Histoiredelachirurgiecardiaque

ErwanFlécher

FestivaldesSciences,Rennes,8octobre2014

LaPréhistoire

Galien(131-201) IbnAlNafis(1210-1288) LéonardDeVinci(1452-1519)

WilliamHarvey(1578-1657)

Etpuis…plusrien

«unchirurgienquichercheàsuturerlesplaiesducœurméritedeperdrelaconsidérationdecesconfrères»ThéodoreBillroth,1880.«lachirurgieducœurreprésentelalimiteofferteparlanatureàtoutesleschirurgies.Aucunenouvelleméthodeniaucunedécouvertenepourradépasserlesdifficultésnaturellesconcernantuneplaieducœur»JamesPaget,Surgeryofthechest,1897.

Lachirurgiecardiaque«extra-cardiaque»

Chirurgiepéricardique

DominiqueJeanLarrey(1766-1842) LudwigRehn(1849-1930)

Chirurgiedesgrosvaisseaux:canalartériel

JohnMunro:1907,cadavreJohnStrieder:1937,échecRobertGross(1905-1989):26aout1938,Succès

Chirurgiedesgrosvaisseaux:Coarctationdel’aorte

OUR SURGICAL HERITAGE

Clarence Crafoord: A Giant in CardiothoracicSurgery, the First to Repair Aortic CoarctationJohn-Peder Escobar Kvitting, MD, PhD, and Christian L. Olin, MD, PhDDepartment of Cardiothoracic Surgery, Linköping University Hospital, Linköping, Sweden

On October 19, 1944, Clarence Crafoord performed thefirst successful repair of aortic coarctation. The operationwas done a year before Robert Gross did his first case (heis often claimed to have been the first). In fact, Gross hadread Crafoord’s report before he performed his own firstoperation. Crafoord=s achievement was not an isolatedevent. In the late 1920s he had performed two successfulpulmonary embolectomies, in the 1930s he introducedheparin as thrombosis prophylaxis, and in the 1940s hepioneered mechanical positive-pressure ventilation dur-ing thoracic operations and worked out a safe and precisetechnique for pneumonectomy. During the 1950s a string

of innovative surgical procedures were done at his unitin Stockholm. These included the second successful caseof cardiopulmonary bypass in the world, the first case ofatrial repair of transposition of the great arteries, endar-terectomy of the left coronary artery, and the first implan-tation of a pacemaker into a human. In this article we willpay tribute to Clarence Crafoord and describe some ofthe contributions that he and his collaborators made tothe field of cardiothoracic surgery.

(Ann Thorac Surg 2009;87:342–6)© 2009 by The Society of Thoracic Surgeons

Clarence Crafoord was born May 28, 1899, in Hudiks-vall, Sweden. His forefathers came originally from

Scotland, but the Crafoord family had lived in Swedenfor almost 500 years. All nine generations on the maleside (besides his grandfather) were high-ranking armyofficers. When his father died at the age of 53, Clarence’smother moved the family, including Clarence and his 3sisters, to Stockholm. Clarence received a scholarship toattend the Whitlock grammar school. He was a goodstudent and was able to sidestep several classes. In hisfree time he enjoyed repairing broken school laboratoryequipment and learned to play the violin. He was such atalented musician that he was accepted for professionaltraining at the Stockholm Musical Academy. Ultimately,he decided to study medicine.

In 1919 Clarence Crafoord graduated from the Karo-linska Institute. In 1921 he married Karin Enblom, andthey stayed married until his death 63 years later.

Crafoord’s surgical career began in 1922 at MörbyHospital (today Danderyd Hospital) in Stockholm underthe guidance of Knut Harald Giertz. Giertz was chief ofthe surgical department and was also interested in car-diorespiratory function. Crafoord started his surgicaltraining without pay but soon became upgraded to sec-ond junior doctor with a salary of 100 SEK a month,beside food and accommodation. During the next 3 years,he learned to do standard surgical procedures. WithGiertz as mentor and instructor, Crafoord started toperform thoracic operations, first experimentally butlater clinically. During the 18 years that they workedtogether, they developed a “master and apprentice rela-

tionship,” based on mutual respect and cordiality. Giertzonce was heard to say “I have seven sons of my own fleshand blood—and then Clarence.”

The Trendelenburg Operation, ClinicalIntroduction of Heparin

In the early times of surgery, pulmonary embolism was adreaded complication, leading to death of among 3% ofpatients after otherwise uncomplicated operation. Tren-delenburg had described in 1908 a surgical procedure toremove the life-threatening emboli from the pulmonaryartery. Crafoord travelled to Germany to observe thelogistics of the operation. Upon returning to Sweden, hestarted to train his operating team by performing theTrendelenburg procedure on deceased patients, withimproved technique and within a minimum of time.

He requested the nursing staff to keep him informedwhenever signs of pulmonary embolism appeared inyoung patients. To save vital time, the selected patientswere then moved to a room next to the operating theaterand observed. In September 1927 a woman showedclinical signs of embolism and was moved to the operat-ing theater. She was operated on in her bed, withoutgeneral anesthesia, because she was already uncon-scious. She recovered after the procedure, and a monthlater Crafoord did a second successful case. An eveningpaper in Stockholm soon afterwards displayed the fol-lowing headline “Two Dead Return To Life.”

At the time, only five successful pulmonary arteryembolectomies had been performed in the world (one byKirschner in 1924 and two by Meyer in 1927). YoungCrafoord was behind two of them [1]. In a retrospectivestudy of 22 patients operated on by Crafoord, the largemajority developed cerebral complications. Interestingly,

Address correspondence to Dr Kvitting, Department of CardiothoracicSurgery, Linköping University Hospital, Linköping, SE-581 85, Sweden;e-mail: john-peder.escobar.kvitting@liu.se.

© 2009 by The Society of Thoracic Surgeons 0003-4975/09/$36.00Published by Elsevier Inc doi:10.1016/j.athoracsur.2008.08.072

MISC

ELLAN

EOU

S

L’opérationdesbébésbleus

HelenTaussig(1898-1986)AlfredBlalock(1899-1969)VisiteBroussais1947:influenceDubost

Lachirurgieàcœurfermé

Commissurotomiemitrale

ElliotCuttler,Boston,1923HenrySouttar,1925CharlesBailey,Philadelphie,1948D.Harken,Boston,1948

Sténosespulmonaireetaortique

ThéodoreTuffier,1912RusselBrock,1948

Lachirurgieàcœurouvert

Chirurgieenhypothermie«OnenightIawokewithasimplesolutiontotheproblem:cooltheentirebody,reduceoxygenrequirements,interruptthecirculationandopentheheart»WilfredBigelowJohnLewis,septembre1952,Minneapolis.

Circulationcroisée

26mars1954:WaltonLillehei,MinnéapolisCirculationplacentaireEthique,mortalitépossiblede200%!

JohnGibbon,1953

Lacirculationextra-corporelle

Lachirurgievalvulaire(1)

CharlesHugnagel(1917-1989)

AlbertStarr,1962

! Valve à monodisque non basculant

Lachirurgievalvulaire(2)

Binet,Ross,DuranCarpentier1967,1968,1983

Lachirurgievalvulaire(3)

Davies,1965,Moulopoulos,1971,AlainCribier,2002

!

Lachirurgiedescoronaires(1)

WernerForssmann,1929F.MasonSones,ClevelandClinic,1958

ClaudeBeck(1894-1971)

Lachirurgiedescoronaires(2)

AlexisCarrel,1910VasiliiKolesov,1964RenéFavaloro,1967

Latransplantationcardiaque

SaintCômeetSaintDamien,HuiledeBalbasesvers1495

AlexisCarrel(1873-1944)

Etpendantcetempslà,enRussie…

In those experiments where the heart was transplanted togetherwith lungs, the transplanted lungs took part in blood–gas exchange.Wecarried out experiments on switching the whole load of supportingblood circulation in anorganismonto an additionally transplanted heartand the blood pressure remained normal.

One dog, Grishka, survived with two hearts and the partiallyreplaced lung for 141 days. The transplanted heart functioned quitenormally and carried out half of the workload of supporting the bloodcirculation. After physiological load (running), heart rate accelerationwas noted not only in the original (innervated) heart but also in thetransplanted (denervated) one. After rest, the heart rate of thetransplanted heart returned to a normal state more rapidly.

Along with the experiments of transplanting the second, addi-tional heart (Fig. 2a), we also performed experiments on the completereplacement of the heart and lungs or only the heart without the lungs(Fig. 3) (For a full description see V.P. Demikhov. Transplantation ofvital organs in experiment. M., State Medical Publishers [Medgiz],1960. This monograph was reprinted in New-York, Berlin and

Madrid). Such experiments on heart and lung replacement (Fig. 4)were the first, not only in our laboratory, but in the history of science.We carried this out on October 20, 1946. Before this time, thepossibility of heart and lung replacement in warm-blooded animalswas not even considered.

It turned out that from a surgical point of view, it is much easier toreplace the heart together with the lungs rather than to replace justthe heart without the lungs, because in the former case, it is notnecessary to sew together multiple pulmonary vessels. Many yearsafter publishing our work, American surgeon Shumway worked out asomewhat different method of heart replacement by means ofsuturing the whole atrium, and not, as we did, the pulmonary veins.This method is being used now in human heart transplantation.

The human being has less pulmonary lobes and therefore lesspulmonary veins than the dog. By using mechanical sutures,pulmonary veins can be sewed together more quickly and the dangeris less in comparison tomanual suturing of the atria. Depending on theway human thoracic organs are affected, it is possible to perform

Fig. 2. Different methods to transplant the second heart. a [а] — The heart is transplanted with one lung. Arterial blood from the transplantate goes to the head. b [б] — The heart istransplanted with one lung. Arterial blood from the transplantate is pumped into aorta. c [в]— The heart is transplanted with one lung. Arterial blood from the transplantate goes tothe head and the peripheral ending of the aorta. d [Ƨ]— The heart is transplanted without lungs. Arterial blood from the heart is pumped into the side of the thoracic aorta. e [∂]— Theheart is transplanted without lungs. Blood from it is pumped to the head; f [е] — The heart is transplanted without lungs. Blood from it is pumped into the head and aorta.

232 M.M. Shoja et al. / International Journal of Cardiology 143 (2010) 230–234

VladimirDemikhov(1916-1998)

JamesHardy,Jackson,Mississipi,1964

NormanShumway,Californie,1968

Enoccident…

ChristianBarnard,LeCap,1967

ChristianCabrol,1968ChristianBarnard,1974JeanFrançoisBorel,1972

Lecœurartificiel

JulienCésarLeGallois,1913A.  Carrel,1931B.  W.Kolf,1957

D.Liotta,1963M.DeBakey,1966

DentonCooley,1969(LiottaHeartenBTT)

Norman,1978:Lancet,TxCœuretrein

LecasBarneyClark«Sputnikducœurartificiel?»

CœurartificielAbiocor

QuiddeCarmat?

Révolutiontechnologique….oumédiatique?

?

Assistancesventriculaires

“We”ismoreimportantthan“I”.Inmedicine,theadvancesarealwaystheresultofmanyefforts

accumulatedovertheyears”.RenéFavaloro

Mercidevotreattention