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Springer Surgery Atlas Series
Series Editors: J. S. P. Lumley · James R. Howe
Francis C. Wells
Editor
Atlas of
Cardiac Surgery
Springer Surgery Atlas Series
Series Editors
J.S.P.Lumley
JamesR.Howe
Francis C. Wells
Editor
Atlas of Cardiac Surgery
Editor
Francis C. Wells
Department of Cardiothoracic Surgery
Papworth Hospital
Cambridge, UK
ISSN 2626-9015 ISSN 2626-9023 (electronic)
Springer Surgery Atlas Series
ISBN 978-3-031-43194-4 ISBN 978-3-031-43195-1 (eBook)
https://doi.org/10.1007/978-3-031-43195-1
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or
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Foreword
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It is a pleasure to provide the Foreword for this splendid Cardiac Surgical Atlas, particularly as
many of the contributors were former colleagues of mine, at the now Royal Papworth Hospital.
The content is comprehensive and reects the experience and meticulous approach the contributors brought to their task. Any surgeon contemplating an operation must feel condent of
the anatomy that will be encountered. This Atlas is an excellent reference work designed to
provide this. It should therefore nd space in any cardiac surgical library.
Oxford, UK TerenceEnglish
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Preface
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Cardiac surgery is a comparatively young speciality having its meaningful origins in the second half of the twentieth century. It is a speciality heavily dependent upon and integrated with
bioengineering. The technology involved is extensive, critical and constantly developing.
Without the steady development of materials, technology and prostheses, surgery of the heart
would not have reached the levels of safety now routinely achieved internationally. Few conditions cannot be treated successfully in the modern world.
To achieve this, the surgeon must have a dexterity of hand and mind allied with a sound
knowledge of physiology, anatomy and embryology. Cardiac surgery is a team endeavour. The
environment of the operating theatre is more akin to an orchestra than a solo effort. The surgeon must act as an interpreter and conductor carrying the ultimate responsibility for the
patient; the players ensure the outcome. The integrated skills and knowledge base of the perfusionist, anaesthetist, nurses and assistants are vital for routine success.
In this Atlas, we have endeavoured to provide an illustration of the basic surgical procedures
as performed by the current team of surgeons at the Royal Papworth Hospital, a place where
innovation, excellence and education are at the forefront of all that we do.
A Short History oftheEvolution ofCardiac Surgery
Surgery of the heart and of the brain are two of the last big conceptual developments in the
history of the surgical profession. For cardiac surgery to develop in a meaningful way, there
has had to be a deeply integrated approach with the biotechnology industry and deep understanding of the physiology of the cardiovascular system and haematology, in particular the
science of blood rheology and clotting.
In this brief review, I have concentrated on the earliest phases of development of the speciality as much of it is unknown by the modern trainee and has slipped into the mists of medical
history. I have not expanded on the more modern techniques and technology as this will be
within the purview of contemporary teachers and our younger colleagues.
The earliest operations on the heart that carried some degree of success were those for cardiac trauma. First among these was done by Ludwig Rehn, a senior surgeon at Frankfurt City
Hospital, a surgeon known for his willingness to innovate. On September 7th in 1896, Rehn was
presented with a 22-year-old gardener’s assistant, Wilhelm Justus, who had been attacked by a
stranger with a knife and stabbed between his fourth and fth ribs. Faced with a decision
between allowing the young man to die of cardiac tamponade or an attempt at surgical closure
of the cardiac wound, Rehn elected to attempt repair. On opening the pericardium and draining
the intrapericardial blood, he was able to nd the small incision in the right ventricle and to
close it with three interrupted sutures. It was a success, and Wilhelm regained consciousness
2h later. The importance of this singular success began the process of undoing the words of
the great Viennese surgeon, Theodor Billroth, who stated, “A surgeon who tries to suture a
heart wound deserves to lose the esteem of his colleagues”. His English contemporary Stephen
Paget stated, “Surgery of the heart has probably reached the limits set by Nature to all surgery:
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no new method and no new discovery can overcome the natural difculties that attend a wound
of the heart”.
Until the advent of effective antibiotics, group C streptococcal pharyngitis induced an autoimmune disorder referred to as rheumatic fever. The brain and the heart were frequently
affected producing choreoathetosis (St. Vitus dance) and myocarditis, which was accompanied
by a valvulitis which scarred the heart valves in the following order of frequency: aortic, mitral,
tricuspid and very occasionally pulmonary. The rst to associate heart disease with rheumatic
fever was David Pitcairn, a Scottish physician working at St. Bartholomew’s Hospital, London,
in 1788. In 1812, William Charles Wells strengthened the association. In 1898, London physician Daniel Samways in a paper in The Lancet predicted that “one day mitral stenosis, a narrowing of the mitral valve caused by rheumatic vegetations, might be relieved by simply
notching the mitral valve and leaving the atrium to continue with its defence”. The word vegetation was used likening the clumps of inammatory tissue on the valve to the small orets of
some vegetables such as broccoli.
Four years later, the English surgeon, Sir Thomas Lauder Brunton, came to the same
conclusion. He noted that at post-mortem, the damaged valve was easy to open with a scalpel.
This was met with derision in much of the medical community. Interestingly, Rehn wrote that
the heart valves were “out of bounds”! Some surgeons in France tried primitive closed procedures but without good effect. The problem was the inability to see inside the heart. In the early
1920s, Evarts Graham with Duff Allen made a “cardioscope” in an attempt to look inside the
chambers of the heart. As can be imagined, little could be seen. They attached a little knife to
it with a view to cutting the fused mitral valve. It was a failure. In Boston, Elliott Cutler
attempted crude valvotomy plunging a knife through the ventricular wall, poking it about until
it met resistance from what was thought to be the mitral valve and making incisions in what
were thought to be the mitral commissures. There were no survivors from nine attempts.
In 1925, Henry Souttar, surgeon at the London hospital and engineer by previous training,
approached the valve differently. Operating on a young woman, he inserted his nger through
a small incision through the left atrial appendage and was able to form a mental image of the
valve at his ngertip. The patient had signicant mitral regurgitation, and he could sense it. He
therefore abandoned his idea of incising the mitral commissures and simply pushed his nger
through the orice. Following a stormy recovery, the patient survived. Objective improvement
could not be found, and therefore, accompanied by the refusal of physicians to refer any more
patients, his work in this area ceased. These events brought attempts at surgical correction to
an end for two decades.
Dwight Harken, a young Boston surgeon, had also been interested in the possibility of a
surgical solution to rheumatic mitral stenosis. However, with the onset of World War II, he was
despatched to London as a military surgeon. On arrival, he was confronted with many patients
with shrapnel wounds to the chest, penetrating the heart and pericardium. He watched, unable
to help, as most of those young men died, needlessly, he thought. He wrote of his amazement
that surgeons of skill and experience would not touch the heart as though it was some mysterious organ. With careful planning, he set about, following the lead of Rehn, a programme of
surgical shrapnel removal and cardiac repair. He succeeded in removing 134 missiles from the
heart and great vessels of wounded soldiers with no deaths [1]. In 1948, following the great
success of his military surgery, Dwight Harken returned to his interest in surgery of the rheumatic heart and tried to relieve mitral stenosis with a valvulotome, as Evarts Graham had suggested, with some success. In Philadelphia, Charles Bailey had been trying with little success.
At about the same time, Lord Russell Brock had been doing similar work in London at
Brompton Hospital. By 1952, Brock reported 100 operations with excellent results. In 1954,
Charles Dubost invented a dilator specically for the valve as did Oswald Tubbs and Brock in
London. These instruments, which were inserted through the left atrial appendage to access the
mitral valve and the left ventricular apex to access the aortic valve, were very successful and
helped many people. Overstretching of the valve would produce valve regurgitation, which
could be fatal, and so experience was invaluable in achieving regular success. Valvotomy was
Preface
Preface
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ix
adopted around the world and, in particular in Third World countries, continues to offer help
where the more expensive programmes of open-heart surgery are unaffordable [2]. The modern adaptation of this technique is percutaneous balloon valvotomy.
Further and more rened surgical management awaited the ability to support the heart and
lungs articially.
Development was directed in two main ways. For children who needed the correction of
congenital defects, the American pioneer Walt Lillehei proposed an idea that reproduced the
situation in the womb with the heart of the mother or, in several cases, the father to provide the
propulsion required for blood ow of the infant (Fig.1). These were the cross-circulation procedures. Mother or father was connected by simple tubing from the femoral artery and vein to
the child’s circulation (Fig.2). Lillehei achieved great success with this courageous approach
and was able to report excellent results at 20 years [3]. This was truly groundbreaking in paediatric cardiac surgery, but of no use for an adult with cardiac disease.
For adult cardiac surgery to develop, it would be necessary to be able to stop the heart and
replace it and the lungs with mechanical support. John Gibbon had been working on this
concept since the 1930s. For it to be possible, manipulation of the clotting mechanism had to
be worked out. Charles Best, the discoverer of insulin, had begun to work with heparin as an
anticoagulant. Together with the work of Gordon Murray, they were able to demonstrate that
the clotting of the blood could be meaningfully delayed with rened heparin. In 1935, Murray
injected heparin into a patient, which delayed the clotting time from 8 to 30min. Working with
his wife Mary, the Gibbons steadily developed their heart and lung machine and by 1935 were
able to sustain a cat for almost 4h. His work was interrupted for 4 years when he insisted on
enlisting for military service. By 1954, he felt he had a machine that was t for purpose, but
many failures continued to occur, which were compounded by inaccurate or simply wrong
diagnoses, and the surgeon regularly did not know what they were going to nd at surgery.
In parallel with these developments, Wilfred Bigelow in Toronto had been working on the
idea of using profound hypothermia for protection and operating on the still, cold heart. Henry
Swan in Denver was the rst to use profound hypothermia in a signicant number of cases
with any degree of success. However, he admitted that these were very nerve-wracking operations, which depended so much on speed and accurate diagnoses, which was not always the
Fig. 1 Dr. Walton Lillehei and the scene in the operating theatre during a cross-circulation operation. All the
attention is focussed on the child. The parent is on a table next to the one in the image with simply an anaesthetist and nurse standing by (UAB Archives, University of Alabama at Birmingham)
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Preface
Fig. 2 The set-up for cross-circulation showing the cannulation of the parent and child with the bubble lter
and augmenting pump in line with the circulation, and inset shows the placement of the cannulae and the defect
to be corrected
case. The technique allowed success with atrial septal defect closure and easy ventricular
defects but was still limited in its application.
Once again, Lillehei was in the frame developing the DeWall-Lillehei bubble oxygenator.
In this device, oxygen was bubbled into the blood. A separating chamber allowed most of the
bubbles to be removed. A heat exchanger was necessary to prevent the blood from cooling too
much before being returned to the body. This machine was used initially and successfully by
Lillehei in VSD closure. A true great of cardiac surgery, in fact in many ways the father of the
speciality, Walt Lillehei fell from grace in his mid-50s. His reputation as a surgical great was
resuscitated by an enormously generous gesture from Dr. John Kirklin, who, in front of the
entire audience of the American Association for Thoracic Surgery, drew him to his feet to a
warm and standing ovation of more than a thousand pairs of surgical hands (Fig.3).
By 1955, John Kirklin, working at the Mayo Clinic, built a Gibbon machine under licence
paying enormous attention to detail, and nally he was able to complete a signicant number
of cases successfully. This demonstration of the practical application of the cardio-pulmonary
bypass machine opened the door for the rapid expansion of the speciality. Though it would be
several years before the problems of haemolysis, renal failure and post-pump syndrome would
be fully understood and resolved. Kirklin played a large part in all of these developments and
in particular demonstrated the importance of complement activation by the passage of blood
across the articial surfaces of the piping in the machine. Post-pump lung was a very signicant problem with many patients remaining ventilator dependent post-operatively and several
dying with adult respiratory distress syndrome.
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xi
Fig. 3 Dr. John Webster Kirklin (1917–2004) (UAB Archives, University of Alabama at Birmingham)
In 1956, Dr. Wilhelm Kolf, who had already developed the renal dialysis machine, devel-
oped a membrane oxygenator, which was to be the basis of the future in oxygen transfer systems, being far less traumatic on the blood.
At that time, only lesions of the heart that could be directly repaired and cardiac trauma
could be dealt with any degree of success. Within this category was mitral regurgitation.
Dwight McGoon, among others, pioneered techniques to reconstruct leaking mitral valves
without the need for replacement. Mural leaet imbrication and triangular resection of the
mural leaet were techniques pioneered by Dr. McGoon. This simple technique remains of use
today. Surgery on the valves of the heart required a whole new branch of technological development, that of replacement heart valves.
Several types were developed, but the most successful that has endured to this day was once
again devised by the fertile mind of Dr. Walt Lillehei. The bi-leaet valve is an ingenious idea
which allowed excellent ow characteristics with washing of all of the leaets in diastolic lling. At the same time, the biotechnology company Shiley was working with the Swedish surgeon Viking Björk on a single tilting disc variety, the Björk-Shiley valve. This too had
excellent characteristics and was soon one of the preferred valves of choice. Many other variations were devised including the Starr-Edwards “ball-in-cage”, which was also very successful, if obstructive to outow. This valve conceived by Albert Starr was in common usage well
into the early twenty-rst century. Poorly thought through changes to the Björk-Shiley valve
resulted in signicant early valve failure and withdrawal of the valve under very stressful circumstances for all, but mostly the patients.
In parallel, the idea of tissue valves was being pursued. The ideas took the form of homografts, xenografts and hand-sewn bovine pericardium. Perhaps the most innovative idea was
that of the National Heart and Guy’s Hospital surgeon, Donald Ross, who conceived of the
idea of switching the pulmonary valve to the aortic position, positing that it would have the
same size as the replaced aortic valve and was naturally designed for the purpose. It is a procedure that requires experience and considerable skill to perfect but is an excellent solution for
younger patients. This Ross procedure has persisted to the present day.
In the early days of tissue valve development, preservation of the tissue in a exible and
durable form was paramount. Alain Carpentier with the assistance of his wife developed the
chemistry of valve preservation using glutaraldehyde to x the cross-linkages on the surface of
the tissue both removing the allergenicity of the surface protein and maintaining molecular
integrity and strength. Working with Edwards, the Carpentier-Edwards valve became a mainstay of tissue valve replacement. The valves were taken from pigs (porcine) and sized with
very careful quality control. For every valve accepted, many more were discarded. The valves
are hand-sewn into the supporting stents, which are covered with Dacron cloth by workers with
immense skill and dedication. The drawback with these valves is the orice area, which is
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