4 July 2018
The early years
Until 1896, the accepted view was that the heart was an impossible organ upon which to operate. That changed when Ludwig Rehn in Germany sutured an actively bleeding wound in the right ventricle of a patient who had been stabbed. The patient recovered, and cardiac surgery was born.
In 1925, Henry Souttar, at the Middlesex Hospital, operated successfully on a young woman with mitral valve disease – the first successful operation anywhere in the world, on a patient’s heart valve. He was never referred another patient by his cardiology colleagues!
The technology which led to the development of cardiopulmonary bypass, the heart-lung machine, was first developed in the 1930s when early experiments were carried out on cats by John H Gibbon in the USA.
In 1939, the history of congenital heart surgery really started with the first successful surgery for patent ductus arteriosus (PDA or hole in the heart), a heart problem that can manifest soon after birth and means that oxygen-rich blood from the aorta mixes with oxygen-poor blood from the pulmonary artery.
The procedure, still used to this day, involves closing the open PDA with stitches or ligatures, and was first carried out in Boston by a surgical trainee, Robert Gross, without the permission of his chief of surgery and when his chief was away on holiday!
In the UK, except for Henry Souttar, the focus during the 1930s and 1940s was largely on thoracic surgery, often treatments for tuberculosis (TB) and its complications. Of course, Royal Brompton Hospital was very much part of the evolution of this area of surgery as it began life originally as a chest hospital.
The birth of the NHS
By the mid-1940s, in the field of congenital heart surgery, surgery for co-arctation (narrowing) of the aorta and an operation to palliate Tetralogy of Fallot, one of the most common congenital heart conditions, had been developed.
In the UK, there were a number of innovative surgeons. Mr Russell Brock – who later became Lord Brock – and who worked at Royal Brompton Hospital and Guy’s Hospital – was perhaps one of the most famous pioneers. He led the way in cardiac surgical innovation and promoted operations to open up the pulmonary valve in order to treat pulmonary valve narrowing. He was also one of the first surgeons in his field to record surgical outcomes meticulously.
The 1950s saw a rapid expansion, albeit with relatively high mortality and morbidity, of procedures to try and palliate congenital heart disease (CHD) and disease of the heart valves. So, cardiac surgery was an extremely young specialty in the nascent NHS of 1948.
The 1960s – an explosion of possibilities
Heart valve replacement in adults wasn’t successful until 1960 when the US surgeon Albert Starr implanted a mechanical valve that he had in fact invented, into a 52-year-old man who would go on to live for another ten years. In the process, Starr kick-started a massive expansion in people trying to develop replacement valves.
It’s difficult to appreciate the sheer scale of the developments during this time, not just in cardiac surgery. These developments depended on the technology to support the heart during surgery, and then on a range of other improvements, such as drug therapy and safer anaesthesia. Intensive care, as a discipline, only developed in the UK during the 1960s once the nature of the multidisciplinary teams required to look after complex patients was more generally appreciated.
In 1967, the era of coronary artery surgery was initiated by Rene Favaloro in Brazil. By developing coronary artery bypass surgery, which diverts blood around narrowed or clogged sections of major arteries, he changed the way that we treat coronary disease. In December of that same year the first heart transplant was performed by Christiaan Barnard in South Africa, albeit most of the research work that preceded it was carried out by Norman Shumway in California.
In this country, the major surgical pioneers of the time were Donald Ross at Guy’s Hospital and the National Heart Hospital (which later merged with Royal Brompton), Terence English at Papworth and Magdi Yacoub at Harefield Hospital.
Magdi was a true pioneer in a number of areas of cardiac surgery. He was one of the first two surgeons in the world to report a successful outcome with the ‘arterial switch’ operation for transposition of the great arteries in children. Magdi, as well as his colleagues at Harefield, Rosemary Radley-Smith as well as many others, deserve special recognition for their innovation and technical skills.
The history of modern cardiac surgery encompasses the last 65 to 70 years, and so mirrors very closely the timeframe of our NHS.
A National Health Service
In the UK, a significant development was the expansion of cardiac surgery geographically as it was highly centralised in London in the early years. In the early 1970s most trainees in cardiac surgery had received at least a significant part of their training at Guy’s Hospital, Royal Brompton Hospital and the London Chest Hospital. This changed as newer regional UK centres were established that provide excellent opportunities for training as well as for clinical work and research.
The NHS has been fantastic in making sure people who need cardiac surgery have access to it whilst the quality of that surgery is of a very high standard, comparing very favourably with outcomes elsewhere in the world. Without being at all complacent, cardiac surgeons can be very proud about their outcomes in the NHS.
Advancements in cardiology
While the 1980s saw major refinements in cardiac surgery, it was the 1990s that brought a transformational change with the development of ‘interventional cardiology’. This meant that some of the procedures which were previously only done by surgeons were now starting to be carried out by cardiologists in catheter laboratories.
Using newer imaging modalities, ischaemic or valvular heart disease, and some congenital heart conditions, could be treated using these new catheter technologies. Many patients could now avoid open-heart surgery, recover more quickly, and were less at risk of infection.
As an example, the treatments for many cardiac arrhythmias and some types of ischaemic heart disease, originally surgical procedures, became catheter-based interventions.
The bigger picture – the 21st century
In the early 21st century the NHS remains one of the leading pioneers in a number of areas of cardiology and cardiac surgery. These include the application of devices which provide mechanical circulatory support to the heart and the preservation of organs for heart and lung transplantation.
Harefield Hospital is currently the only centre in the UK using extra-corporeal membrane oxygenation (ECMO) as a bridge to transplant and is also a leader in the development of the urgent angioplasty programme, a project which started in the 1990s. Cardiac and thoracic surgery has advanced and adopted increasingly less invasive techniques thereby transforming the options for patient care.
We should certainly be celebrating better outcomes for patients, and the sheer number of cutting-edge interventions we have seen over a comparatively short timescale.
Celebrating achievements, paying tribute to the past
Cardiac surgery is a complex intervention and success has depended on effective teamwork, both within and between organisations. Patient outcomes have dramatically improved. The days when it was touch and go whether someone would come out of the operating room are long past. This is a very different environment to that of 40 years ago, especially in my field of congenital heart surgery.
The patients who required heart surgery in the early years of the NHS were very, very brave. Of course, as results have improved, so have people’s expectations. Surgeons should be ruthlessly honest about the way that patients are advised about their treatment options. The expectation of many people today is that they can have an operation with a predictably perfect outcome – that sadly isn’t always the reality.
But when you think of the great names associated with Royal Brompton, for example Paul Wood, Russell Brock, Magdi Yacoub and Jane Somerville, patient outcomes have improved massively compared to those which could have been anticipated in the 1950s.
In time, I predict that cardiac surgery, as we know it today, will become largely obsolete. In a way, much of today’s surgery is a pretty gross intervention as it causes trauma to the patient in the process of achieving access to the area of surgical endeavour. Consider the evolution of the treatment for a simple stomach ulcer – it is treated with antibiotics now, whereas previously, people would undergo surgery. That type of surgery has become obsolete, within a single generation.
Advances in technology will continue to result in further dramatic changes for patients as well as for the practice of surgery, including cardiac surgery, and much of today’s technology will potentially end up as exhibits, a few doors up Exhibition Road in the Science Museum.
With inherited conditions, we are moving into an age where we will be able to modify disease risk by modifying the individual genome, if that’s not too hard to stomach from an ethical viewpoint. This may significantly affect the management of both congenital and acquired heart conditions.
Perhaps a more pressing question will inevitably be the needs of an ageing population. The generation being born now, all things being equal, are likely to have a life expectancy exceeding 100 years and this will affect their medical needs including the need for cardiac interventions.
For now, we can reasonably take a moment to celebrate the remarkable achievements of the NHS in our area of work, and to thank all the patients who continue to help us to advance research and, thereby, our understanding of cardiovascular disorders.
While each era brings with it challenges and opportunities: the NHS has, and continues to, achieve remarkable things for patients with cardiac conditions. It is a story we should all be humbled to be a part of.