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October 2001
Volume 65 |
Number 10
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| Cardiac
Anesthesia Timeline |
Eugene A. Hessel
II, M.D
Cardiac anesthesia is inexorably intertwined with cardiac
surgery. Compared to many medical specialities, cardiac surgery
is remarkably young, having developed almost entirely in the
past 105 years.1-3 The specialty of cardiac
anesthesia has mainly evolved in the past half-century, and
many of its participants are still living and active in our
specialty. 4-6
1896-1937: The Beginnings
In September 1896, Ludwig Rehn of Frankfurt first successfully
sutured a stab wound of the heart — an event that many
consider the beginning of cardiac surgery. While only modest
efforts at cardiac surgery occurred in the next 40 years
(e.g., closed pulmonary embolectomy, pericardiectomy, closed
valvotomies, cardiac trauma), important advances were occurring
that led to its subsequent development (e.g., blood typing
and transfusion [1900-15], discovery of heparin and its
neutralization by protamine [1916-39], cuffed rubber endotracheal
tubes [1919-26], in-line carbon dioxide absorber [1924],
cyclopropane [1933] and thiopental [1934]).
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1938-1951: Closed Heart Surgery Erupts
In 1938, Robert Gross, M.D., at the Children’s Hospital in
Boston first successfully ligated a patent ductus arteriosus.
Anesthesia was provided by Betty Lank, R.N., via a tight fitting
mask. In October 1944, Clarence Crafoord, M.D., of Stockholm first
successfully repaired a coarctation; and in November 1944, Alfred
Blalock, M.D., of the Johns Hopkins Hospital successfully created
a subclavian to pulmonary artery shunt to palliate Tetralogy of
Fallot. Early surgeons were quick to recognize the importance
of the cardiac team and the critical role the (cardiac) anesthesiologist
played in achieving success. Meril Harmel, M.D., and Austin Lamont,
M.D., provided anesthesia for Blalock’s shunt cases and reported
their results in one of the first papers on cardiac anesthesia
in 1946. This type of anesthesia required new understanding of
cardiac pathophysiology and the interaction with anesthesia. In
June 1948, Charles Bailey, M.D., of Philadelphia started a successful
series of closed mitral commissurotomies. Anesthesia for Bailey’s
cases was provided by Kenneth Keown, M.D., who in 1956 authored
the first textbook on cardiac anesthesia. In 1952, Charles Huffnagel,
M.D., began inserting the first prosthetic aortic valve (in the
descending aorta to palliate aortic regurgitation without benefit
of left heart bypass!) with anesthesia care provided by John O’Donnell,
M.D., and Thomas McDermott, M.D.
1952-1959: Open-Heart Surgery Arrives
In September 1952, F.J. Lewis, M.D., at the University of Minnesota
closed an atrial septal defect under direct vision using moderate
surface-induced hypothermia; and on May 6, 1953, John H. Gibbon,
Jr., M.D., did the same utilizing total cardiopulmonary bypass
with a heart-lung machine. (Two weeks earlier, James Watson, M.D.,
and Francis Crick, M.D., published their proposed structure [“double
helix”] of DNA, and three weeks subsequently, Sir Edmond
Hillary and Tenzing Norgay first summited Mount Everest.) Dr.
Gibbon had no further successes, which was partly attributed to
lack of participation of physician anesthesiologists. A year later,
C. Walton Lillehei, M.D., at the University of Minnesota started
his remarkable series of open-heart surgery, utilizing the subject’s
parent as a biologic pump-oxygenator (“controlled cross circulation”).
Anesthesia was provided by Fred vanBergen, M.D., Joseph Buckley,
M.D., James Matthews, M.D., and Earl Schultz, M.D. Finally in
March 1955, John Kirklin, M.D., at the Mayo Clinic began the first
successful series of open-heart surgery utilizing a mechanical
heart-lung machine (a modified IBM-Gibbon machine). Anesthesia
was provided by R.T. Patrick, M.D. Cardiac anesthesiologists around
the country now had to learn about the pump, invasive monitoring,
anticoagulation and bleeding, and “pump lung.”
1960-1969: Explosive Growth of Cardiac Surgery
Rapid growth and expanded applications of cardiac surgery in the
1960s required many more cardiac anesthesiologists with new knowledge
and skills. Successful prosthetic heart valves were introduced
in 1960 and human heart transplantation and aortocoronary bypass
grafting occurred in 1967. In the same year, J. Earl Waynards,
M.D., and colleagues of Montreal published one of the first articles
on anesthetic management of patients undergoing surgery for coronary
artery disease. Complex congenital heart disease was being approached
with the development of Mustard’s operation for transportation
of the great arteries in 1963 and 1968, facilitated by the reintroduction
of deep hypothermic circulatory arrest by the groups in Seattle
and Auckland. Closed chest massage was introduced in 1960 as were
permanent implantable pacemakers and hemodilution prime. Monitoring
of left atrial pressure became common and gave new insight in
discrepancies between right- and left-heart function. The appearance
of surgical intensive care units (ICU) and ICU ventilators offered
a new venue for the anesthesiologist, while the introduction of
the intra-aortic balloon pump in 1967 offered a new approach (“mechanical
circulatory assist”) for the treatment of perioperative cardiac
failure.
1970-1979: Cardiac Anesthesia Gets Organized
In August 1970, H.J.C. Swan, M.D., and William Ganz, M.D., in
Los Angeles introduced their pulmonary artery catheter (PAC),
and cardiac anesthesiologists were quick to bring them into the
operating room, permitting more precise hemodynamic monitoring
and intervention. Joel Kaplan, M.D., among others, “sold”
the importance of cardiac anesthesiologists to surgeons and anesthesiology
residents. He popularized the use of the V5 lead (1976) and the
PAC to detect myocardial ischemia (1981) and nitroglycerine infusions
to treat it (1976) and, in 1979, edited a new comprehensive textbook
on cardiac anesthesia, which became the standard reference in
the specialty. Fellowships in cardiac anesthesia appeared and
attracted many residents who became future leaders in this subspecialty.
In 1972, the Association of Cardiac Anesthesiologists was founded,
followed in 1978 by the Society of Cardiovascular Anesthesiologists
(SCA), which became one of the largest and most influential subspecialty
societies in anesthesiology. (Current membership is 6,500 with
more than 1,000 persons attending the latest annual meeting.)
Meanwhile, important advances were occurring in cardiac surgery
and medicine. Cold potassium cardioplegia was introduced in 1973,
objective monitoring of heparin and its reversal by the activated
clotting time (ACT) in 1975, the use of prostaglandin infusions
to palliate critically ill cyanotic infants in 1976 and percutaneous
transluminal coronary angioplasty in 1977. Arterial switch operation
was first successfully accomplished in 1975; in 1979, William
Norwood, M.D., introduced his staged repair of hypoplastic left-heart
syndrome. Tilting disc valves and bioprostheses (e.g., stent-mounted
porcine valves) gradually displaced Starr-Edwards ball valves.
1980-1989: Maturation of Cardiac Surgery and Anesthesia
With the introduction of cyclosporin in 1980, heart transplantation
grew from about 100 per year to 2,400 per year in the next five
years. The first artificial heart was implanted in 1982, and although
it failed as a permanent device, it opened the way for powerful
assist devices (and preceded a hopefully more satisfactory, totally
implantable artificial heart described in
this issue of the NEWSLETTER). Internal mammary arteries
became the bypass graft of choice for coronary artery bypass,
and mitral valve repair gained acceptance. Better understanding
and modulation of the pathophysiology of cardiopulmonary bypass
(CPB) was being achieved, and cardiac anesthesiologists were intimately
involved in much of this work: Alpha stat pH management during
hypothermic CPB was advocated in 1982 (Reams) and became widely
practiced. Measurement of cerebral blood flow in humans during
bypass in 1983 (Reves, Hendricksen, et al.) spurred interest in
the effect of CPB on the brain, followed in 1986 by Nussmeier
and Slogoff’s study of the cerebro-protective effects of
barbiturates during CPB. The Alabama group drew attention to the
systemic inflammatory response to CPB in 1981, and this led to
the serendipitous discovery of the benefits of aprotinin in reducing
blood loss during CPB by David Roysten, M.D., and others in 1987.
By the end of the decade, membrane oxygenators had nearly replaced
bubble oxygenators, and centrifugal pumps were gaining in popularity.
In 1983, Sebastian Reiz, M.D., and colleagues called attention
to isoflurane steal, and in 1985, Stephen Slogoff, M.D., and Arthur
S. Keats, M.D., emphasized the incidence and significance of perioperative
myocardial ischemia. At the end of this decade, Kenneth J. Tuman,
M.D., and others and Drs. Slogoff and Keats demonstrated that
the choice of anesthetic agent per se had little impact on outcome.
Perhaps of greatest impact on the subspecialty in the 1980s was
the contribution of cardiac anesthesiologists to the introduction
of transesophageal echocardiography (TEE) to cardiology in 1980
(M-Mode: Matsumoto and Oka) and 1982 (2-D: Cahalan, Roizen and
others). It was quickly applied to cardiac surgery and helped
to further define the subspecialty of cardiac anesthesiology.
In 1987, Joel Kaplan, M.D., started the first journal devoted
to cardiothoracic anesthesia, and in that same year, nitric oxide
was identified as the endothelial-derived relaxing factor.
1990-2001: Leadership
Major changes have occurred in cardiac surgery during the past
11 years that have required adaptive changes by cardiac anesthesiologists,
many of whom have contributed to the development, application
and evaluation of these techniques, including “fast-tracking,”
warm bypass, retrograde cerebral perfusion, augmented venous return,
minimal access, port access and off-pump coronary artery surgery
and the use of stentless valves. Heparin-coated circuits and modified
ultrafiltration were introduced, as was the use of nitric oxide
in the O.R. and ICU. Cardiac anesthesiologists conducted studies
of CPB in small animal models (e.g., Grocott, Hindman), cardiac
molecular biology (e.g., Schwinn), inflammatory response to CPB
(e.g., Bennett-Guerrero), effect of CPB on coagulation (e.g.,
Levy, Despotis, Gravlee) and multicenter outcome research (e.g.,
Mangano). In collaboration with surgeons and cardiologists, anesthesiologists
contributed to developing guidelines for preoperative evaluation
of cardiac patients for noncardiac surgery (Fleisher) and symposia
on neurologic effects of cardiac surgery (Murkin, Newman). In
1993 and 1995, cardiac anesthesiologists edited or co-edited two
new textbooks on cardiopulmonary bypass (Gravlee and Davis, and
Mora), and in 1994 and 2001, two new textbooks on cardiac anesthesia
appeared (Estafanous et al. and Thys et al.). In collaboration
with echocardiologists (and the American Society for Echocardiology)
and cardiac anesthesiologists (through the Society of Cardiovascular
Anesthesiologists), ASA developed “Practice Guidelines for
Perioperative TEE” in 1996 (Thys et al.). In 1999, “Guidelines
for Comprehensive Intraoperative TEE Examination” were written
(Shanewise et al.). Cardiovascular anesthesiologists also contributed
to the formation of the National Board of Echocardiography, culminating
with the administration of the first examination in perioperative
TEE in 1998, and in 2000, with efforts to obtain certification
of anesthesiologists in perioperative TEE. In 2000, SCA submitted
an application to the Accreditation Council for Graduate Medical
Education (ACGME) for accreditation of resident education programs
in the subspecialty of cardiothoracic anesthesia.
Cardiac anesthesiologists have long held leadership positions
in ASA, subspecialty societies (including the Society for Education
in Anesthesia) and their hospitals and departments, including
many chairmanships. Now they are advancing to even higher levels
of leadership, including at least five deans of medical schools
(Kaplan, Reves, Roizen, Slogoff and Miller).
1. Shumacker HB Jr. The Evolution of Cardiac Surgery. Bloomington,
IN: Indiana University Press; 1992.
2. Westaby S, Bosher C. Landmarks in Cardiac Surgery.
Oxford: Isis Medical Media; 1997.
3. Shumaker HB Jr. Birth of an Idea and the Development
of Cardiopulmonary Bypass. In: Gravlee GD, Davis RF, Kurusz M,
Utley JR. Cardiopulmonary Bypass: Principles and Practice. Philadelphia:
Lippincott Williams & Wilkins, 2000:22-34.
4. Alston RP. Anaesthesia and cardiopulmonary
bypass: An historical review. Perfusion. 1992; 7:77-88.
5. Bacon DR. Unsung Heros: The pediatric cardiac
anesthesia story. ASA Newsl. 1998; 62(9):9-10.
6. Hessel EA. History of Cardiac Surgery and Anesthesia.
In: Estafanous FG, Barash PG, Reves JG, eds. Cardiac Anesthesia:
Principles and Clinical Practice (2 ed). Philadelphia: Lippincott
Williams & Wilkins; 2001:3-35
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