John Kirklins Inspiration How We Would Fix the Inside of the Heart

DR. JOHN KIRKLIN, WHO WAS more interested in football than medicine in his undergraduate days, remembers clearly the moment he became a cardiac surgeon. He was enrolled in the medical school at Harvard University when Dr. Robert Gross, a Boston surgeon, visited to give a lecture. It was the 1930s, and heart surgery was almost nonexistent — except for Gross, who had become "the only world-famous cardiac surgeon" by successfully closing a patent ductus arteriosus a few months before.

"On this Saturday morning, into this lecture hall, down on the ground level, walked this man," Kirklin said in a 1999 interview. "He was very young, connected through tubes to the child's circulation, and the heart of the parent pumped enough oxygenated blood to also support the circulation of the small child (Fig. 1.1). A mechanical pump was used to control the interchange of blood between the patient and the donor.

On March 26, 1954, Lillehei and associates used the cross-circulation technique at the University of Minnesota to correct a ventricular septal defect, or a hole in the wall between the heart's two pumping chambers, in a twelve-month-old infant.

The patient had been hospitalized ten months for uncontrollable heart failure and pneumonia. During the operation, the child's circulatory system was connected to his father's. The procedure was a success, and the patient seemed to be making a good recovery until death on the eleventh postoperative day from an infection of the trachea. At autopsy, the hole between the pumping chambers was confirmed closed. Two weeks later, and only three days apart, the second and third patients with ventricular septal defect underwent successful heart surgery. Both became long-term survivors with normal heart function.

A year later, Lillehei published a report on thirty-two children with various types of cardiac malformations that had undergone surgical repair. Although Lillehei had met with fairly good success with his technique, it would not become established. After its use in forty-five patients during 1954 and 1955, it was discontinued. Although its clinical use was short lived, cross circulation was an important stepping stone in the development of cardiac surgery.

Kirklin's Heart-Lung Machine

At the same time Lillehei was working on cross circulation, Dr. John W. Kirklin announced he was launching an open-heart program at the Mayo Clinic, only ninety miles away from Lillehei's operating room. Kirklin and his team had developed their own heart-lung machine, basing it on the Gibbon-IBM machine, but with their own modifications.

At that time, there were perhaps fewer than a dozen laboratory research programs, very neat, with slicked-back hair. He was a good-looking man in a blue suit. He walked in and looked around that amphitheater with a slightly haughty look and said he was giving a lecture on wound healing. At that moment, 110 cardiac surgeons came into existence, of which a few of us stayed in business."

Over the next years, Kirklin remembers sitting with colleagues filling notebooks "about how we would fix the inside of the heart if we could get there. We couldn't, of course, but being young, you dream!" The obstacles to overcome in creating an open heart surgery program were awesome. Doctors on the Mayo team thought they were only months from performing the procedure on their first patient when a prominent pathologist, having observed a practice run with the heart-lung machine, said it was impractical and would never work. This pathologist happened to be in charge of the blood bank and declared it would not be possible to supply enough fresh blood to prime the machine for an ongoing open heart surgery program.

Kirklin's development program at the Mayo Clinic did, in fact, overcome the obstacles, resulting in a successful heart-lung machine that finally gave him the opportunity to realize those early ambitions. He was first to have a series of patients successfully undergo heart surgery using the heart-lung machine.

At the Mayo Clinic, Dr. John Kirklin used Gibbon's basic design to build the Mayo-Gibbon heart-lung machine. Pictured below is the screen oxygenator, which was responsible for infusing the blood with oxygen much like a lung does. This model was used in 1955 during the first open-heart operations.

Kirklin Heart

including Kirklin's and Lillehei's, focusing on open heart surgery in the world. Of them all, these two were among the most promising, and, because of their proximity to each other, the competition between the two teams of doctors was fierce, yet remained focused on the goal. Medicine appeared to be on the brink of open cardiac surgery, and doctors from around the world visited the developing programs.

The implications for a major improvement in the treatment of heart birth defects were enormous, and it was an extraordinarily exciting time in the development of medicine. Remembering this period, Kirklin later wrote:

"Dr. Earl Wood,, a great physiologist and my coworker, and I went back to his office ... and decided that we would either have to be content with cardiac surgery as a rather minor specialty, limited to passing instruments into the heart, or we would need a heart-lung machine 'It's the oxygenator that is the problem,' said Wood.

"We investigated and visited the groups working intensely with the mechanical pump oxygenator. We visited Gibbon in his laboratories in Philadelphia and Dodrill in Detroit, among others. The Gibbon pump oxygenator had been developed and made by International Business Machines Corporation and looked quite a bit like a computer. DodriR's heart-lung machine had been developed and built for him by General Motors, and it looked a great deal like a car engine. We came home, reflected, and decided to try to persuade the Mayo Clinic to let us build a pump oxygenator similar to the Gibbon machine but somewhat different.

"Most people were very discouraged with the laboratory progress. The American Heart Association and the National Institutes of Health had stopped funding any projects for the study of heart-lung machines because it was felt that the problem was physiologically insurmountable. Dr. David Donald and I undertook a series of laboratory experiments lasting about a year and a half, during which time the engineering shops at the Mayo Clinic constructed a pump oxygenator based on the Gibbon model

"Of course a number of visitors came our way, and some of them came to the laboratory to see what we were doing. One of those visitors was Dr. Ake Senning (from Stockholm Sweden). I still remember one day when he was there and one of the connectors came loose, and we ruined his beautiful suit as well as the ceiling of the laboratory by spraying blood all around the room.

"The electrifying day came in the spring of 1954 when the newspapers carried an account of Walt LUlehei's successful open-heart operation on a small child. Of course, I was terribly envious, and yet I was terribly admiring at the same moment. That admiration increased exponentially when a short time later a few of my colleagues and I visited Minneapolis and observed one of what was now a series of successful open-heart operations with controlled cross-circulation. Walt then took us on rounds, and it was absolutely exciting to see small children recovering from these miraculous operations. However, it was also a difficult time for me. Some of my colleagues at the Mayo Clinic, and some of my influential ones, indicated to me that we had wasted much time and money. After all, this young fellow in Minneapolis was successful with a very simple apparatus and did not even require an oxygenator

"However, in the winter of 1954 and 1955, we had nine surviving dogs out of ten cardiopulmonary bypass (heart-lung machine) runs. With my wonderful colleague and pediatric cardiologst Dr. Jim DuShane, we had earlier selected eight patients for intracardiac repair. Two had to be put off because two babies with very serious congenital heart disease came along, and we decided to Jit them into the schedule.

"We did our first open heart operation on a Tuesday in March 1955. That evening, I had a telephone call from Dr. Dick Varco in Minneapolis who indicated that Sir Russell Brock (a prominent chest surgeonJrom England) was visiting their cardiac surgical program at the University oJ Minnesota. Walt Lillehei and Dick Varco indicated to Sir Russell that we had done an operation earlier that day, and they called to see J he could come to Rochester the next day to see the patient, to which I said 'Certainly.' "

Kirklin later remembered that he was worried Sir Russell would ask to sit in on another surgery, which he did. "So I sort of said yes, but imagine it," Kirklin said.

"It was one oJ the world's great surgeons saying to some kid, 'May I come and visit?' He was a very imperious, tough guy with a bad reputation, which I think he totally did not deserve. I asked him J he'd like to be on the operating team.. 'No. No,' he said, 'I wouldn't. I don't want to be a problem. I just want to watch. Do you have a gallery? I'll sit in the gallery.'

"The next morning, I walked in to do the second case. He was already in the gallery, but in a place that I knew he wouldn't be able to see very well. I suggested that he might want to move, but he said, 'I'll be in your field oJ vision and I don't want you to be distracted by my presence.' He didn't move and that was a great, great man, a world-Jamous man with a bad reputation who was wonderful to me."

By this time, he and Lillehei "were on parallel but intertwined paths," Kirklin later wrote. "I am extremely grateful

to Walt Lillehei and am very proud for the two of us that during that twelve- to eighteen-month period when we were the only surgeons in the world performing open intracardiac operations with cardiopulmonary bypass and surely in intense competition with each other, we shared our gains and losses with each other. We continued to communicate, and we argued privately in nightclubs and on airplanes rather than publicly over our differences."

In Kirklin's first group of eight patients, four survived the surgery. He was able to lower his open-heart mortality rate to 20 percent the following year and 10 percent the year after that.

During 1955, Lillehei began to gradually switch over from cross circulation to a heart-lung machine of his own team's design. With a colleague, Dr. Richard DeWall, they developed a "bubble" type of oxygenator that, with modifications made by Dr. Denton Cooley in Houston, Texas, became popular. The concept is still used today.

Kirklin's heart-lung machine, which was known as the Mayo-Gibbon heart-lung machine, was the accepted standard in those early days. By this time,

Dr. Richard DeWall helped develop the bubble oxygenator that eventually replaced the screen oxygenator and became a standard in heart-lung machines.

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