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OPINION ARTICLES

Received: September 25^th 2015

Accepted: November 12^th /2015

The third wave of cardiac surgery

Carlos Riera-Kinkel^a

^aDivisión de Cirugía Cardiotorácica, Hospital de Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México

Communication with: Carlos Riera-Kinkel

Telephone: (55) 5627 6927

Email: rierac7@gmail.com

A review of the history of cardiac surgery around the world is made divided into three stages, the first since the beginning of humanity until 300 years BC; the second moment shows how comes the platform that would give the anatomical and functional bases of the cardiovascular system. This historic moment includes: 1. the description and analysis of the function of blood and its components; 2. the description of the normal and abnormal Anatomy of the human heart and its vessels; 3. the anatomic and functional correlation: Foundation of the deductive thinking, and 4. the anatomic and functional integration with the clinic. Finally, the third wave, which is living today, is the stage of the technological explosion that begins with procedures as thoracoscopic surgery with the concept of reducing surgical trauma through minimum approach surgery. Also the use of robotics to solve some of the alterations in the CC, another is hybrid procedures and finally the use of fetal cardiac surgery.

Keywords: Thoracic surgery; Heart; History of medicine

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Canadian sociologist Alvin Toffler¹ describes the stages of evolution of society in three waves, the first wave the agricultural stage, where people came together to form the first sedentary communities, enabling better development. The second wave corresponds to the Industrial Revolution, which establishes the increases in productivity and scientific development. Finally, the third wave, which is what exists today, is the stage of the technological explosion; making a comparison of these events with the development of cardiac surgery, this article comments on each of these stages in relation to the development of cardiac surgery.

First wave

First moment: from praxis to reason (the Palaeolithic to Egypt (30,000-300 years B.C.)

Here we follow the guidelines recommended by Dr. Fause Attie;² primitive man perceived the importance of the heart. He left a mark of this concept in cave drawings, the oldest one being the figure of a mammoth, which was discovered in the cave of El Pinal, Spain, in 1908 by Abbe Breuil, who attributed it the age of 30,000 years. In the drawing one notes the position of a shadow at shoulder height corresponding to the heart, thus being the first historical evidence on record of knowledge of this organ. Mesopotamia was one of the first civilizations that developed an empire, leaving evidence of well-structured writing on ceramic tablets that were replaced by wooden cylinders inscribed with medical treatises, written with cuneiform symbols. The first writings about birth defects in humans were also mentioned in these cuneiform tablets, which were preserved in the Royal Library of Nineveh (today the city of Mosul, Iraq). It is the first writing describing ectopia cordis. Thus, in hyperbola, "the historic heart" of knowledge of the cardiovascular system was born in the Arab world.

With the arrival of the Egyptians (3000 B.C.), much of this information was copied to papyri, the most famous for cardiology being the Edwin Smith and Ebers papyri, where phenomena like circulation and its relation to the heart are clearly described, indicating their locations exactly. It is the Ebers Papyrus that describes in detail the importance of pulse palpation associated with life. In addition, the mystical, magical, and religious interpretation is always present, as illustrated in an Egyptian bas-relief dating from 1250 B.C., where the final judgment evaluated the weight of the heart as an indicator of the subject’s behavior in life, then delivering it to its mystical devourer (Figure 1).

Thus, palpation of the arterial pulse was the only window to the heart for thousands of years, and who would say that after 6000 years of observations and reasoning, pulse palpation would today become a real window to look inside through catheters, allowing not only study, but also treatment.

Around the year 260 B.C. the Chinese, for their part, made important observations. Chi Huang Ti, the Yellow Emperor, said that blood flowed continuously in a circle around the body without a beginning or an end, and "never stopped." He said the blood was ruled by the heart, and was the first to associate the increase of pulse strength with salt intake.

The second historical moment, which Dr. Attie has called the transition from simple descriptive thought to comparative thought, is presented to describe how the platform would emerge that would provide the anatomical and functional bases of the cardiovascular system for more analytical thinking, thus making the great leap to deductive reasoning.² This historic moment is titled: The cardiovascular system in health and sickness: a trip from Aristotle to Maude Abbot. This historic moment is crucial for the evolution of human thought, and medicine was no exception; therefore, if one had to point out the main contributions that would later support not only medicine and cardiology in general, but also the origins of pediatric cardiology, there would be four:   

 

1. The description and analysis of blood function and its components.
2. The description of normal and abnormal anatomy of the human heart and its vessels.
3. Anatomical and functional correlation: the foundation of deductive thinking.
4. Anatomical and functional integration with the clinic.

 

These contributions were the basis for the systematic approach to the study of congenital heart disease, giving the gigantic historical step of deductive thinking to application, i.e. hypothesis testing.

It was Aristotle who described the beating of the heart in chickens. Hippocrates, meanwhile, based his thinking on the four humors, namely: blood, phlegm, yellow bile, and black bile. The variable mixtures of these moods in different people defined their 'temperaments', as well as their physical and mental qualities. The Arabs accepted these hypotheses.

However, it took more than four centuries between Aristotle and Galen for much of cardiac anatomy to be known, and it was precisely Galen who tried to explain the functions of the foramen ovale and the ductus arteriosus. Galen thought that blood passed to the lung where it was purified and mixed with the pneuma to reach the left ventricle; however, he said that the liver was the central organ of the body, producing fresh blood. The Church considered his work an authentic divine inspiration, therefore infallible, giving him the title of “Galen the Divine".

Arab medicine came into this scenario with an active movement of translation of Greek philosophy, science, and medicine. Ibin Al-Nafis was an Arab physician in Damascus in 1210 renowned for the discovery of pulmonary circulation, a concept that must have come from pure reflection, because dissection was forbidden by Islamic law. He said that blood was mixed with the air in the lungs, and flatly denied the porosity of the interventricular septum. His theories were not accepted by his contemporaries.

Upon the arrival of the Italian Renaissance during the fifteenth and sixteenth centuries, knowledge of the heart had a new impetus, especially with the study of human anatomy, based on the method of dissection in cadaver and the introduction of new concepts of pathology.

Thus, Leonardo Da Vinci described and drew a case of atrial septal defect. Leonardo’s works on anatomy continue to surprise those familiar and strangers; one of his sketches shows the first description of the univentricular heart with atrial septal defect and persistent left superior vena cava.

Michael Servetus was not a passive thinker, his rebellious thought undeniably revolutionized science. He was the first figure in the West to doubt Galen’s assertions. In a chapter of his book "Reclaiming Christianity", he described the passage of blood through the lungs, where it changed color; he also denied the presence of pores in the interventricular septum. He was burned alive in 1553, accused of heresy for questioning Galen the Divine and denying the doctrine of the Trinity (Figure 2).

It was in Padua, Italy, where new information about circulation was provided by Hieronymus Fabricius. In his studies of human dissection, he discovered venous valves, and was the first to document the anatomy of the foramen ovale and ductus arteriosus in the human fetus.

Meanwhile, Andreas Vesalius made a treatise on the heart as the central organ, removing the idea of ​​the liver as a reservoir and center of circulation. He said that the pulmonary veins carried blood from the lungs into the left atrium. He also recognized that the veins in general had "ostiolas", or small doors later called venous cusps (Figure 3).

Thus, history is full of partial discoveries that over time great thinkers were able to combine and consolidate to give rise to radical change in knowledge, thus becoming history.

Such is the case of William Harvey, who revolutionized thinking with his ability to synthesize all contributions to medical knowledge. His treatise "De Motu Cordis" marked a new era in cardiology. Thus began the classic clinic, as an attempt to correlate anatomical and functional aspects in health and disease. He begins experimental medicine to prove everything that is synthesized in his treatise. He demonstrates the role of venous valves as containment for venous return, and inferred the existence of capillaries linking arteries and veins, but could not prove it for lack of microscope (Figure 4).

Marcello Malpighi demonstrated experimentally the existence of capillary endothelium, and first described erythrocytes as the reason that blood is red. For this he is considered the father of microanatomy and histology. These findings would be confirmed by the Dutch author Anton Van Leeuwenhoek, who described the corpuscles in the capillaries of the rabbit ear and the skin of the frog, with a system of magnifying glasses later called a microscope. The microcosm would provide a universe of knowledge that we still marvel at today (Figure 5).

Simultaneously at that time, technological discoveries and the creation of machines (mostly steam), would shake the world and, of course, medicine was not left out. Thus, René Descartes, who was a "mechanic" in the conception of the nature, in 1637 described the human being as a machine, and gave his touch to Harvey’s ideas, as he thought that the blood condensed when passing through the lungs and turned back into gas upon arriving in the heart, causing the pulsatile expansion of the heart; he always denied contraction and claimed expansion of the heart as its primary function.

Physiology had its heyday in the early eighteenth century. Stephen Hales described the measurement of blood pressure by placing a tube into the artery of a horse, showing the intermittent pumping of the heart. Special mention in this regard goes to Nicolas Steno (from the Danish Niels Stensen), who was raised in a Lutheran environment. In 1665 he described for the first time what would later be called Tetralogy of Fallot. In addition, Steno was the first to question the hypothesis of condensation of blood in the lungs and gasification in the heart as a means of pumping, as described by William Harvey. Steno became a Catholic missionary and was beatified by Pope John Paul II in 1988.

In the late eighteenth century Morgagni created the basis of anatomical and comparative physiology, and his book is one of the largest in history, as it perfectly describes interventricular communication and the single ventricle, confirming the observations of Leonardo Da Vinci.

It is interesting how, throughout history, acts of great significance for scientific advance are repeated, in many cases without the need for sophisticated equipment. A good example is Laennec, inventor of the stethoscope as a diagnostic tool. In 1819 he gives a huge boost to clinical knowledge and demarcates a new course for cardiology, because his treatise on auscultation described some congenital heart diseases (Figure 6).

The first book on record written about "malformations of the human heart" is by Thomas Peacock in 1858. It is one of the most complete works to correlate anatomical with clinical data. His masterly description of what would later be called Tetralogy of Fallot is today a classic; he also described the murmur of pulmonary stenosis.  

The correlation of anatomy with physical signs takes its course, adding the anomaly of the tricuspid valve described by Ebstein in 1866 and intracavitary flow reversal described by Eisenmenger in 1897.

In tribute to Arthur Fallot, the "father of forensic medicine" was given the eponym of the cyanotic congenital malformation known as Tetralogy of Fallot. Two of the most eminent pathologists, Robert Anderson and Richard van Praagh, who have had disagreements on the nomenclature of congenital heart diseases, agree with the eponym of Tetralogy of Fallot.

The clinic had its boom time with the description of characteristic signs and murmurs; thus, for example, the extraordinary contribution of Roger in 1879, in which he said that the murmur of interventricular communication was pathognomonic- an irrefutable concept that could only be proven at the time of color Doppler ECHO, many decades later. 

Surprisingly, Gibson was not the first to recognize the murmur of ductus arteriosus he described in 1900. However, his publication was extraordinary because he expressed the concept of the murmur in pathophysiological terms by explaining its production by the pressure difference between the aorta and the pulmonary artery. It is amazing to learn that Gibson’s classic auscultation diagram was at least 30 years before the use of phonocardiography.

The great technological discoveries of the late nineteenth century became new tools for the clinic, such as X-rays, fluoroscopy, and electrocardiography, incorporated into testing in clinical practice.

Second wave

Two colleagues who shared classroom, Dr. Maude Abbot and Dr. Helen Brooke Taussig, presented the first classification of congenital heart diseases (CHD), whose foundation lay in two characteristics: the first is the development of the ventricles, and the second, the magnitude of pulmonary flow. At that time, CHDs were classified as non-cyanotic and cyanotic, and diagnosis of any of them was equivalent to a fatal prognosis (Figure 7).

Dr. Taussig was interested in solving the problems of her patients in the halls of the University of Baltimore, children classified as "blue", who died unfortunately without any treatment (Figure 8).

In 1939, Dr. Robert Edward Gross, a surgeon at Harvard University, extolled the importance of closure of the ductus arteriosus or Botal, given that life expectancy for these patients was only two decades. Dr. Taussig offers the possibility of increasing pulmonary flow by creating a very similar duct to the ductus arteriosus, to solve the problem of the blue children. Dr. Gross quickly rejects this proposal, justified by the fact that he had recently published the benefits of closure, and a counter proposal would be inconsistent.2

For Dr. Taussig this was no limitation to her ideas, so she approaches another eminent surgeon renowned for his academic qualities, Dr. Alfred Blalock, who accepts that it is a good idea, and that it was possible to apply the models that he had previously designed with the help of the head of the Experimental Surgery Laboratory, Vivian Thomas, an African-American from a family of carpenters, notable for his creativity and surgical skill (Figure 9).

The model was to lower the left subclavian artery and to anastomose it directly to the left pulmonary artery. Before the wondering eyes of both the anesthesia and nursing staff, Dr. Blalock was assisted by the then resident Dr. Denton Cooley, who agreed to help Blalock, although many surgeons were opposed to performing this procedure.³

Dr. Billroth, during a meeting of the Academy of Surgeons, said: "Anyone who dares to suture the heart must be expelled from the academy"; one surgeon who dared to go against this maxim was Dr. Walter Lilihei, who was experimenting on organ perfusion and cross circulation, which had been proposed by Carrel and Lindberg, who created organ perfusion with a low-porosity glass system, which would later become the company Pyrex.⁴

One morning in April 1954, a girl named Pamela became the first patient to benefit from the first heart surgery, with a system of cross-circulation, reminiscent of the painting by Frida Kahlo, subject to the closing of an interventricular communication that before this date was considered fatal (Figure 10).

Her mother consented to this procedure, which was successful, allowing the process to be extended throughout the United States (U.S.). Centers of cardiac surgery soon began to develop, mainly in Michigan and Houston, Texas, focusing on the development of various systems of cardiopulmonary bypass, such as the case of the de Wall prototype in 1955 and de Wall-Gott in 1956, which were bubble oxygenators, later Ellis-Cooley-Debakey in 1961.⁵

Dr. John Gibbon and his wife Mary Hopkinson, who lived all their lives in a suburban area in the central U.S.; Gibbon grew up in a small farm in Kentucky and worked milking cows; the same principle of sequential scanning that caused the propulsion of milk, as well as a system of rollers, ended up in the development of the extracorporeal circulation pump.⁶(Figure 11)

Once cardiopulmonary bypass systems were perfected, advances were possible in various techniques to totally correct various CHDs such as complex ailments like Tetralogy of Fallot and double outlet right ventricle.

Rastelli⁷ proposed many techniques that serve both the heart septal to the atrioventricular canal, and to restore arterioventricular continuity with a valval tube, a principle applied by Ross and Konno using lung grafts to widen the aortic annulus, and homografts to restore arterial ventricle continuity.⁸

The next problem to be solved was the transposition of the great vessels, primarily aiming for the physiological reconstruction proposed by Senning⁹ and Mustard,¹⁰ but due to the high incidence of atrial arrhythmias, Jatene,¹¹ a Brazilian surgeon, proposes anatomical reconstruction, which involves making an arterial switch, with reimplantation of the coronary arteries; this procedure has proven its effectiveness over the years.

The next big step in CHD surgery, which was associated with Jatene’s surgery, was Dr. Aldo Castañeda’s proposal to correct CHD in the first months of life, transforming neonatal cardiac surgery, which was then forced to improve circulatory support systems and reduce inflammatory response during cardiopulmonary bypass.¹²

Among the techniques that require great technical skill, like Jatene’s surgery, are the other two difficult to resolve malformations, pulmonary atresia with ventricular septal defect, and aorto-pulmonary collaterals, in which Dr. Frank Hanley^13,14 has participated so actively, and on the other hand the correction of hypoplastic left ventricle, by Dr. William Norwood,¹⁵ which establishes the concepts that add to Fontan for univentricular correction.

Once these complex CHDs were resolved, in large part by the advanced countries, it was shown that the results of pediatric cardiothoracic surgery depend on a well-integrated team of surgeons, anesthesiologists, perfusionists, instrumentalists, interventionists, and critical medicine specialists who, together, get results directly proportional to the volume of procedures performed, and inversely proportional to the degree of complexity of these procedures, which have been categorized by six levels of risk.¹⁶

Third wave

The third wave of CHD cardiac surgery begins with thoracoscopic procedures, predominantly driven by Dr. Redmond Burke, who supports the concept of reducing surgical trauma through minimally invasive surgery.¹⁷ Likewise, Dr. Pedro del Nido and his group, in Boston, have promoted the use of robotics to solve some of CHD disorders.¹⁸

Improved techniques in fetal echocardiography showed that prognosis of life is improved strongly when diagnosis is made in the preoperative period, causing an inertia of thought which raises the possibility of fetal intervention, which is proposed for several areas, as is the case with left diaphragmatic hernias that cause ipsilateral lung hypoplasia with secondary pulmonary hypertension. Likewise it is possible to solve obstructive lesions of the trachea, and to do ultrasound-guided catheterization for pulmonary artery and/or aortic angioplasty. Both interventions strongly improve ventricular development and, thus, the prognosis for these patients.

The difference between advanced and developing countries is precisely that developing countries have only been able to improve their results in the second wave, with fair to poor results in the third wave, their problem lying not in one single problem for each service, but in the interactions thereof. This principle pushes what we already are seeing in CHD surgery, which is that hybrid procedures in the future will have exponential growth, when both surgeons and interventionists understand that their tasks are not exclusive to their area, but are the product of joint support from each specialty to improve the quality of life of patients.

Progress in CHD surgery is undoubtedly immense, which has caused not only increased survival and quality of life of patients, but changes in the epidemiology of all cardiac surgery for the future, for heart surgeons seasoned in CHD in the future will be able to treat many of the patients operated on for congenital problems during childhood and who, frequently, will meet later with significant valvular problems that must be solved by a heart surgeon familiar with the pathophysiology and anatomical varieties of these patients. 

Advances in this type of surgery are compared with its costs, causing ethical depths to be resolved, as some countries opt for abortion rather than raise the possibility of resolving such highly complex problems. But whatever the ethical criterion of each institution, this gives many of our institutions the challenge of solving them, which gives us new surprises every day.

The technological development of sophisticated systems for monitoring and cardiopulmonary bypass were the basis for a glimpse of concepts that can take us to the border of the unimaginable. These advances have focused on three areas:

Thoracoscopic surgery. Applying the principle of minimal invasion, not only for aesthetic purposes but to reduce surgical trauma. With this we have been able to design surgical procedures that allow ductus arteriosus closure, vascular ring correction, etc.¹⁹

Minimal invasion. This was developed with the aim of reducing trauma, and was associated with the design of the extracorporeal circulation system, allowing venous drainage using active suction to make devices smaller, thus giving the patient cardiopulmonary bypass with smaller incisions.^20,21

Robotic surgery. This combines the previous concepts, giving the surgeon greater precision to do the surgery.²²

Hybrid surgery. This concept is picking up speed; it is possible to do surgical correction simultaneously with surgery and interventional cardiology, as it resolves difficult circumstances of access for the surgeon, to reduce surgical time or the magnitude of the invasion. This process has created several techniques such as percutaneous implantation of pulmonary prosthesis, placement of aortic coarctation stents in increasingly younger children, intraoperative endoscopic surgery for the placement of perioperative stents, Norwood hybrid (stent placement in ductus arteriosus, binding both branches of the lung), which allows the patient's growth and improves the survival rate of patients with hypoplastic left ventricle.²³ 

Fetal surgery. This refers to interventionism related to cardiac and non-cardiac malformations that improve the survival of patients once they are born. With the help of fetal echocardiogram, in utero congenital heart defects can be identified such as hypoplastic left ventricle, making it possible to introduce into the fetus’ myocardium directly a balloon that dilates the left ventricle output using an ultrasound-guided needle.²⁴ Moreover, it is possible to solve pulmonary hypoplasia resulting from Bochdalek hernia, because when working in utero, the fetus develops the lung normally, thereby avoiding hypertension.^25,26

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