In 19 years of developing the heart-lung machine, he performed only four open heart surgeries. Nonetheless, this pivotal momentous event heralded the beginning of modern cardiac surgery.
Between and , five medical centers were competing in the development of the heart-lung machine. Sharing his experience and expertise with others, Gibbon sparked a number of surgeons who were on the horizon.
Most promising of those was Dr. John Kirklin at the Mayo Clinic. Conjointly, Dr. Walton Lillehei was developing the technique of "controlled cross-circulation.
Soon thereafter, Richard DeWall, from Lillehei's laboratory, developed the bubble oxygenator. With the ability to manufacture the oxygenator and pump with readily available materials, such as polyvinyl tubing and a commercially available pump by the Sigmamotor Company , visiting surgeons quickly expanded the use beyond the laboratories of these world-famous surgeons.
A third type of oxygenator, the rotating-disc oxygenator, was developed by Kay and Cross in Cleveland and was being mass produced. The development of the heart-lung machine spurred innovation in a number of initiatives to treat heart disease. Soon coronary bypass grafting, valvular replacement, congenital correction and heart transplantation were to become standard treatment.
Today, mechanical circulatory support via implantable pumps owes its credits to a handful of researchers from over 60 years ago. Thousands of patients are the beneficiaries of one the most pioneering advances in medicine: the creation of the heart-lung machine. A device for the experimental creation of ventricular septal defects; preliminary report. J Thorac Surg ; Gibbon JH Jr.
Artificial maintenance of the circulation during experimental occlusion of the pulmonary artery. Arch Surg ; Cross-circulation and the early days of cardiac surgery. Ann Surg ; Coronary artery bypass grafting: Part 1—the evolution over the first 50 years.
Head , Stuart J. Oxford Academic. Teresa M. Volkmar Falk. Hans A. Revision received:. Cite Cite Stuart J. Select Format Select format. Permissions Icon Permissions. Abstract Surgical treatment for angina pectoris was first proposed in Figure 1. Open in new tab Download slide.
Figure 2. Figure 3. Figure 4. Table 1 Incidence and predictors of early clinical outcomes after coronary artery bypass surgery, with a focus on perioperative considerations to prevent complications. Specific predictors. These are generally factors that are associated with how well the patient tolerates the procedure, the progression of disease, the procedural complexity, and the postoperative recovery.
Postoperative stroke has been found to increase the risk of day mortality by five- to six-fold. Other predictors are: urgency of procedure, recent MI, number of distal anastomoses, incomplete revascularization, longer cardiopulmonary bypass time.
Operative graft flow measurement may identify grafts that need revision. Re-exploration for bleeding increases the risk of stroke, MI, pneumonia, and deep sternal wound infection, but also significantly increases the use of blood products and prolongs postoperative hospital stay by about 2 days. Antifibrinolytic agents may reduce blood loss. The reduction in operative time should be weighed against increased rates of re-exploration.
Delirium is associated with increased morbidity and mortality, as well as prolonged hospital stay and increased hospitalization costs. A multicomponent intervention for the management of cognitive impairment, sleep deprivation, immobility, visual and hearing impairment, and dehydration reduces number and duration of delirium episodes.
Renal failure is a significant predictor of short- and long-term mortality, even in patients with preoperative normal renal functions. Easy preventive strategies consist of: preoperative hydration, prevention and correction of hypotension, abandon the use of nephrotoxic drugs, and use of nonionic contrast during angiography. Postoperative sternal wound infections increase the postoperative process, stay are associated with incremental costs, and lead to a drastic increase in early or delayed mortality.
Prevention of mediastinitis through preoperative antiseptic showers, hair removal, and administration of perioperative antibiotics has been instated. Limiting the need for re-exploration for bleeding will furthermore reduce its rate. Often of transient nature due to early postoperative inflammatory responses and oxidative stress that are reduced over subsequent days post-surgery. Atrial fibrillation is a predictor of stroke and was found to significantly reduce long-term survival in a number of studies.
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There were no statistically significant differences in surgical reexploration or length of stay. They found that the mean cost for an on-pump surgery was significantly higher than an off-pump surgery.
Interestingly, Yadava et al. In-hospital mortality was higher in women as compared to men, 2. The most common causes of mortality were low cardiac output and renal failure. The primary short-term endpoint, a composite of death or complications within 30 days of surgery, occurred with similar frequency 5.
The primary long-term endpoint, a composite of death from any cause, a repeat revascularization procedure, or a nonfatal myocardial infarction MI within 1 year of surgery, occurred more often in those undergoing off-pump CABG 9. Neuropsychological outcomes were not different between the groups, and graft patency was higher in the on-pump group Minimally invasive and robotic assisted approaches have also been developed.
Minimally invasive cardiac surgery does not use CPB and can be performed through smaller incisions. However, the total number of bypassable vessels is reduced secondary to exposure making these approaches useful for a select group of patients.
Multiple conduits may be employed to establish cardiac revascularization. The LIMA is the vessel of first choice. Other arterial conduits, such as the radial, gastroepiploic, and inferior epigastric arteries, have been used in CABG. Radial artery graft patency is best when used to graft a left-sided coronary artery with high grade stenosis and worst when utilized on the lower pressure right heart. The gastroepiploic artery is most often used to bypass the right coronary artery or its branches, but it is prone to spasm [ 31 ].
It is also prone to spasm. The study reviewed the records of nearly The median follow-up period was 2. At 1 year, there was no significant difference in mortality between the groups 6. Survival was the same for single and multivessel CAD. The incidence of MI was similar at 5 years after randomization. Risk factors include age, previous stroke, diabetes mellitus, hypertension [ 37 ], and female sex [ 38 ].
Hypoperfusion is also risk factor for postoperative stroke [ 39 ]. Mortality rate is fold higher among post-CABG patients with prior stroke with longer lengths of hospital stay [ 40 ]. Although off-pump CABG was introduced to reduce adverse neurological outcomes associated with CPB, this has not been proven in the literature. Postoperative delirium has been linked to functional decline at 1 month, short-term cognitive decline, and risk of late mortality [ 42 ].
Short-term cognitive changes occur in some patients after on-pump CABG. Risk factors for short-term postoperative cognitive decline include preexisting risk cerebrovascular disease, central nervous system disorders, and cognitive impairment [ 43 — 45 ]. To prevent surgical site infections in CABG patients, a multimodality approach involving several perioperative interventions must be considered. Infection rates may be improved by smoking cessation, optimizing nutritional status, tight glucose control, and weight loss.
Transfusion of homologous blood has been correlated, in a dose-dependent manner, to an increased risk of postoperative infection, morbidity, and both early and late death [ 50 ]. They have been additionally associated with a higher incidence of sternal wound infections [ 51 ].
In a retrospective analysis of This finding correlates with a RCT showing that leukocyte-depleted blood had reduced rates of infection Transfusions have also been identified as an independent risk factor for adverse outcomes [ 54 ]. Commonly, postoperative myocardial depression is observed consistently after transfusion in a dose-dependent manner.
Survival rates after CABG are reduced in patients requiring transfusion [ 55 ]. There are multiple conditions that influence postoperative renal failure. These risk factors include pre-existing renal dysfunction, decreased cardiac output, as in CHF or shock, insulin dependent diabetes, and concomitant peripheral artery disease.
Advanced age, black race, female gender, and the need for emergent surgical intervention or preoperative intraaortic balloon support have all been implicated in increasing the risk of ARF [ 57 — 60 ]. Post-CABG myocardial dysfunction is another commonly seen adverse event. Intraaortic balloon counterpulsation has been shown to increase cardiac output and to improve coronary blood flow [ 58 ].
Furthermore, both the short day and long-term 2-year outcomes were worse in these patients, and this correlated with the degree of biomarker elevation [ 61 ].
Mariscalco et al. There are multiple conditions which predispose patients to postoperative AF. These include the presence of peripheral artery disease, COPD, concomitant valvular heart disease, previous cardiac surgery, preoperative AF, and pericarditis. Male gender and advanced age are also risk factors for AF. Postoperative AF almost always occurs within 5 days of surgery peaking on postoperative day 2 [ 63 ]. Multiple pharmacologic interventions have been attempted, but only perioperative beta blockade and amiodarone have been shown to be effective in reducing AF [ 64 ].
As such, rate control with beta blockers or conversion with amiodarone is the first line of treatment [ 65 ]. Postoperative anticoagulation may be warranted in rate controlled patients still in fibrillation. Advances in medical therapy and percutaneous intervention have led to ever shrinking numbers of CABG being performed each year. Furthermore, the patients undergoing these procedures have a much more complicated combination of disease processes.
The future of coronary artery bypass grafting is making these difficult procedures better tolerated by this complex subset of patients through smaller incisions or without any incision. Operative changes and challenges are trying to be addressed. Minimally invasive procedures and approaches will continue to be developed. Robotic intervention strives for a totally endoscopic CABG. Anastomotic devices are being researched to make this goal more feasible.
However, most of these devices are infrequently utilized and are in the infancy of their potential development [ 66 ].
Additionally, many of the patients have extensive coronary artery disease with prior attempts at revascularization. The determination of graft patency, intraoperatively, in these patients is vital.
For this reason, several techniques using transit-time flow and intraoperative fluorescence imaging are being developed. However, neither method has been proven to be adequate in the assessment of small abnormalities in graft patency [ 67 ]. This has been proposed to decrease the morbidity rate of traditional CABG in high-risk patients.
The National Institutes of Health has sponsored a randomized control trial to evaluate the hybrid procedure versus CABG or stenting alone [ 66 ]. Additionally, nonoperative placement of substances known to promote myocardial regeneration and angiogenesis is being researched [ 68 , 69 ]. With the success of stem cell therapy and molecular medicine in other fields of science and medicine, this has great potential for myocardial repair.
In a little over a century, heart surgery has gone from prohibitive to commonplace. Major advances have made the CABG a much safer and more accepted procedure.
Continued research into different approaches, methods and medical interventions may make cardiac surgery less invasive and safer in the future. The benefits and risks for each patient must be evaluated with a team approach to determine which method is best for that patient. Even with paradigm shifts in medical treatments and stenting, the continued development of coronary surgery is vital for those patients who cannot be managed nonsurgically.
As surgical interventions become relatively less common, the issue of how many and how to train future cardiac surgeons may become an issue. Furthermore, as the procedures and patients become more complex, the development of different specialized postoperative strategies will need to be considered. Lastly, the field of cardiac surgery will need to become more specialized as people are surviving cardiac operations for longer period of time and may need further interventions such as higher risk reinterventions.
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Article of the Year Award: Outstanding research contributions of , as selected by our Chief Editors. Read the winning articles. Journal overview. Michael Diodato 1 and Edgar G. Academic Editor: H. Received 27 Jun Accepted 25 Jul Published 02 Jan Abstract The development of the heart-lung machine ushered in the era of modern cardiac surgery.
Methods Although the fundamental basis of CABG is to reestablish perfusion to the myocardium, there are several different approaches to accomplish this goal. Conduits Multiple conduits may be employed to establish cardiac revascularization. Future Directions Advances in medical therapy and percutaneous intervention have led to ever shrinking numbers of CABG being performed each year. Summary In a little over a century, heart surgery has gone from prohibitive to commonplace. Conflict of Interests The authors have no financial interests to disclose.
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