The history of cardiac surgery

Generally speaking, September 9th 1896 is regarded as the day on which heart surgery was founded: on this day, L. Rehn successfully closed a heart stab wound by means of a direct suture. Historically speaking, the first methods were developed on the beating heart.

Operations on the pericardium:

L. Brauer proposed cardiolysis, but this only partially freed the heart (1903). The more radical pericardial resection was mainly perfected by V. Schmieden in Frankfurt (1918).

Operations on the cardiovascular system:

The first successful pulmonal embolectomy was carried out by M. Kirschner in 1924, the first removal of an aneurysm of the right ventricle by F. Sauerbruch in 1931, the first ligature of a ductus arteriosus by K.E. Frey in 1938 in Düsseldorf, though this was not reported until later. In the USA, a ductus ligation was also performed by R. E. Gross in Boston in 1938.

As a result of World War II, the main focus of the development of cardiac surgery shifted to North America, the UK and Scandinavia. W. Forßmann's brilliantly performed catheterisation of the human heart in 1929 was not recognised in Germany, although he won the Nobel Prize for Medicine for this achievement in 1956. Sauerbruch's comment was simply: "That's of no use at all in surgery".

Development of heart surgery outside Germany:

T. Tuffier was the first to dilate an aortic valve in 1912, while E. Cutler did the same with a mitral valve in 1923. These were isolated accomplishments, however. Internists often refrained from applying the therapy concept to other patients because they did not believe in its effectiveness. It was not until 20 years later that the method of digital or instrumental dilation became established. Names worthy of mention in this connection are C. Bailey in Philadelphia in 1946, D. Harken in Boston in 1948 and R.C. Brock in London in 1948.

In 1944 the first operation was carried out to treat an aortic coarctation by means of resection and end-to-end suture by C. Crafoord in Stockholm. This operation was performed for the first time in Germany by F. Bernhard in Gießen in 1948.
Encouraged by the paediatrician H. Taussig, A. Blalock created an arterial pulmonary anastomosis in 1944 in an 18-month-old girl suffering from tetralogy of Fallot with the aim of improving pulmonary blood circulation. For the first time, this gave so-called "blue babies" a chance of survival.

Operations on the non-beating heart:

A major advance in the development of cardiac surgery was achieved by the development of surface hypothermia (1950) by G. Bigelow, Toronto, and extracorporeal circulation (1953) by J. H. Gibbon, Philadelphia, as well as the combination of these two procedures. This made it possible to perform surgery on the non-beating heart with visual control.

In 1952 the first closure of an atrial septal defect was carried out by F.J. Lewis in Minneapolis and by H.C. Swan in Denver utilising surface hypothermia; this was achieved for the first time in Germany in 1955 by E. Derra in Düsseldorf.
After the first successful deployment of the heart-lung machine by J.H. Gibbon to close an atrial septal defect in an 18-year-old girl, the method of extracorporeal circulation became increasingly well established, though this was not at the initiation of Gibbon himself. Since his other patients died, he took a break. It was during this break that J.W. Kirklin, working at the Mayo Clinic with a Gibbon-type oxygenator, performed a series of successful intracardiac operations, as did W. Lillehei, who made use of cross circulation to correct congenital malformations. After 45 operations, however, the Minnesota group also embraced the principle of the heart-lung machine, the prototype of a bubble oxygenator now having been developed by De Wall and Lillehei.

In February 1958, R. Zenker - in Marburg at the time, later Munich - was the first surgeon in Germany to operate on a patient with atrial septal defect using the heart-lung machine.

Development of cardiac valve surgery:

The first aortic valve replacement was performed in 1960 by D. Harken, the first mitral valve replacement also in 1960 by A. Starr, each with a Starr Edwards valve using the heart-lung machine. From these ball-cage valves, of which various design models subsequently appeared, developments moved on to tilting disc valves (Björk Shiley prosthesis 1969, Medtronic Hall prosthesis 1977) and bileaflet valves (St. Jude Medical prosthesis, 1977, or Carbomedics prosthesis, 1986).

Development of coronary surgery:

After the initial use of indirect methods to improve blood circulation in the myocardium - here one might mention C. Beck with the stitching of the pectoral muscle to the myocardium, A. Lecius with the cardio-omentopexy and M. Vineberg with the implantation of the A. mammaria in the myocardium - coronary surgery did not fully flourish until 1967 when direct revascularisation emerged. This development is attributed to R. Favaloro of the Cleveland group. This method involves the bypassing of coronary stenoses using the body's own veins or arteries.

Development of heart transplantation:

Building in particular on preliminary studies by N. Shumway and R. Lower, C. Barnard performed the first heart transplant in December 1967. His patient died of a Klebsiellae infection on the 18th day after the operation. The first German transplant, likewise unsuccessful, was performed in February 1969 by F. Sebening and W. Klinner in Munich. The high rate of early lethality initially shown by many groups due to rejection reactions caused greater reluctance around 1969. This did not change until ciclosporin became increasingly available in the 1980s, allowing the rejection reaction to be controlled. Today the survival rate after a heart transplant is 70% after five years.