In 1896, Stephen Paget, a renowned British surgeon claimed, “Surgery of the heart has probably reached the limits set by nature to all surgery; no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart.”1
The story of the first implantable cardiac device is typical of the advancement of science and medicine, with early disappointment, courageous explorations upon sacrificially willing patients, catastrophic failure, renewed investigations, and eventual triumph by a small group of investigators with almost pathological determination.
Electronics were, for decades, only utilized in cardiac medicine, starting in the 1950s. Today, implantable electronic devices enjoy widespread use in general surgery, urology, otolaryngology, neurosurgery, orthopedics, and even gynecology. The story of their implantation is a synthesis of improved surgical techniques, advanced anesthesia, antibiotics, upgraded metallurgy, and modern electronics, and particularly, the development of the transistor.
Even as surgical treatment of gastrointestinal and musculoskeletal issues was improving in the 1930s, no one dared operate on the heart. Risk of brain damage, sudden death, and failure of surgery was so grave that surgery was simply untenable. In 1938, Robert Gross at the Boston Children’s Hospital performed ligation of the ductus arteriosus—the small artery that connects the pulmonary artery and the aorta in utero, helping the fetus bypass the nonfunctioning lungs; it should spontaneously close in the days following birth, but its ongoing patency is debilitating to an infant.
In 1944, Alfred Blalock, at Johns Hopkins, performed palliative treatment for a child suffering from the cardiac condition known as the “tetralogy of Fallot,” a cardiac defect where the pulmonary valve is too constricted, leading to a hypertrophied right ventricle, a hole in the heart between the right and left ventricles and “overriding of the aorta,” in which the aorta empties both the right and left ventricles, instead of just the left ventricle. Simply stated, the constellation of physical defects in the heart of tetralogy of Fallot patients makes it impossible to adequately oxygenate the blood, resulting in a “blue baby,” a child whose oxygenation is so compromised they acquire a bluish hue to their skin. To be curative, incising the muscular wall of the heart—and looking inside the heart—was necessary, but no surgeon in the world could conceive of a method of “opening” the heart without killing the patient. Tetralogy of Fallot was a death sentence, but Blalock’s work-around palliative surgery did improve patients’ lives by connecting large vessels on the outside of the heart.
The world’s first “open-heart surgery” was on September 2, 1952, at the University of Minnesota when F. John Lewis operated on a five-year-old girl using total-body hypothermia and inflow stasis. This was accomplished by placing the child in a horse-watering tank full of ice water in the operating room, cooling her to 82°F and, after surgically opening the chest, clamping the blood vessels entering the heart (inflow stasis). A quick operation to close a pathological hole between heart chambers was performed, and after warming, the child was resuscitated and survived the operation. More than fifty children with an abnormal passage between heart chambers were treated in this manner, but concerns over the ability to properly normalize the heart rhythm while rewarming led the Minnesota surgeons to consider another way of unlocking the heart.
Heartened by Lewis’s progress, Dr. John Gibbon at the Jefferson Medical College in Philadelphia corrected the same cardiac defect in an eighteen-year-old in 1953, while using an artificial device to oxygenate the blood. The screen oxygenator, later named the Mayo-Gibbon heart-lung machine, was large, complex, and expensive, but did achieve success in the first application. The machine was the size of a hotdog vendor’s cart, connected to the patient through a series of plastic tubes, whirring the blood to and from the patient with DeBakey’s roller pump (stay tuned). Not only did the patient survive the world’s first open-heart operation using cardiopulmonary bypass, she lived another forty-seven years before dying at age sixty-five.2 Sadly, Gibbon’s next three patients all died in the operating room (or shortly thereafter). It had taken nineteen years of laboratory research, with countless animal operations and endless hours of investigation to develop the machine, but by 1954 he decided to suspend all open-heart operations for at least a year while attempting to improve outcomes. It must have been a crushing defeat for Dr. Gibbon; in fact, he never performed another open-heart operation again.3
The surgeons in Minneapolis were working on their own cardiopulmonary machine (with little progress) and also innovated with biological solutions. In early 1954, during a brainstorming session among clinicians, one of the young surgeons reflected on his pregnant wife’s ability to support her fetus with blood flow to the womb, and the idea of “cross-circulation” was born. The team investigated the ability of a dog to function as an external, biological, cardiovascular machine to keep another dog alive during surgery. After dozens of sham dog operations, Dr. Walton Lillehei at the University of Minnesota performed an operation on a one-year-old boy who was connected to his father, who served as a “biologic oxygenator.” One can only imagine the anguish of a mother watching her husband and child wheeled away on gurneys to the operating room for the cross-circulation operation, or the gallantry of a father placing his own life at risk while sustaining his infant son. The “general discouragement about open-heart surgery changed drastically”4 that day, even though the young patient succumbed to pneumonia eleven days later. Undeterred, Lillehei and his team performed forty-five operations over the next year using cross-circulation, each time the pediatric patient being sustained and saved through a parent (who risked their own life), with two thirds of the patients surviving surgery and being discharged from the hospital. Major cardiac defects were treated, including atrial and ventricular defects (“holes in the heart”), and even tetralogy of Fallot. A year earlier, these conditions were unqualified death sentences. After a year’s experience, in 1955 (a decade after Alfred Blalock’s original blue baby operation), Dr. Lillehei presented his data on the first tetralogy of Fallot patients, with Blalock in the audience in Philadelphia at the American Surgical Association meeting.
In the ten-patient series, six had excellent outcomes, but four died, all within hours of surgery. Such a failure rate would not be tolerated today, but in 1955 this was nothing short of a triumph. Dr. Blalock commented after Walton Lillehei read his paper, “I suspect it’s a mistake for an old conservative surgeon to discuss this paper. I must say I never thought I would see the day when this type of operative procedure could be performed. I want to commend Dr. Lillehei and Dr. Varco and their associates for their imagination, their courage, and their industry.”5 Occasionally, in science, a groundbreaking presentation in a darkened conference center is given, and the magnitude of the moment is comprehended by every colleague in the room. Like aerospace engineers embracing and waving flags after a successful rocket launch, the surgeons in that room in Philadelphia were no doubt wiping away tears of joy, and were energized with a renewed optimism. Thirty years later at the 1985 meeting of the Society of Thoracic Surgeons, Dr. Lillehei presented the long-term results of those forty-five patients. Remarkably, seventeen of his twenty-seven patients who suffered from ventricle septal defects were still alive, a stunning finding in light of the impossibility of their survival without surgery. Dr. Denton Cooley, one of the great pioneering surgeons in the history of the art, spoke from the podium afterward, saying, “Dr. Lillehei provided the can-opener for the largest picnic thoracic surgeons will ever know.”6 While cross-circulation cardiopulmonary support was only briefly used, it ushered in the ability to perform open-heart surgery, and by the end of the 1950s, surgeons around the world were inspired to consider the impossible … maybe nothing was impossible.
Walton Lillehei and his team demonstrated that serious cardiac defects were treatable, reigniting a quest to perfect the mechanical cardiopulmonary machine. The Gibbon machine, modified at the Mayo Clinic, was considered too costly for practical use, and Dr. Lillehei turned to his young crew of lab assistants to develop a better machine. The chief architect was Richard DeWall, a recent medical school graduate who envisioned a life of research and laboratory medicine. Starting with a clean slate, DeWall became the “MacGyver of medicine”7 by assembling a “Rube Goldberg” contraption of twisted hoses, pumps, needles, and oxygen tanks. Instead of fragile glass tubes, DeWall used polyvinyl hoses, which had the dual advantage of being cheaper and surprisingly less reactive with blood than glass was. His shoestring budget actually became an advantage, energizing an openness to the polymer revolution; the polyvinyl tubing for pumping mayonnaise had come from a nearby factory.
DeWall’s bubble oxygenator was inexpensive and reproducible, and more importantly … worked. During the proving grounds of 1954, while using cross-circulation, Lillehei had shown that open-heart surgery was possible, but by the middle of 1955, the bubble oxygenator became the chief method of sustaining life during the groundbreaking operations. Today, in every major hospital in the Western world, cardiopulmonary bypass machines are the vehicles that keep humans alive while surgeons operate on the heart. The full history of the development of the bypass machine is beyond the scope of this book, but not unlike the development of any device, occurred across continents, was pioneered by self-financed tinkerers, and was finally achieved after many, many failures. For a time, the only open-heart operations being performed were at the University of Minnesota and ninety miles away, at the Mayo Clinic. As successful as the operations themselves were, there was still one critical issue: postoperative complete heart block.
Scientists have been fascinated for centuries with the concept of the electrical nature of the human body and nowhere more so than the heart. The electrical impulse from the Sinoatrial node, also known as the natural “pacemaker of the heart,” communicates to the Atrioventricular node, which drives the contraction of the ventricles. Your brain does not tell your heart to contract—it has its own metronome, a built-in electrical timer, rhythmically firing across the muscles of the heart. Put your hand on your chest, and the slight flutter you feel is your heart contracting and squeezing the blood to your entire body. Slide your hand up to your neck, and feel the pulse by your windpipe—that rhythmic beating is the echo of your heart valves slamming shut, in regularity, in response to the syncopated muscular contractions of the heart. In complete heart block, wherein the electrification of the heart has gone haywire, the patient suffers severe bradycardia (low heart rate), hypotension (low blood pressure), and extremely compromised cardiac function. In essence, the muscular pump that is the heart is uncoordinated and dysfunctional, and unless properly electrified, unable to sustain life. The Minnesota surgical team had been researching ways of dealing with cardiac pacing emergencies, and were able to save a child’s life using a simple laboratory electrical testing device, the Grass Stimulator.
In Minneapolis in January 1957, following open-heart surgery to repair a ventricular septal defect, a child was crippled with complete heart block. A physiologist at the University of Minnesota had recommended that the heart team stimulate contraction of the child’s heart with their lab machine, the Grass Stimulator, which produces a small-voltage electrical charge. In physiology labs and introductory classes around the globe (to this day), scientists use the stimulator to send a small pulse of electricity through the wires into a test subject. To make the leg of a frog jump, a physiologist pokes tiny wires into the leg muscles, connects them to a Grass Stimulator, and adjusts the voltage and timing to make the muscles contract. After preliminary tests on dogs, Lillehei’s team was hopeful that the stimulator could work on a child suffering complete heart block.
When an open-heart child suffered complete heart block in 1957, Dr. Lillehei and his team inserted an insulated wire into the heart muscle of the patient, connected it to the stimulator, and realized—in triumph—that he could control the beating of the heart. By turning the dial, Lillehei was able to increase the beating of the heart, a contrivance that William Harvey would have savored. While this represented real achievement, it is astonishing to consider the real-world logistics of applying the life-supporting electrical current. The Grass Stimulator was the size of a microwave oven, requiring an AC outlet and extension cord. In fact, to venture from the operating room to the recovery room, a one-hundred-foot extension cord was required to keep the equipment plugged in and the patient alive. Imagine the cardiac team, venturing from the open-heart room with a small child on a postoperative gurney, the anesthesiologist monitoring the breathing of the unconscious patient (still intubated), and the surgeons feeding out orange extension cord down the hallway to keep the heart pacing at a life-sustaining rate.
The AC-powered cardiac stimulator was a lifeline for those patients who had suffered complete heart block, but a disaster occurred on October 31, 1957, when a municipal power outage in Minneapolis led to loss of electrical power to the patient ward rooms, resulting in the death of a young patient. The loss of the patient must have been crushing to Lillehei, and frustrated over being bound to a wall socket, he asked a local electrical engineer and electronics consultant to investigate the possibility of miniaturizing the stimulator and creating a battery-powered unit. Recognizing that most complete heart block patients returned to their own sinus rhythm within a couple weeks, Lillehei hoped that some type of innovation might untether patients from a wall socket and serve as a bridge to normal cardiac function. In one of medical history’s great moments, Lillehei turned to the young engineer, Earl Bakken.
Earl Bakken and his brother-in-law, Palmer Hermundslie, had founded a company in 1949 to maintain and repair electronic equipment in the Minneapolis area hospitals, but in their first month had only $8 to show for their efforts (the servicing of a centrifuge).8 In the burgeoning field of electronics and transistors, these handymen figured that someone would need to fix all the gadgets in the hospitals around town. Earl was a Minneapolis native, and after graduating high school in 1941, enlisted in the Army Signal Corps and became a radar instructor and maintenance technician. His lifelong interest in home electronics logically led him to a military posting in the field, and even in his nineties, Earl says that he finds “a deep, almost inexpressible joy in the sight, sound, feel, and even smell of old radios, machines, and electrical equipment. There is a magic about those devices that a person can appreciate only when he knows them inside and out, and when he loves them not only for what they do, but how they do it.”9 This sentiment recalls Steve Jobs and every entrepreneurial tinkerer, and proves the point that almost all innovators are “garage guys” who can’t stop turning over an idea in their mind and fabricating the solution with their own hands.
Upon returning to Minnesota at the conclusion of the war, Earl Bakken attended the University of Minnesota and earned undergraduate and master’s degrees in electrical engineering. All who knew Earl were not surprised with his career choice, being a child prodigy with gadgets and models. As a young boy, Earl saw the movie, Frankenstein, and was captivated with the life-giving power of electricity. He later recalled, “I was simply awestruck by the fact that electricity, properly applied, could do a great deal more than light up a room or ring a doorbell. I realized that electricity defines life. When electricity flows, we’re alive. When it doesn’t, we’re dead.”10
While Earl Bakken was completing his coursework at the university, he would often walk across the street to the academic hospital, forming relationships with the scientists and technicians whose jobs were increasingly dependent upon electronic equipment. This led to the formation of Earl’s company in 1949, but years of low-paying contract work and crude business development left his company in precarious health. The breakthrough opportunity came in 1957 (after the power outage), and when Dr. Lillehei charged Earl Bakken with developing a solution, he immediately began tinkering with an idea to provide battery-powered, rhythmic, electrical pacing.
Recalling an issue of Popular Electronics one year earlier, Earl Bakken drew inspiration from an article explaining how to make an electronic, transistorized metronome. To a lifetime fan of electrical gizmos and contraptions, Earl’s simple challenge was finding a circuit that he could construct. In the April 1956 magazine article, the simplified circuit diagram with two transistors was presented, and Bakken cleverly innovated the amusement into a lifesaving device.
A circuit is an electronic grid, composed of wires, resistors, capacitors, and transistors. But it is the transistor part of a circuit that has revolutionized all of electronics, communications, and medicine. The invention of the transistor is the “central artifact of the electronic age.”11 The unreliable vacuum tube of earlier electronics was a power hog and generated too much heat; what was needed was an electronic device that could amplify an electronic signal that was smaller and more energy efficient. Bell Laboratories was the industrial research arm of the American Telephone & Telegraph Company, and as Alexander Graham Bell’s telephone patents were facing expiration, an intense research effort to develop improved transcontinental communications led to the evolution of Bell Labs into the foremost scientific development organization in the world. Numerous Nobel Prizes have been awarded to Bell Labs researchers, and numerous revolutionary technologies were developed there, including the laser, solar cell, communications satellites, and the transistor.12 The group that created the transistor was the contentious, eventual Nobel Prize–winning threesome of William Shockley, Walter Brattain, and John Bardeen, although none of them monetarily benefitted from their invention. Shockley departed for Palo Alto, California, where he founded Shockley Semiconductor, which employed the eventual founders of Fairchild Semiconductor and Intel Corporation. Silicon Valley germinated from companies innovating telegraph and radio technology, and was further fueled by the semiconductor and computer companies that were founded in the 1950s. Transistors and integrated circuits permitted miniaturization, decreased energy consumption, and enhanced computing power, all of which powered the space race, made possible the personal computer, and gave firm foundation for the modernization of medicine and the implant revolution.
Earl Bakken designed a two-transistor circuit and enclosed it in a crude aluminum box that was only four-inches-square and an inch-and-a-half-thick—about the size of a small stack of coasters or a deck of cards. Instead of multiple controls like the Grass Stimulator, there was only an on/off toggle switch and pulse rate and current output rheostats. On top of the unit were the exposed terminals to connect the wires to the patient, and inside was housed a powerful 9.4-volt mercury battery. The wires that emanated from the device were designed to pass through the skin and into the heart, so that when they were not needed they could simply be withdrawn at the patient’s bedside.
Four weeks of experimentation yielded a device that was fit for experimentation at the university’s animal lab, and a single day of trialing in dogs raised expectations that refinement could lead to a device that could be implanted in a human. In his autobiography, Bakken recalls returning to the hospital the very next day to work on another project, and “I happened to walk past a recovery room and spotted one of Lillehei’s patients. I must have done a double-take when I glanced through the door. The little girl was wearing the prototype I had delivered only the day before! I was stunned. I quickly tracked down Lillehei and asked him what was going on. In his typical calm, measured, no-nonsense fashion, he explained that he’d been told by the lab the pacemaker worked, and he didn’t want to waste another minute without it. He said he wouldn’t allow a child to die because we hadn’t used the best technology available.”13
I am gobsmacked when I consider that an American surgeon was able to implant a device in 1957 without any FDA device clearance, but none existed at that time. The 1950s was the Wild West of device development, with no laws and no sheriff. While it was personally risky for Lillehei and Bakken to implant a “MacGyver” implant, it wasn’t against the law. Today you would quite literally go to jail for such an offense. But in 1957, medical devices were about heroic gallantry and optimism, and the ambulance-chasing enterprise of personal injury law was yet to be born.
The world’s first battery-powered, wearable cardiac pacemaker had come about from a confluence of new transistor and polymer technologies, and the evolution of batteries and new coating materials, and the prepared mind of Earl Bakken. What was the name of Earl’s struggling little medical electronic service company? Medtronic. It has grown into the world’s largest medical device company, with annual revenues approaching $30 billion, employing over 80,000 people, and boasting a market capitalization of about $100 billion.14 Pacemakers were soon made implantable, with the main application for elderly patients suffering from age-related cardiac arrhythmias. Almost 500,000 pacemakers are implanted every year, and it’s a virtual guarantee that you, Dear Reader, know someone with a tiny pacemaker implanted under their skin, resting upon their pectoralis muscle, covertly flickering away. They are so efficient, it doesn’t seem revolutionary to an individual, but it does feel like a miracle.
Aged ninety-four and living in a grand house on the Kona coast of Hawaii, one of the great pioneers of the electronic implantable medical device industry is at peace. Earl Bakken has invited me to his exceptional home on the big island of Hawaii. For the man who understands how electricity can sustain life, it is not that surprising that he is completely “off the grid,” owning the largest personal photovoltaic farm in the world. Overlooking Kiholo Bay, Mr. Bakken is self-powered and even makes his own fresh water with desalination machines. He favors “high touch and high technology,” and is worried that mankind is losing the sense of the mystical and becoming too obsessed with newfangled technology.
Although Earl Bakken hasn’t granted an interview in years, he was receptive to a visit by this surgeon once he learned the purpose of my project. (Earl Bakken would die eight months later, in October 2018.) Meeting one of the giants of the implant revolution is a sobering honor, and after navigating a series of guard gates with electronic key pads (I’m armed with the codes) and driving along a paved road surrounded by volcanic rocks, I park under palm trees outside his office. Inside, Earl is seated on his scooter, flanked by bookshelves. There are awards and plaques here and there, but a toy Frankenstein doll up high on a shelf brings a smile to my face.
Earl Bakken recounts the old days, the threat of business failures along the way, his regrets and his triumphs, but the thing I am most impressed with is his belief in living a “full life.” The mission statement of Medtronic genuinely beats in his heart, and our conversation is peppered with his lifelong sense of obligation to alleviate pain, restore health, and extend life.
Medtronic now has a traditional request of every patient who has benefited from one of their devices, a sense of obligation to “pass it on” in a meaningful way. Earl repeats this entreaty to me as our interview ends, imploring me to, “Live on! Give on!”
In a sense, that is the purpose of this book, to illuminate the contributions of the pioneers who have made modern life so less risky and human existence so much more enjoyable. We all benefit from the advances in medicine and surgery (as imperfect—even perilous—as it can be), and for those whose lives have been enriched and lengthened, there is a compulsion to “pay it forward.”
The story of the pacemaker, is, of course, only one small part of the story of heart surgery. Prior to the heart-lung bypass machine, it was unfathomable that any cardiac defect or heart valve surgery could be considered. As noted earlier, it was the pioneering work of Minnesota surgeons that opened the door to the heart, and over the course of the 1950s, defect closure and valve repair became predictable and effective.
The first forays into valve surgery were rapid-fire incursions in which Mayo surgeons John Kirklin and Henry Ellis made small incisions in the side of a beating heart, working blindly with a specialized knife attached to the end of the surgeon’s finger. The device was repeatedly and forcefully plunged into the diseased and constricted aortic valve.15 The sobering reality is that the mortality rate in those early days was 20 percent, and was somehow deemed acceptable.
Dr. Lillehei achieved much greater success (in nearby Minneapolis) when he operated on diseased aortic and mitral valves while using a heart-lung machine. Instead of operating on a beating, blood-filled heart, Lillehei had the advantage of looking into the inner cavity of the heart and attempted to partially resect tightened and diseased valves, or to repair flimsy, incompetent valves.
The first artificial valve operations occurred in 1960, and with no device clearance needed, there was a “dizzying pace of progress” among cardiac surgeons in America.16 The first valve replacement devices were silicon-covered Lucite balls contained in a stainless steel cage; the ball was designed to bob back-and-forth at the site of the resected valve. Although blood clots, arrhythmias, and sudden death were always a risk, lives were being saved and the quality of life for hundreds of patients was dramatically improving. “Open-heart surgery had evolved from an experimental procedure in 1955 to a standard treatment technique in less than a dozen years.”17 Any operation into the thorax was unthinkable prior to World War II, and by 1961, there were 303 hospitals in the United State fully equipped for open-heart operations and angiography.18 Cardiac care had transitioned from the treatment of children with life-threatening cardiac anomalies to surgical management of cardiac valve disease. Completely unaddressed was the handling of coronary artery disease and heart attacks—an even more pressing issue—but it would take a fortuitous mistake to begin a critical revolution.
On October 30, 1958, Mason Sones, a cardiologist at the Cleveland Clinic, was performing a cardiac catheterization on a twenty-six-year-old male with valve disease as part of cardiac workup. At the time, a catheterization procedure consisted of inserting a thin, flexible catheter into the brachial artery (of the arm) and threading the catheter all the way to the root of the aorta, just above the aortic valve. (Today, catheterization is performed while watching massive, ceiling-mounted flat screen monitors, but from the 1950s and up into the 1990s, catheterization was captured on 35mm motion picture film and later viewed on a projector.) As Dr. Sones was sneaking the catheter tip across the aortic valve, an automated pressure syringe injected 50cc of contrast solution into the chamber.19
Almost all of the contrast material, instead of emptying into the aorta, filled the right coronary artery, resulting in “extremely heavy opacification” of the artery and temporary slowing of the heart. “Sones’s fear that filling a coronary artery with so much contrast would cause a life-threatening ventricular arrhythmia gave way to a feeling of ‘considerable satisfaction regarding the further diagnostic evolution of the technique.’”20 His hopes buoyed by his experience, Sones soon collaborated with a company to produce custom, taper-tipped catheters to intentionally catheterize coronary arteries. Overnight, this resulted in the ability to image the coronary arteries, and more importantly, determine the degree and location of blockage. Doctors had always been impotent in determining the cause of chest pain or localizing the relevant area of vascular blockage—that is, until it was time for an autopsy. The grim reaper would now have to wait: physicians could now uncover the mystery of angina and heart attacks in real time, upon a beating heart.
The serendipitous discovery that visualization of the coronary arteries was possible—and not lethal—was seized upon by Sone’s surgical colleagues at the Cleveland Clinic, realizing that they “had the best possible set-up for the surgical treatment in selected patients with coronary artery disease.”21 Indeed they did—and they do. Donald Effler, then chief of cardiothoracic surgery, made good use of the new diagnostic tool, performing the world’s first coronary artery operation in January 1962. This would be the bailiwick of the Cleveland Clinic till this day, and more coronary artery bypass operations are performed there every year than anywhere else in the world. Coronary artery bypass grafting (CABG) was pioneered in Cleveland, and the technique of bypassing an area of blockage with vein harvested from the leg was the work of René Favaloro, an Argentinian surgeon on staff at the Cleveland Clinic. It is one of mankind’s greatest operations, and is still performed today in every major hospital around the globe, with modifications.
The Cleveland Clinic is a world leader in multiple fields, ranking at the top of the list in multiple specialties, including most all surgical fields. This is no accident—the CEO of the clinic has traditionally been a surgeon, including the CEO at the time of this writing, Tomislav Mihaljevic, a cardiothoracic surgeon. The modus operandi in Cleveland is simply different than most hospitals, but it is no accident that some of the greatest institutions in the world, like the Hospital for Special Surgery, are also led by a surgeon.
Coronary artery bypass grafting was a decade old when the world’s first angioplasty was performed in 1977 in Zurich, Switzerland, by Andreas Gruentzig. The development of angioplasty, and later coronary stenting, follows a typical path in medicine and surgery. Technological refinement begins with crude interventions, transitioning to less invasive and more sophisticated techniques, eventually leading to solutions that seemed impossible only a few years before. The first selective imaging of a coronary artery was in 1958, and less than twenty years later, angioplasty was developed to open up a clogged artery with a tiny inflatable balloon, followed shortly by the innovation of the cardiac stent in 1986.22
In the New York Public Library, there is a small globe (five inches in diameter) that is one of the earliest surviving cartographic spheres in existence. It is made of copper, and if you position yourself over the land mass of Asia, you can see the inscription, “Hic sunt dracones,” Latin for “Here be dragons.”23 It might be the only globe (or map) that actually contains that expression, but has now become a popular saying for “no trespassing.” The last major frontier of the human body was finally challenged, and mastered in the 1960s, and it was no accident that movies and television shows started portraying surgeons as heroes—unthinkable representations a century before. Here be dragons no longer applies in the human body.
We simply cannot fathom the extreme passivity of care given to the Senate majority leader Lyndon Johnson and President Dwight Eisenhower in 1955. Both men suffered heart attacks in the space of a couple months, and other than diagnostic EKGs, there was nothing to speed their recovery. In an era before angiography, cardiac stents, and coronary artery bypass surgery, it seems ridiculous that the President of the United States was given a pair of slippers and ferried about in a wheelchair, praying that his heart attack would respond to a program of six weeks’ rest.24 Today, every American undoubtedly expects a full cardiac resuscitation, with angiographic stenting or open-heart surgery following a heart attack. Cardiac valve repair or replacement, and aneurysm repair represent sobering surgical challenges, but it would not require undaunted courage to undergo such operations.
It is ironic that the heart was the last organ that yielded itself to the surgeon’s scalpel, even though it was the first organ to be quantified through physiology by William Harvey. Denton Cooley, the famous Houston heart surgeon, said, “It’s about the only organ in the body that you can really witness its function.”25 I had seen the heart of a dead horse in the necropsy room at my father’s veterinary hospital when I was an adolescent, and it was confusing, lifeless, and smelly. But when I witnessed my first open-heart operation in college, I was dumbstruck, because there before me was a strikingly pulsating, wriggling, colorful, organ; replenishing and nourishing the entire frame of a human body.
No diagram or painting can possibly capture the dynamic function of the heart, and it was only when the hearthstone of the body was governed that surgeons could claim full ascendancy from a previously shameful trade to respectful—even glorious—profession. Think I’m too melodramatic? Position yourself in a hospital waiting room, and wait for a heart surgeon to meet with a small congregation of frightened family members, whose mother suffered a heart attack the day before, and witness the gratefulness for the ability, over the course of a few hours, to conquer the heart and sustain life. That’s when the implant revolution feels like a miracle.