Asked to name the greatest scientific achievements of the 1960s, it鈥檚 a fair bet most people will list two that remain as awe-inspiring now as they were then: landing men on the moon and giving a dying man a new heart. When Christiaan Barnard performed the first heart transplant in 1967, he made headlines around the world. The operation heralded a new era in medicine, one in which surgeons could cheat death by replacing even this most vital of organs. Just 15 years earlier, however, surgeons despaired of ever being able to repair damaged hearts. What changed their minds? In 1954, American surgeon Walt Lillehei performed an operation both daring and dangerous: he connected a desperate dad to his sick baby and created a human-powered heart-lung machine.
ON 26 March 1954, Walt Lillehei scrubbed up and walked into his operating theatre at the University of Minnesota Hospital in Minneapolis. The room was small and cramped: instead of one operating table there were two, as well as several extra doctors and some unfamiliar equipment. Alongside the usual array of surgical instruments was a small electric pump and a pile of clear plastic tubing 鈥� the sort used to transport beer from barrel to bar-room tap. With these, Lillehei was going to connect two people鈥檚 circulatory systems so that one heart did the work of two, allowing him to stop the flow of blood to his patient鈥檚 heart, open it up and make the necessary repairs. If everything went well, he would save a life. If he failed, two people might die.
Given the millions of major heart operations performed today, it鈥檚 hard to believe that as recently as the 1950s heart surgery we now regard as routine seemed far beyond medicine鈥檚 reach. Surgeons had always been reluctant to interfere with the heart: it was too critical an organ to take risks with. In the 19th century a few daring doctors had operated on the pericardium, the membranous sac around the heart. In 1896, a German doctor went a little further, saving the life of a young man by stitching up a stab wound to his heart.
Advertisement
By the early 20th century, some surgeons were operating on the outside of the heart and on its great blood vessels, but it wasn鈥檛 until the 1940s that anyone dared to consider going right inside it. The wall of the heart had always seemed an impenetrable barrier, but there was a powerful incentive to cross it. So many people needed surgery to repair and many of them were children. Large numbers of babies were born with holes in their hearts, blocked or missing valves, misdirected blood vessels or a combination of all of these. , then a common disease, also left many with blocked and damaged valves.
鈥淭he wall of the heart had always seemed an impenetrable barrier鈥�
The first breakthrough was an operation to clear blocked valves between the upper and lower chambers of the heart. This was relatively simple and very quick, requiring a small incision in the upper chamber and a swift probing with a finger to clear the obstruction. It could be done by 鈥渃losed heart surgery鈥� 鈥� with the heart still pumping and the surgeon working by touch alone. For anything more complicated, the heart would have to be opened and drained of blood so surgeons could see what they were doing. How could that be done without starving the body of oxygen?
Surgeons dreamed of machines that could take over the job of the heart and lungs, keeping the patient鈥檚 blood replenished with oxygen for as long as it took to repair holes or adjust the heart鈥檚 plumbing. Some built them and by the start of the 1950s had begun to experiment.
The first trials of heart-lung machines looked promising. In dogs they could keep the body oxygenated for half an hour with no ill effects. The first trials in heart patients were a disaster. The crude machines broke up the blood cells and triggered huge and fatal immune responses. Because no one realised what was happening, they attributed the deaths to patients鈥� frailty rather than the machines. 鈥淓ven experienced investigators came to believe that the 鈥榮ick human heart鈥�, ravaged by failure, could not be expected to tolerate the magnitude of the operation required and then recover,鈥� Lillehei wrote. Open heart surgery, it seemed, would have to wait until someone found a way to overcome this apparently insurmountable obstacle.
Lillehei remained convinced that machines were the answer, but in the meantime he had another idea. In readiness for the moment when someone perfected a bypass machine, he and his team had made a habit of going to the morgue whenever a heart patient died and performing mock operations to repair the defects they found. 鈥淚n almost all cases the defects were completely correctable,鈥� he wrote. 鈥淭he only obstacle was a method of working within the open heart for a reasonable length of time.鈥�
Lillehei had also learned that it isn鈥檛 essential to keep blood pumping round the body at the rate a healthy heart does: the body can manage with as little as 10 per cent of the oxygen carried in the blood. He also found that it was possible to keep enough oxygenated blood circulating through a patient by linking them to a donor and making the donor鈥檚 heart and lungs do the work. At least, it was possible when the patient was a dog.
Soon Lillehei was ready to try such 鈥渃ross-circulation鈥� with a human patient. There was no shortage of candidates. For a child with a failing heart, the operation offered at least a small chance of life. The problem with Lillehei鈥檚 scheme was the need for a healthy donor. Most surgeons were horrified by the idea. The risks were too great. The pipes might block, there might be a catastrophic immune reaction or air might get into the system and cause a fatal embolism. None of this had happened in his experiments, so Lillehei was willing to risk it 鈥� if he could find a donor who was prepared to take the risk and whose blood was a match with the patient.
On 26 March 1954, he performed his first operation using cross-circulation. The patient was 13-month-old Gregory Glidden and the donor was his father. Gregory had a large hole in the wall separating the two lower chambers of his heart, a defect considered irreparable at the time. He had spent most of his life in hospital, plagued by recurring pneumonia. The operation was a success, and Gregory鈥檚 father suffered no ill effects. Gregory began to recover. Then he caught pneumonia and 11 days after the operation he died.
Gregory had not died because of his operation and the hole in his heart had healed perfectly, so Lillehei tried again. Over the next 15 months he and his team performed 44 more operations using cross-circulation. The patients were all children, many very young and all destined for an early death. Most of the donors were mothers or fathers, but there were also aunts, uncles and cousins, friends of the family and one total stranger.
To start with, Lillehei chose children who, like Gregory, had a hole between their ventricles. Of 27 patients, 19 recovered and 17 were still fit and healthy 30 years later. By August 1954, Lillehei was operating on children with multiple defects in their hearts. This was uncharted territory and diagnoses weren鈥檛 always right. Sometimes he opened a heart and found defects he had never seen before. Lillehei was inventing operations as he went along and the learning curve was steep. Nevertheless, 60 per cent of the children survived the surgery, without which none would have lived much longer.
鈥淚t was a truly courageous thing to do,鈥� says Francis Wells, heart surgeon at Papworth Hospital in Cambridge, 鈥渂ut the procedure was so nerve-racking that no one else took it up.鈥� Lillehei had always seen cross-circulation as a temporary measure. By July 1955 he abandoned it. His prot茅g茅, Richard DeWall, had invented a cheap and simple 鈥渂ubble oxygenator鈥� 鈥� a machine that replenished the patient鈥檚 blood with oxygen before returning it to the body. It was precisely what Lillehei had asked for: cheap, simple to use and effective enough to persuade the world鈥檚 heart surgeons to try it themselves.
Lillehei had proved there was no such thing as the 鈥渟ick human heart鈥�. It could and did recover from major surgery. He had shown even the most 鈥渦ncorrectable鈥� defects could be corrected. He had done what was necessary to convince the doubters that open heart surgery was possible. Just 12 years later, Christiaan Barnard performed the first heart transplant.
