s, which showed that arteries if handled properly can be cut apart and stitched together again, with or without an intervening graft, Gross next developed an operation to cut out an abnormal narrowing (coarctation) of the aorta.
Meanwhile, at Johns Hopkins, Surgeon Alfred Blalock worked with Pediatrician Helen Taussig on Fallot's tetralogy, developed their famous blue-baby operation (since 1944 Blalock and his assistants have done 1,500 such operations, with about 85% long-term survivals).
Still circling the heart, surgeons were almost ready for a landing.
Finger & Knife. Philadelphia's Bailey was impatient to touch down. He had strong personal reasons: as a boy of twelve, he had seen his father, a broker, die at 42 of a lung hemorrhage, the direct result of heart disease. After what Bailey considers less than average preparation for such a post (New Jersey's Rutgers University, Philadelphia's Hahnemann Medical College, a year's internship, four years of general practice in Lakewood, N.J., two years of intensive lung surgery), he was placed in charge of chest surgery at Hahnemann in 1940. He is now professor and head of the department of thoracic surgery in Hahnemann Medical College and its attached hospital.
After working on dogs for five years, duplicating earlier abortive mitral-valve operations, Bailey thought he knew what had been wrong with them--faulty approach and damaging the leaflets of the valves. He worked out his own approach, first put his finger inside a human heart to open a scarred mitral valve in June 1945. Through an accident (no fault of Bailey's) the patient bled to death. Misfortune beset him in three other cases. Not until June 10, 1948 did he have a "good risk" patient at Philadelphia's Episcopal Hospital. Mrs. Melville Ward, 24, of East Orange, N.J., an invalid for five years, had been told she had six months to live. Bailey slipped his finger through the "tail" of the auricle (the "appendage"), slid a knife along it and slit the joined valve leaves apart. Eight days later Claire Ward went to Chicago to appear before a meeting of chest physicians. Last October, almost nine years after her operation, she had a second child. She takes full care of her children and her second-floor walk-up apartment.
The Doughnut Method. The operation (which, with variations, had been duplicated almost simultaneously in Boston and in Britain) "suddenly became too popular and was being done in practically every country hospital," says Bailey. In 1953 Detroit Surgeon Forest Dewey Dodrill convinced Bailey that his operation was still not good enough, and Bailey worked out improvements that are now widely used.
Bailey made another contribution (January 1952) with an operation to close a hole in the wall between the auricles. The right auricle is bigger than it needs to be and is soft and pliable. So Bailey pressed the outer wall down over the septum, covering the hole in it, and joined the two together with a circular line of stitches. This made the right auricle into a doughnut-shaped chamber, with excellent results for the patient. Says Bailey with professional pride: "Technically, this is the best accomplishment I have to my credit, because it's so nearly perfect a procedure."
Into the Freezer. But there are some holes between the auricles which are so placed, or of such size, that they cannot be closed by closed techniques, i.e., without opening the heart. Gross had devised an ingenious way of sewing a rubber well to the auricle so that he could open the chamber and work inside it with his fingers and suture needle, but he was still operating blindly by feel in a puddle of pulsing blood. The problem was that, at normal body temperature, the brain suffers irreparable damage if deprived of blood for more than about four minutes. But if the body's temperature is lowered, its tissues need less blood, and the brain can survive without damage for twice the normal time. Bailey wondered whether by chilling the patient (hypothermia) he could reduce the body's blood requirement to a level where some sort of pump could handle it. Then the bold idea struck him: Why not try hypothermia alone if he needed only six or eight minutes inside the heart?
On Aug. 29, 1952 a girl with a big hole between her auricles received standard anesthesia, was then put in a 6-ft. kitchen-type freezer until her body temperature dropped to 75DEG. The patient's circulation was slowed at first, then stopped by clamps. Bailey slit open the auricle, put a patch over the hole and closed the heart, with two minutes to spare against his eight-minute limit. But because of air trapped in the heart, the patient died. History's first truly open-heart operation in a dry field looked like a failure.
Only four days later Floyd John Lewis, one of the leaders in a team of brilliant young heart specialists assembled by Surgery Professor Owen H. Wangensteen at the University of Minnesota, did a virtually identical operation on a five-year-old girl, and she survived. Within ten days Bailey repeated the operation with complete success.
Enter the Machine. This method can only be used in cases where the surgeon can count on getting in and out of the heart in less than eight minutes. Moreover, under hypothermia the heart is especially likely to lose its regular beat and flutter uselessly (fibrillate), which may cause death. What was still needed was a pumping device to take over the functions of both heart and lungs for as long as necessary to operate. At Philadelphia's Jefferson Medical College, Surgeon John Heysham Gibbon Jr. had been working on such a device for almost 20 years. Bailey himself was experimenting with pumps when he hit on the chilling technique. In October 1952 Detroit's Dodrill announced that he had used a pump developed in cooperation with General Motors research engineers to bypass the left side of the heart. In May 1953 Gibbon announced the breakthrough: his heart-lung machine was ready at last.
Cecelia Bavolek, 18. a freshman at Pennsylvania's Wilkes College, had a hole as big as a half dollar between her auricles--a condition similar to that of Bailey's first hypothermia patient, and one that could not be corrected by his closed operation. Surgeon Gibbon and his Jefferson team piped Cecelia's blood to a "lung" made of stainless-steel screens set in an oxygen-filled chamber and pumped it back and forth for a total of 26 minutes. Cecelia Bavolek recovered quickly. It was the first time in history that man's artifice had successfully replaced the heart and lungs given him by nature.
The Bubble Problem. Despite this hopeful start the heart-lung machine was far from perfected. Minnesota's Clarence Walton Lillehei developed an ingenious temporary expedient: he used a donor, usually the father, for a child patient, connected their circulatory systems and thus made the donor's heart and lungs do the work of the patient's during the operation. The trouble was that this method risked two lives instead of one. Next, Lillehei & Co. used a freshly removed dog's lung, carefully cleaned and cleared of its own blood, for the same purpose. Two years ago, there was a break.
Early heart-lung designers, starting with Gibbon, tried oxygenation by "filming" the blood, i.e., letting it run thin over a flat surface. They wanted to avoid bubbling it because of the danger that some bubbles might be left in, and if these reached the brain, they could cause paralysis or death. Richard DeWall, a general practitioner from Anoka, Minn., went to work with Lillehei. Neophyte DeWall figured: Instead of dreading bubbles, why not put them to use? After all, the blood could be made to "film" around bubbles. He took the revolutionary step of pumping the patient's blood into a plastic cylinder and deliberately bubbling, almost foaming it, with a stream of oxygen. Then, to get rid of excess bubbles, he let the blood settle slowly in a slightly inclined cylinder and a helical reservoir, both coated on the inside with an antifoaming compound long used by brewers. The DeWall oxygenator, coupled to two standard commercially available pumps, won quick favor in many surgical centers. It is now--with minor local modifications--the type most widely used in the U.S. (see diagram), though some surgeons still refuse to bubble blood.
Stopping the Beat. There is sharp disagreement as to how much blood a patient should get from the heart-lung machine during an operation. One school favors giving as much blood as the heart normally pumps at rest (about four quarts a minute in a 150-lb. man). Say their critics: any pump run at such high speed may damage the blood cells. Another major disagreement involves stopping the heartbeat. With its major vessels shut down and their blood bypassed to the machine, the heart goes somewhat limp, but keeps on beating because it continues to receive some blood through minor channels. This can be a serious problem: the surgeon wielding his needle holder has to "take aim on a moving target." Moreover, stitches inserted while the heart muscle is tense may tear out. So surgeons at the Cleveland Clinic, headed by Donald Brian Effler, adopted the technique of injecting a heart-stopping chemical, potassium citrate, to let them operate on a completely stilled, relaxed heart. When the clamps are removed at operation's end, blood coursing through the heart washes out the chemical, and the beat is usually resumed spontaneously.
One danger of stopping the heart is that if the surgeon inadvertently puts a stitch through a nerve bundle (which can later prove fatal), the quiescent organ can give no signal of distress until the heart is sewed up and filled with blood--and by that time it may be too late to undo the damage. In recent months several noted surgeons, including Blalock, Dodrill and the Mayo Clinic's John Webster Kirklin, have decided that the advantages of stopping the heart outweigh the risks.
Three to Watch. By one method or another, heart surgeons can now correct an impressive number of defects, including patent ducts, narrowing of the aorta, aneurysms (ballooning blisters) of the aorta, holes between the walls of either auricles or ventricles, scarred and narrowed valves. Three problems are getting special attention:
P: Blue babies. The Blalock-Taussig operation, with later modifications, is relatively safe but does not correct the underlying defects; it merely seeks to counteract them by adding an abnormal blood shunt. Young enthusiasts believe that an effort should be made to correct the abnormalities (open the pulmonary valve, close the interventricular defect and thus correct the overriding of the aorta). But deaths during and soon after operations of this type, with the heart-lung machine, run to 30%.
P: Leaky valves, particularly the aortic. At Georgetown University Hospital, Surgeon Charles Anthony Hufnagel has developed an ingenious solution: into the aortic channel he introduces an additional valve made of plastic, with a floating ball which stops the backflow when the heart relaxes. (Such valves used to tick like a clock inside the patient, are now silent because the ball is covered with silicone rubber.) The gadget does not prevent all backflow but stops enough to keep most patients' hearts from being overloaded.
P: Transposition of the pulmonary artery and aorta. This represents such a drastic reversal of nature's design that it still offers more challenge than hope to the surgeon. At Children's Memorial Hospital in Chicago, Thomas Gus Baffes has done 38 operations (switching some of the major vessels from one side of the heart to the other) with 23 survivors.
The commonest of all heart defects is the one that most consistently defies the surgeon's efforts: reduced or blocked blood flow through the coronary arteries embedded in the heart muscle itself. This is caused by atherosclerosis, i.e., branches of the coronary arteries are plugged with fatty material, leaving the muscle starved of blood. If this happens gradually, it causes angina pectoris; if suddenly, a heart attack. Surgeons in general have long neglected the problem because it seemed so hopeless.
Four-Point Plan. Outstanding among the few who refused to give up is Cleveland's Claude Schaeffer Beck. For 20 years he has staked his professional reputation on a still controversial operation now universally known as the Beck I. He tries to restore the blood supply to deprived muscle by: 1) partly closing the coronary sinus to keep the blood in the heart muscle longer; 2) deliberately irritating the surface of the heart muscle itself and the lining of the heart sac by scraping them with an abrader like a spiked golf shoe; 3) dusting irritant asbestos powder inside the sac; and 4) stitching a piece of fat (from the lining of the chest wall) to the sac when he closes it.
Some surgeons frankly doubted whether Beck's operation did any good. Others noted that after any surgery in the chest, the heart sac was likely to become irritated (and therefore develop better circulation), so they argued that Beck could do as much good simply by opening the chest, looking at the heart and closing it up again. Recently, Beck has amassed figures which make a good case for his operation: out of 100 consecutive cases, 90% are alive after six months to five years (far more than could have been expected without surgery), and 50% are well enough to have gone back to work. Perhaps the best accolade for the Beck I is that it has recently been adopted in principle by Blalock's group at Johns Hopkins.
Another coronary operation, as practiced by Washington's Hufnagel, involves cutting and tying off both mammary arteries--the chest wall can get along without their blood supply--and thus shunt their contents over into the coronaries. Hufnagel hit on this theory by chance when, during different cardiac operations, mammary arteries were cut accidentally, and patients made better recoveries. Hufnagel has been doing this type of operation for years, is still patiently compiling data on his patients' progress before making claims of its effectiveness. Virtually the same operation, though done in execution of a different theory, attracted wide U.S. attention in January. It was reported by Philadelphia's Robert Prentice Glover. Glover gives credit to Italian surgeons for developing the technique, finds that the operation can be performed under a local anesthetic promptly after a heart attack.
Charles Bailey himself launched the most direct assault imaginable on coronary disease--reaming out the diseased part of the arteries (TIME, Nov. 26). The first two patients, on whom Bailey based his preliminary announcement, have both done well. One, a man of 52, has gone back to work. But Bailey was not content with the instrument that he used (it had a rigid steel shank), so he soon designed another. The result is a piece of piano wire with a loop handle at one end, a tiny ball at the other, and 1 1/2 in. from the tip, a thicker section with woodscrew thread. Bailey has used this to ream the diseased plaques out of the coronaries of three more patients, all of whom seem considerably improved.
Matter of Time. For all his firsts in heart surgery, Charles Bailey is the first to admit the difficulty of proving the results of coronary operations. He is impatiently awaiting delivery of an X-ray machine which will take pictures at 1/500 sec. and, with radiopaque dyes, will show precisely where and how extensively a coronary artery is blocked--or unblocked. This will make it possible to judge with far more accuracy how much good an operation has done. Thanks to the prospects of such machines, surgeons who have so far held aloof from coronary disease are now showing interest. Even so, the reaming operations for coronary disease are likely to be limited to men under 55 who have localized obstructions--the older group, with more widespread disease, will probably have to rely on medical management or a Beck operation.
Apparently immune to the emotional strain of the surgeon's task, Charles Bailey (married to a former nurse, and father of three) drives himself with awesome energy. He sometimes schedules as many as four open-heart operations in a week, takes two a week in his stride. Last week he and his colleagues (including two other surgeons) in the Bailey Thoracic Clinic performed no fewer than 15 heart operations, one with the heart-lung machine and one to close a septal defect. Within Charles Bailey's lifetime, surgery has changed from a relatively blunt and blind art, executed singlehanded. into a skill supported by a team of experts and a world of machines delicate enough to approach the center of life itself. Yet unlike his predecessor. Stephen Paget. Bailey refuses to believe there are no more conquests ahead. As he sees it, nothing is impossible in surgery. Bailey looks forward to the day when an entire heart may be taken from a man killed in an accident and grafted into another whose heart is diseased. Fantastic? "Merely a matter of time," says Surgeon Bailey.
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