The History of Pediatric Cardiology and Cardiovascular Surgery

Pediatric cardiology and pediatric cardiac surgery

have developedinterdependently

CHD: Primordial heart?CHD: Primordial heart?

FISH 1A+1VAMPHIBIA 2A+1V Snakes rudiment. VSREPTILES 2A+2V Turtles spongy VSBIRDS 2A+2V Alligators VSD MAMMALS 2A+2V

The Foundations

Scientific medicineThe danger of touching the heartAnesthesiaControl of the airwayVascular surgeryCardiac catheterizationHeart-lung bypassThe price of innovation

Scientific medicine begins

Marcello Malpighi—1661

Anton van Leeuwenhoek—1674

Antoine Lavoisier—1777

Early scientific foundations1785 William Withering introduces Foxglove1790 Luigi Galvani--electrical stimulation of frog muscle1808 Humphrey Davy identifies Na, K, Mg, Ca, Sr, & Ba1830s Claude Bernard--wide-ranging experiments1830s Michael Faraday--electricity: anode, cathode, electrolyte, anion and cation. 1880s Joseph Lister--antiseptic surgery (phenol)1883 Ringer shows that K inhibits, Ca stimulates heart1887 Augustus Waller--Hg cardiogram

1903 Willem Einthoven invents the string galvanometer EKG

1895 Wilhelm Conrad Roentgen--X-Rays1896 Scipinio Riva-Rocci--Hg sphygmomanometer1900 Karl Landsteiner--biocompatibility, ABO system

The danger of touching the heart

"Surgery of the heart has probably reached the limits set by Nature to all surgery. No method, no new discovery, can overcome the natural difficulties that attend a wound of the heart."

Stephen Paget, 1896The Surgery of the Chest

Anesthesia for Thoracic Surgery

21 And the LORD God caused a deep sleep to fall upon Adam, and he slept; and he took one of his ribs, and closed up the flesh instead thereof.

22 And the rib, which the LORD God had taken from man, made he a woman, and brought her unto the man. -- Genesis 2

Humphrey Davy--1800

“As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations…”

Crawford W. Long--1842 Horace Wells--1844

Charles Jackson--1846William T.G. Morton--1846

Control of the airway

But that life may in a manner of speaking be restored to the animal, an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put; you will then blow into this, so that the lung may rise again and the animal take in air. Andreas Vesalius, 1543

John Hunter—1667James Curry—1815John Snow—1858J O’Dwyer—1885 (peroral)Rudolph Matas—1902

The muzzle of these bellows was fixed into the trachea of a dog, and by working them he was kept perfectly alive. While this artificial breathing was going on, I took off the sternum of the dog, and exposed the lungs and heart; the heart continued to act as before, only the frequency of its action was considerably increased.

John Hunter, F.R.S.Phil. Trans. (1776)

Vascular surgery

Cardiac Catheterization

Heart-lung bypass

Von Frey and Gruber--1885

Early Open Heart Surgery With Early Open Heart Surgery With Heart-lung MachineHeart-lung Machine

C.Dennis 1952 2/2 DiedJ.Gibbon 1953 5/6 DiedJ.Helmsworth 1953 1/1 DiedD.Dodrill 1953 2/2 DiedG.Clowes 1953 2/2 DiedW.Mustard 53/54 5/5 Died

17/18 94.5%

Controlled Cross-circulationControlled Cross-circulation3/26/54-7/19/553/26/54-7/19/55

NO. MORT. <2Y MORT.VSD 28 8(28%) 16 6(37%)TOF 11 4(36%) 5 3(60%)CAVC 4 3(75%) 3 2(67%)IPS 2 0 45 15(33%) 24 11(49%)

William HarveyLudwig RehnHumphrey DavyHorace WellsRudolph MatasWerner ForssmannJohn Gibbon

The price of innovation

The more radical (important) the innovation, the greater the ridicule and vilification by colleagues

“I did not repeat the operation because I could not get another case. Although my patient made an uninterrupted recovery, the Physicians declared that it was all nonsense and in fact the operation was unjustified. In fact, it is on no use to be ahead of one’s time.”

PED CARD HX:NADAS

Alexander Nadas

Born and educated in HungaryTo London in 1938, Paul Wood’s tutelageThen to NY, 3-4 yr in various rolesJoined Children’s Hosp HS in 1942To Detroit with Dr Clem Smith-pvt practice in Mass1949-Dr Janeway invited him to develop Ped Card at Boston Children’s Hosp

Spent 1 yr with Sam Levine and Lewis Dexter at PBBHUncanny ability to select the right course of action, right person, be on the winning sideAuscultation, EKG-first tools – a masterBasic diagnostic and natural hx facts for all major pediatric cardiac problemsTrained the leaders in the field

Alexander Nadas

Ped Card Hx: BT Shunt

3 pts-pt 1-premature 1.1 kg, 15 mos, 4 kg, stormy course, “had it not been for the excellent care by the pediat house staff,the child’s life would not have been saved”Pt 2-12 yr-hgb 24, innominate artery usedPt 3-7 yr, 02 sat 36 %,innominate arteryAll pts markedly improved, “pink”, conitnuous murmurs, Qp increased

Incredible success, JHH –the place to goThe operation “perfected” at Vanderbilt by Dr Blalock and his TechnicianThe operation exported around the world Training programs begun at JHHMedical/Surgical collaboration exemplified

Ped Card Hx: BT Shunt

Extracardiac Repair and Extracardiac Repair and PalliationPalliation

PDAPDA R.GROSS 08/26/38 R.GROSS 08/26/38

COARCT. C.CRAFOORD 10/01/44COARCT. C.CRAFOORD 10/01/44

S-P SHUNT BLALOCK-TAUSSIG 11/29/44S-P SHUNT BLALOCK-TAUSSIG 11/29/44

P-A BAND DAMMON-MULLER 1952P-A BAND DAMMON-MULLER 1952

Pediatric Cardiac SurgeryPediatric Cardiac Surgery

1953-1969

* Early Palliation

* Elective Repair at ± 5 to 6 Years

1970-1982

* Primary Repair in Infancy

1983 * Primary Repair in Neonates

Surgical Mortality According Surgical Mortality According To Age And YearsTo Age And Years

0%

5%

10%

15%

20%

25%

30%

35%

<1Y 1-5 Y 6-12Y >12Y

1954-641990-2000

PGE & Imaging

Early ’70s-M-mode echo in CHD1974-First 2D images1975-First reports of PGE use1977-Axial Angiography1978-First reports of subxiphoid 2D imaging in CHD1980s-Doppler studies, fetal studiesLate ’80s-90s-TEE, intraoperative studies

Pediatric Cardiology: Summary1938-Essentially no Rx for CHD

Pioneers-pathologists, cardiologists, surgeons, imaging experts, intensivists, interventionalists

2002-Rx for virtually all CHD, BUT mort./morb.:ventricular functionarrhythmiacnsvalves/conduitspulm hypertension

New frontiers-causation, gene-based Rx, CHF Rx, Arrhythmia Rx, imaging, safety of CPB, PVRAn incredibly exciting run--much for the future