548986 editorial2014
PRF0010.1177/0267659114548986Perfusion
Editorial Perfusion 2014, Vol. 29(5) 383–384 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114548986 prf.sagepub.com
Unforeseen consequences
Events and decisions made over the course of time can profoundly change the path of one’s life or that of others in unforeseen ways. Sometimes an event considered inconsequential at the time, or even forgotten, becomes appreciated decades later as its true import is put into context. The same is true in the evolution of cardiac surgical techniques or components of the heart-lung machine. The first example in cardiac surgery: in the 1950s, when it became evident that using a heart-lung machine was the most viable way to perform increasingly complex cardiac surgery, Professor Denis Melrose sought a way to stop the beating heart after it was effectively unloaded by cardiopulmonary bypass (CPB). He began using what came to be known as “the Melrose solution”—the major component of which was potassium citrate.1 A 30 cc injection from a handheld syringe promptly stopped the heart, but was later found to cause myocardial necrosis in many patients. Some hearts could not be restarted. Based on this experience, early attempts to chemically preserve the myocardium and define the early form of “cardioplegic arrest” were largely abandoned for nearly two decades. Careful reading of Melrose’s early reports revealed the potassium concentration was exceedingly high (200 mM) so, when cardioplegia techniques reappeared in the 1970s, the potassium content was much lower, the solutions were isotonic and hypothermia was added to further protect the heart during ischemia.2 Another curious and unforeseen example: retrograde cerebral perfusion was first used by Dr. Noel Mills in a desperate attempt to remove air from a patient’s brain after a massive air embolism incident.3 The patient recovered and left the hospital with no residual injury. What evolved was elective hypothermic retrograde cerebral perfusion for brain protection during aortic arch surgery that was embraced by surgeons for a time and continues to be used in some settings. But, in recent years, this distinctly non-physiologic technique has been replaced by antegrade cerebral perfusion for more predictable cerebral protection. Who could have imagined how these events would evolve when first reported? Similarly, for CPB technology, one well-known example is the roller pump. While frequently called the DeBakey roller pump, its appearance can be traced
back to 1855 when the Porter-Bradley rotary pump was first patented in the United States.4 Many other iterations predating Dr. DeBakey’s report5 in 1934 followed. His description was for a hand-operated pump for rapidly transfusing blood from donor to recipient. A section of plastic tubing with a flange running the length held it in place to prevent the pump segment from creeping as two rollers compressed and rotated to produce forward flow. Dr. John Gibbon, Jr.’s first efforts in the animal laboratory at Harvard Medical School to use a heart-lung machine6 incorporated a finger cot (originally described as a rubber finger stall7) to pump blood. His first report of successfully occluding the pulmonary artery in a cat was followed two years later by another report wherein the finger cot had been replaced by a “modified DeBakey” pump.8 The modification was to use an electric motor to rotate the rollers. When Dr. DeBakey was once asked how Dr. Gibbon and his research team began using the roller pump, he simply said that he had sent one to their laboratory (Personal communication, 1985). That chance event, followed by Dr. Gibbon’s successful clinical case in 1953, presaged universal adoption of the roller pump for subsequent applications of CPB—that is, until the 1970s when another unforeseen event occurred: a blood pump was proposed originally as an implantable artificial heart,9 but that effort was abandoned and, instead, the centrifugal pump became widely used for CPB. According to Wikipedia,10 the origins of the centrifugal pump can be traced back to the year 1475 when an Italian engineer, Francesco di Giorgio Martini, envisioned a centrifugaltype pump for lifting mud, of all things. Think of it—six centuries from mud to blood. Fast-forward to the present and the centrifugal pump concept has broadened even further into long-term circulatory support. Who could have foreseen these developments, taken for granted today? Consider the contents of this issue of the journal. A meta-analysis (Attaran et al.) compares off-pump with on-pump coronary artery surgery and concludes randomized trials will be required to determine patient benefits. Really? Off-pump coronary artery surgery was attempted in the laboratory by Alexis Carrel a century ago,11 so he may have been alone in foreseeing
Downloaded from prf.sagepub.com at KAI NAN UNIV on March 20, 2015
384
Perfusion 29(5)
subsequent developments in the coronary artery bypass graft (CABG) operation. A second review (Rozeik et al.) addresses percutaneous heart valves and suggests a bright future which, based on past developments in treating cardiac valve disease, may or may not be realized in quite the way predicted. Just when you thought all that could have been written about pump-induced hemolysis or the activated clotting time in ECMO patients had been reported, two more studies are published herein (Botrell et al. and Atallah et al.). The issue of what fluid to use for priming the CPB circuit was addressed decades ago, yet a group has restudied whether the traditional use of albumin for pediatric patients or hydroxyethyl starch (HES) shows benefit of one over the other; Miao et al. conclude HES may be a viable alternative when considering clinical results and costs. There are two case reports, one emphasizing a surgical approach for mitral valve repair (Karapanagiotidis et al.) and the other the use of a microaxial pump for severe right heart failure (Peltan et al.). Mitral valve disease was one of the first indications for cardiac surgery that predated CPB and, in the case of mechanical circulatory support, innovators using the catheter-mounted Hemopump® as a temporary left ventricular assist device12 may not have anticipated its use as described herein for right heart failure. Other articles in this issue report new findings on older subjects (aortic dissection, left ventricular function after CABG, organ preservation, cerebral embolization and hypoperfusion). And, for good measure, two book reviews are included to alert readers of publications they may wish to add to their library. In closing, how do you think today’s information will be considered decades from now? How might these procedures or devices be implemented? Will a contemporary report be seen to diverge from its intent in unforeseen ways and usher in a whole new way of delivering medical care for cardiac patients? It will be interesting to see and, if history is a guide, it boggles the
mind. Enjoy reading this issue of the journal and think about possible consequences. Mark Kurusz Section Editor, Perfusion References 1. Melrose DG, Dreyer B, Bentall HH, Baker JBE. Elective cardiac arrest: preliminary communication. Lancet 1955; 2: 21–22. 2. Tyers GFOT, Manley NJ, Williams EH, Shaffer CW, Williams DR, Kurusz M. Preliminary clinical experience with isotonic hypothermic potassium-induced arrest. J Thorac Cardiovasc Surg 1977; 74: 674–681. 3. Mills NL, Ochsner JL. Massive air embolism during cardiopulmonary bypass; causes, prevention, and management. J Thorac Cardiovasc Surg 1980; 80: 708–717. 4. Cooley DA. Development of the roller pump for use in the cardiopulmonary bypass circuit. Texas Heart Inst J 1987; 14: 113–118. 5. DeBakey ME. A simple continuous-flow blood transfusion instrument. New Orleans Med Surg J 1934; 87: 386– 389. 6. Gibbon JH Jr. Artificial maintenance of circulation during experimental occlusion of pulmonary artery. Arch Surg 1937; 34: 1105–1131. 7. Dale HH, Schuster EHJ. A double perfusion-pump. J Physiol 1928; 64: 356–364. 8. Gibbon JH Jr. The maintenance of life during experimental occlusion of the pulmonary artery followed by survival. Surg Gynecol Obstet 1939; 69: 602–614. 9. Rafferty EH, Kletschka HD, Wynyard M, Larkin JT, Cheathem B. Artificial heart. I. Application of nonpulsatile force-vortex principle. Minnesota Med 1969; 51: 11–16. 10. http://en.wikipedia.org/wiki/Centrifugal_pump (Accessed 4 Aug 2014) 11. Carrel A. VIII. On the experimental surgery of the thoracic aorta and heart. Ann Surg 1910; 52: 83–95. 12. Frazier OH, Macris MP, Wampler RK, Duncan JM, Sweeney MS, Fuqua JM. Treatment of allograft failure by use of an intraaortic axial flow pump. J Heart Transplant 1990; 9: 408–414.
Downloaded from prf.sagepub.com at KAI NAN UNIV on March 20, 2015
PRF0010.1177/0267659114548986Perfusion
Editorial Perfusion 2014, Vol. 29(5) 383–384 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114548986 prf.sagepub.com
Unforeseen consequences
Events and decisions made over the course of time can profoundly change the path of one’s life or that of others in unforeseen ways. Sometimes an event considered inconsequential at the time, or even forgotten, becomes appreciated decades later as its true import is put into context. The same is true in the evolution of cardiac surgical techniques or components of the heart-lung machine. The first example in cardiac surgery: in the 1950s, when it became evident that using a heart-lung machine was the most viable way to perform increasingly complex cardiac surgery, Professor Denis Melrose sought a way to stop the beating heart after it was effectively unloaded by cardiopulmonary bypass (CPB). He began using what came to be known as “the Melrose solution”—the major component of which was potassium citrate.1 A 30 cc injection from a handheld syringe promptly stopped the heart, but was later found to cause myocardial necrosis in many patients. Some hearts could not be restarted. Based on this experience, early attempts to chemically preserve the myocardium and define the early form of “cardioplegic arrest” were largely abandoned for nearly two decades. Careful reading of Melrose’s early reports revealed the potassium concentration was exceedingly high (200 mM) so, when cardioplegia techniques reappeared in the 1970s, the potassium content was much lower, the solutions were isotonic and hypothermia was added to further protect the heart during ischemia.2 Another curious and unforeseen example: retrograde cerebral perfusion was first used by Dr. Noel Mills in a desperate attempt to remove air from a patient’s brain after a massive air embolism incident.3 The patient recovered and left the hospital with no residual injury. What evolved was elective hypothermic retrograde cerebral perfusion for brain protection during aortic arch surgery that was embraced by surgeons for a time and continues to be used in some settings. But, in recent years, this distinctly non-physiologic technique has been replaced by antegrade cerebral perfusion for more predictable cerebral protection. Who could have imagined how these events would evolve when first reported? Similarly, for CPB technology, one well-known example is the roller pump. While frequently called the DeBakey roller pump, its appearance can be traced
back to 1855 when the Porter-Bradley rotary pump was first patented in the United States.4 Many other iterations predating Dr. DeBakey’s report5 in 1934 followed. His description was for a hand-operated pump for rapidly transfusing blood from donor to recipient. A section of plastic tubing with a flange running the length held it in place to prevent the pump segment from creeping as two rollers compressed and rotated to produce forward flow. Dr. John Gibbon, Jr.’s first efforts in the animal laboratory at Harvard Medical School to use a heart-lung machine6 incorporated a finger cot (originally described as a rubber finger stall7) to pump blood. His first report of successfully occluding the pulmonary artery in a cat was followed two years later by another report wherein the finger cot had been replaced by a “modified DeBakey” pump.8 The modification was to use an electric motor to rotate the rollers. When Dr. DeBakey was once asked how Dr. Gibbon and his research team began using the roller pump, he simply said that he had sent one to their laboratory (Personal communication, 1985). That chance event, followed by Dr. Gibbon’s successful clinical case in 1953, presaged universal adoption of the roller pump for subsequent applications of CPB—that is, until the 1970s when another unforeseen event occurred: a blood pump was proposed originally as an implantable artificial heart,9 but that effort was abandoned and, instead, the centrifugal pump became widely used for CPB. According to Wikipedia,10 the origins of the centrifugal pump can be traced back to the year 1475 when an Italian engineer, Francesco di Giorgio Martini, envisioned a centrifugaltype pump for lifting mud, of all things. Think of it—six centuries from mud to blood. Fast-forward to the present and the centrifugal pump concept has broadened even further into long-term circulatory support. Who could have foreseen these developments, taken for granted today? Consider the contents of this issue of the journal. A meta-analysis (Attaran et al.) compares off-pump with on-pump coronary artery surgery and concludes randomized trials will be required to determine patient benefits. Really? Off-pump coronary artery surgery was attempted in the laboratory by Alexis Carrel a century ago,11 so he may have been alone in foreseeing
Downloaded from prf.sagepub.com at KAI NAN UNIV on March 20, 2015
384
Perfusion 29(5)
subsequent developments in the coronary artery bypass graft (CABG) operation. A second review (Rozeik et al.) addresses percutaneous heart valves and suggests a bright future which, based on past developments in treating cardiac valve disease, may or may not be realized in quite the way predicted. Just when you thought all that could have been written about pump-induced hemolysis or the activated clotting time in ECMO patients had been reported, two more studies are published herein (Botrell et al. and Atallah et al.). The issue of what fluid to use for priming the CPB circuit was addressed decades ago, yet a group has restudied whether the traditional use of albumin for pediatric patients or hydroxyethyl starch (HES) shows benefit of one over the other; Miao et al. conclude HES may be a viable alternative when considering clinical results and costs. There are two case reports, one emphasizing a surgical approach for mitral valve repair (Karapanagiotidis et al.) and the other the use of a microaxial pump for severe right heart failure (Peltan et al.). Mitral valve disease was one of the first indications for cardiac surgery that predated CPB and, in the case of mechanical circulatory support, innovators using the catheter-mounted Hemopump® as a temporary left ventricular assist device12 may not have anticipated its use as described herein for right heart failure. Other articles in this issue report new findings on older subjects (aortic dissection, left ventricular function after CABG, organ preservation, cerebral embolization and hypoperfusion). And, for good measure, two book reviews are included to alert readers of publications they may wish to add to their library. In closing, how do you think today’s information will be considered decades from now? How might these procedures or devices be implemented? Will a contemporary report be seen to diverge from its intent in unforeseen ways and usher in a whole new way of delivering medical care for cardiac patients? It will be interesting to see and, if history is a guide, it boggles the
mind. Enjoy reading this issue of the journal and think about possible consequences. Mark Kurusz Section Editor, Perfusion References 1. Melrose DG, Dreyer B, Bentall HH, Baker JBE. Elective cardiac arrest: preliminary communication. Lancet 1955; 2: 21–22. 2. Tyers GFOT, Manley NJ, Williams EH, Shaffer CW, Williams DR, Kurusz M. Preliminary clinical experience with isotonic hypothermic potassium-induced arrest. J Thorac Cardiovasc Surg 1977; 74: 674–681. 3. Mills NL, Ochsner JL. Massive air embolism during cardiopulmonary bypass; causes, prevention, and management. J Thorac Cardiovasc Surg 1980; 80: 708–717. 4. Cooley DA. Development of the roller pump for use in the cardiopulmonary bypass circuit. Texas Heart Inst J 1987; 14: 113–118. 5. DeBakey ME. A simple continuous-flow blood transfusion instrument. New Orleans Med Surg J 1934; 87: 386– 389. 6. Gibbon JH Jr. Artificial maintenance of circulation during experimental occlusion of pulmonary artery. Arch Surg 1937; 34: 1105–1131. 7. Dale HH, Schuster EHJ. A double perfusion-pump. J Physiol 1928; 64: 356–364. 8. Gibbon JH Jr. The maintenance of life during experimental occlusion of the pulmonary artery followed by survival. Surg Gynecol Obstet 1939; 69: 602–614. 9. Rafferty EH, Kletschka HD, Wynyard M, Larkin JT, Cheathem B. Artificial heart. I. Application of nonpulsatile force-vortex principle. Minnesota Med 1969; 51: 11–16. 10. http://en.wikipedia.org/wiki/Centrifugal_pump (Accessed 4 Aug 2014) 11. Carrel A. VIII. On the experimental surgery of the thoracic aorta and heart. Ann Surg 1910; 52: 83–95. 12. Frazier OH, Macris MP, Wampler RK, Duncan JM, Sweeney MS, Fuqua JM. Treatment of allograft failure by use of an intraaortic axial flow pump. J Heart Transplant 1990; 9: 408–414.
Downloaded from prf.sagepub.com at KAI NAN UNIV on March 20, 2015
