The development of coronary artery surgery: personal recollections.

Senior Cardiovascular Surgical Society The Development of Coronary Artery Surgery Personal Recollections John E. Connolly, MD This paper was presented at the 10th Annual Meeting of the Senior Cardiovascular Surgical Society, 21-25 March 2001, Orlando, Florida. Key words: Animal; coronary artery bypass; history of medicine, 20th cent.; Vineberg procedure From: The Department of Surgery, University of California, Irvine, Irvine, California 92697 Address for reprints: John E. Connolly, MD, Department of Surgery, UCIMC, 101 City Drive, Orange, CA 92868 © 2002 by the Texas Heart ® Institute, Houston A bout a month before graduation from Harvard Medical School, I had the opportunity to attend the 1948 meeting of the American Surgical Association in Quebec. At that meeting, Claude Beck of Cleveland re- ported the 1st creation, in a human being, of an arteriovenous fistula between the aorta and the coronary sinus by the use of a free brachial artery graft. The Beck II, as it was called, had its basis in the theory that such an A-V fistula could provide a large amount of retrograde flow into the coronary system via communication be- tween the venous and arterial sides of the circulation. Unfortunately, the patient, a 48-year-old man who had suffered from angina for 5 years, died 1 day after sur- gery. After a short period of popularity, this operation fell into general disuse. How- ever, hearing Beck’s paper stimulated my interest in the possibility of surgically treating coronary artery occlusive disease. Early Canine Studies. One year later, in 1949, as an assistant surgical resident at Stanford, I began a research year in the surgical animal laboratory, trying to devel- op a dog model of coronary artery disease that could be used to evaluate the effec- tiveness of possible surgical therapeutic approaches. Figure 1 shows a dog’s heart with an ameroid constrictor around the left anterior descending coronary artery and a saphenous vein bypass from the aortic arch to the distal left anterior de- scending coronary artery (LAD). I tried a saphenous vein as the conduit after learning of Kunlin’s 1 use of a reversed saphenous vein for femoral–popliteal bypass. Anastomosis of the vein to the coronary artery was facilitated by elevating it away from the beating heart with loop sutures. I was trying to develop a method of oc- clusion of the vein bypass external to the chest when my year of animal research ended and I was re-immersed into a busy residency. As a senior resident and subsequent faculty member at Stanford, I tried poudrage of the pericardium in an effort to create new avenues of arterial flow to the epi- cardium, but had little success. During these same years, Angelo May, 2 a surgeon friend in San Francisco, invented a corkscrew instrument to endarterectomize the LAD coronary artery. Fortunately, I did not try it in a patient but I did have the opportunity to observe, on closed-circuit television, Charles Bailey of Philadelphia use it in the beating heart with a disastrous result. Needless to say, coronary endar- terectomy was not safe until cardiopulmonary bypass became available. Transaortic Coronary Endarterectomy. In 1962, 3 I performed the 2nd successful transaortic coronary endarterectomy to be reported, after that of Dubost in Paris in 1960. 4 His patient had syphilitic blockage of the right coronary ostium, while mine had arteriosclerotic occlusive disease of the ostium. Distal to the blockage, my patient’s right coronary artery appeared to be normal on a postoperative an- giogram. This operation also had the distinction of being documented by preoper- ative and postoperative supra-aortic bolus arteriography. I used conventional cardiopulmonary bypass with continuous open perfusion of the left coronary ar- tery, as opposed to Dubost’s cardiopulmonary bypass with profound hypothermia. Figure 2 is a drawing of the operative approach that I used. Selective Coronary Arteriography. It is of great historical interest to note that Sones, a pediatric cardiologist at the Cleveland Clinic, performed the 1st selective coro- nary arteriogram in 1958 quite by accident. 5,6 He was attempting to inject a large bolus of contrast medium retrograde into the left ventricle, in the hope that some of it would enter the coronaries. At that time, it was believed that direct injection of even a few cubic centimeters of dye into a coronary artery would be fatal. Dur- ing the injection, he found that about 30 cc of contrast solution had gone into the Development of Coronary Artery Surgery Volume 29, Number 1, 2002