Cardiac Surgery in the Adult 5th Edition

Lawrence H. Cohn
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IN THE ADULT

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CARDIAC SURGERY

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Notice
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Medicine is an ever-changing science. As new research and clinical experi-
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ence broaden our knowledge, changes in treatment and drug therapy are

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required. The authors and the publisher of this work have checked with
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sources believed to be reliable in their efforts to provide information that is
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complete and generally in accord with the standards accepted at the time of
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publication. However, in view of the possibility of human error or changes in
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medical sciences, neither the authors nor the publisher nor any other party
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who has been involved in the preparation or publication of this work war-
rants that the information contained herein is in every respect accurate or
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for the results obtained from use of the information contained in this work.
Readers are encouraged to confirm the information contained herein with
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importance in connection with new or infrequently used drugs.
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CARDIAC SURGERY
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IN THE ADULT
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Fifth Edition
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Lawrence H. Cohn, MD
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Virginia and James Hubbard Professor of Cardiac Surgery
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Harvard Medical School
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Division of Cardiac Surgery
Brigham and Women’s Hospital
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Boston, Massachusetts
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David H. Adams, MD
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Cardiac Surgeon-in-Chief, Mount Sinai Health System
Marie-Josée and Henry R. Kravis Professor and Chairman
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Department of Cardiovascular Surgery
Icahn School of Medicine at Mount Sinai and The Mount Sinai Hospital
New York, New York
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New York  Chicago  San Francisco  Athens  London  Madrid  Mexico City

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Milan  New Delhi  Singapore  Sydney  Toronto
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Lawrence H. Cohn, MD
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The 5th edition of Cardiac Surgery in the Adult is dedicated to adult cardiac surgery. During his career Dr. Cohn earned the
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Dr. Lawrence Cohn, Emeritus Chief of the Division of Cardiac highest awards and honors a cardiac surgeon could possibly
Surgery at Brigham and Women’s Hospital and Virginia and achieve, serving as the 79th President of the American Asso-
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James Hubbard Professor of Cardiac Surgery at Harvard ciation for Thoracic Surgery, receiving an honorary Masters
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Medical School, who sadly passed away unexpectedly during of Medicine from Harvard, and receiving the American Heart
the final stages of preparation of this latest edition of “his” Association’s Paul Dudley White Award, among numerous
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reference textbook. Dr. Cohn leaves a legacy of excellence others. He would claim his greatest honor, however, was the
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seldom seen in academic surgery, and he will be sorely missed
by all of us who knew him, and especially those of us lucky
enough to have been mentored by him. Dr. Cohn received his
training in cardiothoracic surgery under the tutelage of
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opportunity to train over 200 residents and fellows from all
over the world, many of whom went on to become Divi-
sion Chiefs, Department Chairs, and leaders in the specialty.
His American Association for Thoracic Surgery presidential

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Dr. Norman Shumway at Stanford University, and after com- address “What the Cardiothoracic Surgeon of the 21st Century
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pleting his fellowship in 1971 he joined the staff of the Peter Ought to Be” personifies the essence of what made him one
Bent Brigham Hospital in Boston. Over the next 45 years of the masters of cardiac surgery who will be remembered
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he was the driving force behind the success of the Harvard by generations to come. Through leadership by example in
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program, and became the Chief of the Division of Cardiac all phases of his career, his unwavering commitment to the fre
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Surgery in 1986. A clinical cardiac surgeon first and foremost, individual patient was the foundation of all of his accomplish-
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Dr. Cohn performed over 11,000 open heart procedures dur- ments, and few surgeons have had such a profound impact on
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ing his career, and was best known for his pioneering and our specialty. Dr. Cohn was my teacher, mentor, and friend,
international leadership in minimally invasive valve surgery. and it was an honor to be asked by his wife of 55 years, Roberta,
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His academic contributions included over 500 peer-reviewed to assume the role of Co-Editor to complete this 5th edition of
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publications, 100 book chapters, and 750 invited lectures on
virtually all topics in cardiac surgery, but perhaps his greatest
academic legacy was his editorship of the 2nd, 3rd, and 4th
editions of Cardiac Surgery in the Adult, which under his vision
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his textbook. Dr. Cohn left footprints too large to fill, but with
the help of the many authors who contributed chapters and
the publisher’s leadership, we now present this peer tribute to
one of the greatest cardiac surgeons of all time.

became the most widely referenced international textbook in

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David H. Adams, MD
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CONTENTS

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Contributors xi PERIOPERATIVE/INTRAOPERATIVE
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II
CARE 221
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10. Preoperative Evaluation for Cardiac
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Surgery 223
I FUNDAMENTALS 1 Christian T. Ruff / Patrick T. O’Gara
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1. History of Cardiac Surgery 3 11. Cardiac Anesthesia 233
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Larry W. Stephenson / Frank A. Baciewicz, Jr.
2. Surgical Anatomy of the Heart 21
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John G. Augoustides / William C. Culp / Wendy Gross /
Annette Mizuguchi / Prakash A. Patel / Kent Rehfeldt /
Pinak Shah / Usha Tedrow / Stanton K. Shernan

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Michael R. Mill / Robert H. Anderson / Lawrence H. Cohn
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12. Echocardiography in Cardiac Surgery 267
3. Cardiac Surgical Physiology 43
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Eliza P. Teo / Michael H. Picard / Hanjo Ko /
Edward B. Savage / Nicolas A. Brozzi Michael N. D’Ambra
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4. Cardiac Surgical Pharmacology 71
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13. Extracorporeal Circulation 299
Jerrold H. Levy / Jacob N. Schroder / James G. Ramsay John W. Hammon / Michael H. Hines
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5. Cardiovascular Pathology 99
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14. Transfusion Therapy and Blood
Frederick J. Schoen / Robert F. Padera Conservation 347
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Andreas R. de Biasi / William J. DeBois /
6. Computed Tomography of the Adult O. Wayne Isom / Arash Salemi
Cardiac Surgery Patient: Principles
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and Applications 157 15. Deep Hypothermic Circulatory Arrest 361
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Andreas A. Giannopoulos / Frank J. Rybicki / Bradley G. Leshnower / Edward P. Chen
Tarang Sheth / Frederick Y. Chen
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16. Myocardial Protection 373
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7. Risk Assessment and Performance

Improvement in Cardiac Surgery 183
M. Salik Jahania / Roberta A. Gottlieb /
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Robert M. Mentzer, Jr.

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Victor A. Ferraris / Fred H. Edwards / Jeremiah T. Martin

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17. Postoperative Care of Cardiac Surgery

8. Simulation in Cardiac Surgery 207 Patients 405
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Jennifer D. Walker / Philip J. Spencer / Toni B. Walzer / Farhang Yazdchi / James D. Rawn
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Jeffrey B. Cooper
18. Temporary Mechanical Circulatory
9. The Integrated Cardiovascular Center 217 Support 429
T. Konrad Rajab / Lawrence Lee / Edwin C. McGee, Jr. / Nader Moazami
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Vakhtang Tchantchaleishvili / Mandeep R. Mehra /

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John G. Byrne
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31. Surgical Treatment of Aortic Valve
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III ISCHEMIC HEART DISEASE 451 Endocarditis 731

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Gösta B. Pettersson / Syed T. Hussain

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19. Myocardial Revascularization with
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Percutaneous Devices 453 32. Minimally Invasive Aortic
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James M. Wilson / James T. Willerson Valve Surgery 743
Prem S. Shekar / Lawrence S. Lee / Lawrence H. Cohn
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20. Myocardial Revascularization with
Cardiopulmonary Bypass 471 33. Percutaneous Treatment of Aortic Valve
Michael H. Kwon / George Tolis, Jr. / Thoralf M. Sundt Disease 751
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Stephanie L. Mick / Lars G. Svensson
21. Myocardial Revascularization Without
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Cardiopulmonary Bypass 519
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Bobby Yanagawa / Michael E. Halkos / John D. Puskas MITRAL VALVE DISEASE 759
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22. Myocardial Revascularization after
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Acute Myocardial Infarction 539 34. Pathophysiology of Mitral Valve
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Disease 761
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Deane E. Smith III / Mathew R. Williams
James I. Fann / Neil B. Ingels, Jr. / D. Craig Miller
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23. Minimally Invasive Myocardial
Revascularization 559 35. Mitral Valve Repair 797
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Piroze M. Davierwala / David M. Holzhey / Dan Loberman / Paul A. Pirundini / John G. Byrne /
Friedrich W. Mohr Lawrence H. Cohn
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24. Coronary Artery Reoperations 575 36. Mitral Valve Repair: Rheumatic 817
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Bruce W. Lytle / George Tolis, Jr. Javier G. Castillo / David H. Adams
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25. Surgical Treatment of Complications 37. Surgery for Functional Mitral
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of Myocardial Infarction, Ventricular Septal Regurgitation 825
Matthew A. Romano / Steven F. Bolling
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Defect, Myocardial Rupture, and Left
Ventricular Aneurysm 595
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38. Surgical Treatment of Mitral Valve
Donald D. Glower
Endocarditis 835
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Gösta B. Pettersson / Syed T. Hussain
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IV AORTIC VALVE DISEASE 631 39. Mitral Valve Repair for Congenital
Mitral Valve Disease in the Adult 847
26. Pathophysiology of Aortic Valve Disease 633
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David P. Bichell / Bret Mettler
Anna Brzezinski / Marijan Koprivanac / A. Marc Gillinov /
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Tomislav Mihaljevic 40. Minimally Invasive and Robotic Mitral
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and Tricuspid Valve Surgery 855
27. Aortic Valve Replacement with a
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Mechanical Cardiac Valve Prosthesis 649

W. Randolph Chitwood, Jr./ Barbara Robinson /
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Robert W. Emery / Rochus K. Voeller / Robert J. Emery
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41. Percutaneous Catheter-based Mitral Valve

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28. Stented Bioprosthetic Aortic Valve Repair 885

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Replacement 665 Mani Arsalan / J. Michael DiMaio / Michael Mack

Bobby Yanagawa / Subodh Verma / George T. Christakis
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42. Mitral Valve Replacement 895

29. Stentless Aortic Valve and Root Tsuyoshi Kaneko / Maroun Yammine /
Replacement 695 Dan Loberman / Sary Aranki
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Paul Stelzer / Robin Varghese

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30. Aortic Valve Repair and Aortic

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Valve-Sparing Operations 717

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Tirone E. David
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VALVULAR HEART DISEASE 54. Surgery for Atrial Fibrillation 1167
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(OTHER) 925 Matthew C. Henn / Spencer J. Melby /

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Ralph J. Damiano, Jr.

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43. Tricuspid Valve Disease 927
55. Surgical Implantation of Pacemakers
Richard J. Shemin / Peyman Benharash
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and Automatic Defibrillators 1181
44. Multiple Valve Disease 943 Henry M. Spotnitz / Michelle D. Spotnitz
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Hartzell V. Schaff / Rakesh M. Suri

45. Valvular and Ischemic Heart Disease 965 OTHER CARDIAC

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Kevin D. Accola / Clay M. Burnett OPERATIONS 1213
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46. Reoperative Valve Surgery 983 56. Surgery for Adult Congenital Heart
Disease 1215
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Julius I. Ejiofor / John G. Byrne / Marzia Leacche
Redmond P. Burke
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VII SURGERY OF THE GREAT

57. Pericardial Disease 1225
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VESSELS 1001 Eric N. Feins / Jennifer D. Walker
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58. Cardiac Neoplasms 1243
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47. Aortic Dissection 1003
Basel Ramlawi / Michael J. Reardon
Ravi K. Ghanta / Carlos M. Mery / Irving L. Kron

48. Ascending and Arch Aortic Aneurysms 1037

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Chase R. Brown / Joseph E. Bavaria / Nimesh D. Desai X TRANSPLANT AND MECHANICAL
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CIRCULATORY SUPPORT 1277
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49. Descending and Thoracoabdominal
Aortic Aneurysms 1075
fre

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fre

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59. Immunobiology of Heart and Lung
Joseph S. Coselli / Kim de la Cruz / Ourania Preventza / Transplantation 1279
ks

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ks

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Scott A. LeMaire Bartley P. Griffith / Agnes Azimzadeh
oo

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50. Endovascular Therapy for the Treatment 60. Heart Transplantation 1299
eb

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eb

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of Thoracic Aortic Disease 1101 Richard J. Shemin / Mario Deng
Susan D. Moffatt-Bruce / R. Scott Mitchell
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61. Lung Transplantation and Heart-lung
51. Trauma to the Great Vessels 1109 Transplantation 1331
Tom P. Theruvath / Claudio J. Schonholz / Hari R. Mallidi / Jatin Anand / Robert C. Robbins
m

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John S. Ikonomidis
co

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co

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62. Long-term Mechanical Circulatory
52. Pulmonary Embolism and Pulmonary Support and the Total Artificial Heart 1361
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Thromboendarterectomy 1127 Andrew C. W. Baldwin / Courtney J. Gemmato /
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Stuart W. Jamieson / Michael M. Madani William E. Cohn / O. H. Frazier fre

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63. Tissue Engineering for Cardiac Valve

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VIII SURGERY FOR CARDIAC

Surgery 1391
ARRHYTHMIAS 1145
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Danielle Gottlieb / John E. Mayer

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53. Interventional Therapy for Atrial and Index 1401

Ventricular Arrhythmias 1147
Jason S. Chinitz / Robert E. Eckart / Laurence M. Epstein
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CONTRIBUTORS

sf
ks

ks

ks

k
oo

oo

oo

oo
eb

eb

eb

eb
m

m
m

om
co

co

co

co

c
e.

e.

e.

e.
Kevin D. Accola, MD Agnes Azimzadeh, PhD
Director, Valve Center of Excellence Associate Professor
re

fre

re

re
Florida Hospital Cardiovascular Institute Department of Surgery
sf

f
Cardiovascular Surgeons, PA University of Maryland School of Medicine
ks

ks

ks
Orlando, Florida
k

Baltimore, Maryland
oo

oo

oo

oo
David H. Adams, MD Frank A. Baciewicz, Jr., MD
eb

eb

eb

eb
Cardiac Surgeon-in-Chief, Mount Sinai Health System Professor and Chief
Marie-Josée and Henry R. Kravis Professor and Chairman Division of Cardiothoracic Surgery
m

m
Department of Cardiovascular Surgery Wayne State University
Icahn School of Medicine at Mount Sinai and Harper University Hospital/Karmanos Cancer Center
The Mount Sinai Hospital Detroit, Michigan
New York, New York
m

m
Andrew C. W. Baldwin, MD
co

co

co

co

co
Jatin Anand, MD Clinical Fellow in Cardiothoracic Transplant
Duke University Medical Center Texas Heart Institute
e.

e.

e.

e.
Durham, North Carolina Houston, Texas
fre

fre

fre

fre
Resident in General Surgery
Robert H. Anderson, BSc, MD, FRCPath Yale School of Medicine
ks

ks

ks

ks
Visiting Professorial Fellow New Haven, Connecticut
Institute of Genetic Medicine
oo

oo

oo

oo
Newcastle University Joseph E. Bavaria, MD
eb

eb

eb

eb
Newcastle-upon-Tyne Roberts-Measey Professor and Vice-Chief
United Kingdom Department of Cardiovascular Surgery
m

m
Hospital of the University of Pennsylvania
Sary Aranki, MD Philadelphia, Pennsylvania
Associate Professor of Surgery
Brigham and Women’s Hospital Peyman Benharash, MD
m

m
Harvard Medical School Assistant Professor in-Residence
co

co

co

co

co
Boston, Massachusetts Division of Cardiac Surgery
Department of Surgery
e.

e.

e.

e.
Mani Arsalan, MD David Geffen School of Medicine at UCLA
re

fre

fre

fre
Department Cardiac Surgery Los Angeles, California
Kerckhoff Heart Center
sf

ks

ks

ks
Bad Nauheim, Germany David P. Bichell, MD
k

The Heart Hospital Baylor Plano Cornelius Vanderbilt Chair in Surgery

oo

oo

oo

oo

Plano, Texas Chief, Pediatric Cardiac Surgery

eb

eb

eb

eb

Vanderbilt University
John G. Augoustides, MD, FASE, FAHA Monroe Carell Jr. Children’s Hospital
m

Professor Nashville, Tennessee

Cardiovascular and Thoracic Section
Department of Anesthesiology and Critical Care Steven F. Bolling, MD
Perelman School of Medicine The University of Michigan Hospitals
m

University of Pennsylvania Department of Cardiac Surgery

co

co

co

co

co

Philadelphia, Pennsylvania Cardiovascular Center

Ann Arbor, Michigan
e.

e.

e.

e.
fre

fre

fre

fre

xi
s

ks

ks

ks
ok

oo

oo

oo
o
eb

eb

eb

eb
m

Cohn FM_pi-xx.indd 11 08/05/17 4:55 pm

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e
m

m
m

om

m
xii
co

co

co

co
Contributors

c
e.

e.

e.

e.
Chase R. Brown, MD George T. Christakis, MD, FRCS(C)
fre

fre

fre

re
Cardiothoracic Surgery Professor, Department of Surgery

sf
Department of Cardiovascular Surgery Division of Cardiac Surgery, Schulich Heart Centre
ks

ks

ks

k
Hospital of the University of Pennsylvania Sunnybrook Health Sciences Centre
oo

oo

oo

oo
Philadelphia, Pennsylvania Director, Undergraduate Medical Education
University of Toronto
eb

eb

eb

eb
Nicolas A. Brozzi, MD Ontario, Canada
Department of Cardiothoracic Surgery
m

m
Cleveland Clinic Florida William E. Cohn, MD, FACS, FACCP
Weston, Florida Professor of Surgery
Director of Surgical Innovation
Anna Brzezinski, MD
m

om
Baylor College of Medicine
Medical Student (M2) Director of Minimally Invasive Surgical Technology
co

co

co

co
University of Illinois at Chicago Texas Heart Institute

c
Chicago, Illinois
e.

e.

e.

e.
Houston, Texas
re

fre

re

re
Redmond P. Burke, MD Lawrence H. Cohn, MD*
Chief, Division of Cardiovascular and Thoracic Surgery
sf

f
Emeritus Virginia and James Hubbard Professor
ks

ks

ks
Miami Children’s Hospital
k

Harvard Medical School

Miami, Florida
oo

oo

oo

oo
Division of Cardiac Surgery
Brigham and Women’s Hospital
Clay M. Burnett, MD
eb

eb

eb

eb
Boston, Massachusetts
Florida Hospital Cardiovascular Institute *
Deceased
m

m
Orlando, Florida
Jeffrey B. Cooper, PhD
John G. Byrne, MD
Professor of Anesthesia
Hospital Corporation of America
Department of Anesthesia, Critical Care, and Pain Medicine
m

m
Houston, Texas
Harvard Medical School
co

co

co

co

co
Massachusetts General Hospital
Javier G. Castillo, MD
Executive Director Emeritus and Senior Fellow
e.

e.

e.

e.
Assistant Professor
Center for Medical Simulation
Department of Cardiovascular Surgery
fre

fre

fre

fre
Boston, Massachusetts
The Mount Sinai Medical Center
ks

ks

ks

ks
New York, New York
Joseph S. Coselli, MD
oo

oo

oo

oo
Edward P. Chen, MD Professor and Chief of the Division of Cardiothoracic Surgery
Director of Thoracic Aortic Surgery Vice Chair, Michael E. DeBakey Department of Surgery
eb

eb

eb

eb
Associate Professor Baylor College of Medicine
Division of Cardiothoracic Surgery Chief of the Section of Adult Cardiac Surgery
m

m
Emory University School of Medicine Texas Heart Institute
Atlanta, Georgia Houston, Texas

Kim I. de la Cruz, MD, FACS

m

m
Frederick Y. Chen, MD, PhD
Associate Surgeon Assistant Professor
co

co

co

co

co
Director, Cardiac Surgery Research Laboratory Division of Cardiothoracic Surgery
Division of Cardiac Surgery Michael E. DeBakey Department of Surgery
e.

e.

e.

e.
Brigham and Women’s Hospital Baylor College of Medicine, and Clinical Staff
re

fre

fre

Associate Professor of Surgery Texas Heart Institute

Houston, Texas fre
sf

Harvard Medical School

ks

ks

ks
Boston, Massachusetts
k

William C. Culp, Jr., MD

oo

oo

oo

oo

Jason S. Chinitz, MD, FACC, FHRS Professor

eb

eb

eb

eb

Director, Cardiac Electrophysiology Scott & White Hospital

Assistant Professor, Hofstra Northwell School of Medicine Department of Anesthesiology
m

Southside Hospital The Texas A&M University System Health Science

Bayshore, New York Center College of Medicine
Bryan, Texas
W. Randolph Chitwood, Jr, MD, FACS, FRCS (Eng)
m

Emeritus Professor and Chairman Michael D’Ambra, MD

co

co

co

co

co

Department of Surgery Associate Professor of Anesthesia

Founder—East Carolina Heart Institute Harvard Medical School
e.

e.

e.

e.

Brody School of Medicine Boston, Massachusetts

fre

fre

fre

fre

East Carolina University

Greenville, North Carolina
s

ks

ks

ks
ok

oo

oo

oo
o
eb

eb

eb

eb
m

Cohn FM_pi-xx.indd 12 08/05/17 4:55 pm

 e

e
m

m
m

om

m
xiii
co

co

co

co
Contributors

c
e.

e.

e.

e.
Ralph J. Damiano, Jr., MD Robert J. Emery, BS, MMS
fre

fre

fre

re
Evarts A. Graham Professor of Surgery Medical University Medical School

sf
Chief, Division of Cardiothoracic Surgery Philadelphia, Pennsylvania
ks

ks

ks

k
Co-Chair, Heart & Vascular Center
oo

oo

oo

oo
Washington University School of Medicine Robert W. Emery, MD
St. Louis, Missouri Director Emeritus, Cardiovascular and Thoracic Surgery
eb

eb

eb

eb
HealthEast Care System
Tirone E. David, MD St Joseph’s Hospital
m

m
Professor of Surgery St Paul, Minnesota
University of Toronto
Toronto, Ontario, Canada Laurence M. Epstein, MD
m

om
Professor of Medicine
Piroze M. Davierwala, MD Harvard Medical School
co

co

co

co
Department of Cardiac Surgery Chief, Arrhythmia Service

c
e.

e.

e.

e.
Heart Center Leipzig Brigham and Women’s Hospital
Leipzig, Germany Boston, Massachusetts
re

fre

re

re
sf

f
Andreas R. de Biasi, MD James I. Fann, MD
ks

ks

ks
Research Fellow
k

Professor
oo

oo

oo

oo
Department of Cardiothoracic Surgery Department of Cardiothoracic Surgery
Weill Cornell Medical College Stanford University
eb

eb

eb

eb
New York-Presbyterian Hospital Stanford, California
New York, New York
m

m
Eric N. Feins, MD
William J. DeBois, CCP, MBA Division of Cardiac Surgery
Chief Perfusionist and Director Department of Surgery
Department of Perioperative Services Massachusetts General Hospital
m

m
New York-Presbyterian Hospital Boston, Massachusetts
co

co

co

co

co
Weill Cornell Medical Center
New York, New York Victor A. Ferraris, MD, PhD
e.

e.

e.

e.
Tyler Gill Professor of Surgery
fre

fre

fre

fre
Mario Deng, MD, FACC, FESC Division of Cardiothoracic Surgery
Professor of Medicine University of Kentucky Chandler Medical Center
ks

ks

ks

ks
Advanced Heart Failure/Mechanical Support/Heart Transplant Lexington, Kentucky
David Geffen School of Medicine at UCLA
oo

oo

oo

oo
Ronald Reagan UCLA Medical Center O.H. Frazier, MD
eb

eb

eb

eb
Los Angeles, California Professor of Surgery
Michael E. DeBakey Department of Surgery
m

m
Nimesh D. Desai, MD, PhD, FRCSC, FAHA Baylor College of Medicine
Co-Director, Aortic and Vascular Center of Excellence Chief of the Center for Cardiac Support
Director, Thoracic Aortic Surgery Research Program Texas Heart Institute
Assistant Professor, Division of Cardiovascular Surgery Houston, Texas
m

m
Hospital of the University of Pennsylvania
co

co

co

co

co
Philadelphia, Pennsylvania Courtney J. Gemmato, MD
Resident in Cardiothoracic Surgery
e.

e.

e.

e.
J. Michael DiMaio, MD Texas Heart Institute
re

fre

fre

The Heart Hospital Baylor Plano

Plano, Texas
Baylor College of Medicine
Houston, Texas fre
sf

ks

ks

ks
k

Robert E. Eckart, DO Ravi K. Ghanta, MD

oo

oo

oo

oo

Heart Specialists of Sarasota Assistant Professor of Surgery

Sarasota, Florida
eb

eb

eb

eb

Department of Surgery
University of Virginia
m

Fred H. Edwards, MD Charlottesville, Virginia

Emeritus Professor of Surgery
University of Florida Andreas A. Giannopoulos, MD
Jacksonville, Florida Research Fellow
m

Applied Imaging Science Laboratory

Julius I. Ejiofor, MD
co

co

co

co

co

Brigham and Women’s Hospital

Division of Cardiac Surgery Harvard Medical School
e.

e.

e.

e.

Brigham and Women’s Hospital Boston, Massachusetts

Harvard Medical School
fre

fre

fre

fre

Boston, Massachusetts
s

ks

ks

ks
ok

oo

oo

oo
o
eb

eb

eb

eb
m

Cohn FM_pi-xx.indd 13 08/05/17 4:55 pm

 e

e
m

m
m

om

m
xiv
co

co

co

co
Contributors

c
e.

e.

e.

e.
A. Marc Gillinov, MD Syed T. Hussain, MD
fre

fre

fre

re
The Judith Dion Pyle Chair in Heart Valve Research Assistant Professor of Surgery

sf
Department of Thoracic and Cardiovascular Surgery Department of Thoracic & Cardiovascular Surgery
ks

ks

ks

k
Cleveland Clinic Cleveland Clinic
oo

oo

oo

oo
Cleveland, Ohio Cleveland, Ohio
eb

eb

eb

eb
Donald D. Glower, MD John S. Ikonomidis, MD, PhD
Professor of Surgery Professor of Surgery
m

m
Duke University Medical Center Chief, Division of Cardiothoracic Surgery
Durham, North Carolina University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
m

om
Danielle Gottlieb Sen, MS, MD, MPH
Assistant Professor of Surgery Neil B. Ingels, Jr., PhD
co

co

co

co
Pediatric Cardiovascular Surgery Consulting Professor

c
e.

e.

e.

e.
Children’s Hospital of New Orleans/LSU Health Science Center Department of Cardiothoracic Surgery
New Orleans, Louisiana Stanford University School of Medicine
re

fre

re

re
Stanford, California
sf

f
Roberta A. Gottlieb, MD
ks

ks

ks
Director, Molecular Cardiobiology O. Wayne Isom, MD
k
oo

oo

oo

oo
Dorothy and E. Phillip Lyon Chair in Molecular Cardiology in The Terry Allen Kramer Professor of Cardiothoracic Surgery
honor of Clarence M. Agress MD Chairman, Department of Cardiothoracic Surgery
eb

eb

eb

eb
Research Scientist, Heart Institute Cardiothoracic Surgeon-in-Chief
Los Angeles, California Weill Cornell Medical College
m

m
New York-Presbyterian Hospital
Bartley P. Griffith, MD New York, New York
The Thomas E. and Alice Marie Hales
Distinguished Professor in Transplantation M. Salik Jahania, MD
m

m
Executive Director, Program in Lung Healing Associate Professor of Surgery
co

co

co

co

co
University of Maryland School of Medicine Cardiothoracic Surgery
Baltimore, Maryland Wayne State University
e.

e.

e.

e.
Detroit, Michigan
fre

fre

fre

fre
Wendy Gross, MD
Assistant Professor of Anesthesia Stuart W. Jamieson, MD, FRCS, FACS
ks

ks

ks

ks
Department of Anesthesiology, Perioperative and Pain Medicine Endowed Chair and Distinguished Professor
oo

oo

oo

oo
Brigham and Women’s Hospital Dean, Cardiovascular Affairs
Harvard Medical School University of California
eb

eb

eb

eb
Boston, Massachusetts San Diego, California
m

m
Michael E. Halkos, MD, MSc, FACS, FACC Tsuyoshi Kaneko, MD
Associate Professor of Surgery Division of Cardiac Surgery
Division of Cardiothoracic Surgery Brigham and Women’s Hospital
Scientific Director, Cardiothoracic Center for Clinical Research Boston, Massachusetts
m

m
Associate Program Director
co

co

co

co

co
Thoracic Surgery Residency Program Hanjo Ko, MD
Atlanta, Georgia Assistant Professor
e.

e.

e.

e.
Department of Anesthesiology and Critical Care
re

fre

fre

John W. Hammon, MD
Professor of Surgery, Emeritus
University of Pennsylvania Health System
Philadelphia, Pennsylvania fre
sf

ks

ks

ks
Department of Cardiothoracic Surgery
k

Wake Forest University School of Medicine Marijan Koprivanac, MD, MS

oo

oo

oo

oo

Winston-Salem, North Carolina Resident, Department of General surgery

eb

eb

eb

eb

Cleveland Clinic
Matthew C. Henn, MS, MD Research Fellow
m

Cardiac Surgery Research Fellow Department of Cardiothoracic Surgery, Cleveland Clinic

Washington University School of Medicine Clinical Instructor, Case Western University
St. Louis, Missouri Cleveland, Ohio
m

David M. Holzhey, MD Irving L. Kron, MD

co

co

co

co

co

Department of Cardiac Surgery S. Hurt Watts Professor and Chair

Heart Center Leipzig Department of Surgery
e.

e.

e.

e.

Leipzig, Germany University of Virginia

fre

fre

fre

fre

Charlottesville, Virginia
s

ks

ks

ks
ok

oo

oo

oo
o
eb

eb

eb

eb
m

Cohn FM_pi-xx.indd 14 08/05/17 4:55 pm

 e

e
m

m
m

om

m
xv
co

co

co

co
Contributors

c
e.

e.

e.

e.
Michael H. Kwon, MD Hari R. Mallidi, MD
fre

fre

fre

re
Research Fellow, Brigham and Women’s Hospital BWH Thoracic and Cardiac Surgery

sf
Clinical Fellow in Surgery (EXT), Harvard Medical School Co-Director, Program in Heart and Lung Transplant and MCS
ks

ks

ks

k
Boston, Massachusetts Surgical Director of Lung Transplant and Pulmonary
oo

oo

oo

oo
Vascular Disease
Marzia Leacche, MD Senior Surgeon, Collaborative Center for Advanced Heart Failure
eb

eb

eb

eb
Spectrum Health Executive Director, BWH ECMO Program
Meijer Heart Center Boston, Massachusetts
m

m
Grand Rapids, Michigan
Jeremiah T. Martin, MBBCh, FRCSI
Lawrence Lee, MD Assistant Professor of Surgery
Clinical Fellow in Surgery
m

om
University of Kentucky Chandler Medical Center
Harvard Medical School Lexington, Kentucky
co

co

co

co
Resident in Cardiothoracic Surgery

c
Brigham and Women’s Hospital
e.

e.

e.

e.
John E. Mayer, Jr., MD
Boston, Massachusetts Senior Associate in Cardiac Surgery
re

fre

re

re
Childrens Hospital, Boston
sf

f
Lawrence S. Lee, MD Professor of Surgery
ks

ks

ks
Assistant Professor of Surgery Harvard Medical School
k
oo

oo

oo

oo
Division of Cardiothoracic Surgery Department of Cardiac Surgery
University of Tennessee Graduate School of Medicine Children’s Hospital
eb

eb

eb

eb
Knoxville, Tennessee Boston, Massachusetts
m

m
Scott A. LeMaire, MD Edwin C. McGee, Jr., MD
Professor and Director of Research Thoracic and Cardiovascular Surgery
Division of Cardiothoracic Surgery Professor
Michael E. DeBakey Department of Surgery Director, Heart Transplant & Ventricular Assist Device Program
m

m
Baylor College of Medicine, and Cardiovascular Surgery Staff Loyola Medicine
co

co

co

co

co
Texas Heart Institute Maywood, Illinois
Houston, Texas
e.

e.

e.

e.
Mandeep R. Mehra, MD
fre

fre

fre

fre
Bradley G. Leshnower, MD Professor of Medicine
Assistant Professor of Surgery Harvard Medical School
ks

ks

ks

ks
Division of Cardiothoracic Surgery Medical Director
Emory University School of Medicine
oo

oo

oo

oo
Heart and Vascular Center
Atlanta, Georgia Brigham and Women’s Hospital
eb

eb

eb

eb
Boston, Massachusetts
Jerrold H. Levy, MD, FAHA, FCCM
m

m
Professor of Anesthesiology Spencer J. Melby, MD
Associate Professor of Surgery Associate Professor of Surgery
Co-Director Cardiothoracic Intensive Care Unit Department of Surgery
Duke University School of Medicine Division of Cardiothoracic Surgery
m

m
Durham, North Carolina Washington University in St. Louis and Barnes Jewish Hospital
co

co

co

co

co
St. Louis, Missouri
Dan Loberman, MD
e.

e.

e.

e.
Division of Cardiac Surgery Robert M. Mentzer, Jr., MD
re

fre

fre

fre
Brigham and Women’s Hospital Professor of Medicine and Surgery
Harvard Medical school Cedars-Sinai Heart Institute
sf

ks

ks

ks
Boston, Massachusetts Cedars-Sinai Medical Center
k

Los Angeles, California

oo

oo

oo

oo

Bruce W. Lytle, MD
Director of Strategic Operations
eb

eb

eb

eb

Carlos M. Mery, MD, MPH

The Heart Hospital Baylor-Plano Assistant Professor of Surgery and Pediatrics
Dallas, Texas
m

Department of Surgery
Texas Children’s Hospital/Baylor College of Medicine
Michael Mack, MD Houston, Texas
The Heart Hospital Baylor Plano
m

Plano, Texas Bret A. Mettler, MD

co

co

co

co

co

Assistant Professor in Surgery

Michael M. Madani, MD
Vanderbilt University
e.

e.

e.

e.

Professor and Chief

Monroe Carell Jr. Children’s Hospital
Division of Cardiovascular and Thoracic Surgery
fre

fre

fre

fre

Nashville, Tennessee
University of California, San Diego
La Jolla, California
s

ks

ks

ks
ok

oo

oo

oo
o
eb

eb

eb

eb
m

Cohn FM_pi-xx.indd 15 08/05/17 4:55 pm

 e

e
m

m
m

om

m
xvi
co

co

co

co
Contributors

c
e.

e.

e.

e.
Stephanie L. Mick, MD Friedrich-Wilhelm Mohr, MD, PhD
fre

fre

fre

re
Cardiac Surgery, Surgical Director of Transcatheter Valve Insertion Professor of Cardiac Surgery

sf
Program University of Leipzig
ks

ks

ks

k
Department of Thoracic and Cardiovascular Surgery, Medical Director Heart Center Leipzig
oo

oo

oo

oo
Heart and Vascular Institute Director Department of Cardiac Surgery
Cleveland Clinic Heart Center Leipzig
eb

eb

eb

eb
Cleveland, Ohio Leipzig, Germany
m

m
Tomislav Mihaljevic, MD L. Wiley Nifong, MD
Professor of Surgery Division of Cardiothoracic Surgery
Cleveland Clinic Lerner College of Medicine Department of Cardiovascular Sciences
m

om
Cleveland, Ohio East Carolina Heart Institute
Chief Executive Officer Brody School of Medicine at East Carolina University
co

co

co

co
Cleveland Clinic Abu Dhabi Greenville, North Carolina

c
e.

e.

e.

e.
Abu Dhabi, United Arab Emirates
Patrick T. O’Gara, MD
re

fre

re

re
Michael R. Mill, MD Watkins Family Distinguished Chair in Cardiology
sf

f
Professor Brigham and Women’s Hospital
ks

ks

ks
Departments of Surgery and Pediatrics
k

Professor of Medicine
oo

oo

oo

oo
University of North Carolina Harvard Medical School
Chapel Hill, North Carolina Boston, Massachusetts
eb

eb

eb

eb
D. Craig Miller, MD Robert F. Padera, MD, PhD
m

m
Thelma and Henry Doelger Professor of Cardiovascular Surgery Associate Pathologist
Dept. of Cardiothoracic Surgery Department of Pathology
Stanford University School of Medicine Brigham and Women’s Hospital
Falk CV Research Building Assistant Professor of Pathology
m

m
Stanford, California Harvard Medical School
co

co

co

co

co
Boston, Massachusetts
R. Scott Mitchell, MD
e.

e.

e.

e.
Professor Emeritus Prakash A. Patel, MD
fre

fre

fre

fre
Department of Cardiothoracic Surgery Assistant Professor
Stanford University School of Medicine Cardiovascular and Thoracic Section
ks

ks

ks

ks
Falk Cardiovascular Research Building Department of Anesthesiology and Critical Care
oo

oo

oo

oo
Stanford, California Perelman School of Medicine
Attending Surgeon University of Pennsylvania
eb

eb

eb

eb
Division of Cardiac Surgery Philadelphia, Pennsylvania
V.A. Hospital Palo Alto
m

m
Palo Alto, California Gösta B. Pettersson, MD, PhD
Professor of Surgery
Annette Mizuguchi, MD Vice Chairman
Assistant Professor of Anesthesia Department of Thoracic and Cardiovascular Surgery
m

m
Department of Anesthesiology, Perioperative and Pain Medicine Cleveland Clinic
co

co

co

co

co
Brigham and Women’s Hospital Cleveland, Ohio
Harvard Medical School
e.

e.

e.

e.
Boston, Massachusetts Michael H. Picard, MD
re

fre

fre

Nader Moazami, MD
Professor of Medicine
Harvard Medical School fre
sf

ks

ks

ks
Thoracic and Cardiovascular Surgery Director, Echocardiography
k

Cleveland Clinic Massachusetts General Hospital

oo

oo

oo

oo

Cleveland, Ohio Boston, Massachusetts

eb

eb

eb

eb

Susan D. Moffatt-Bruce, MD, PhD Paul A. Pirundini, MD

Chief, Cardiac Surgery
m

Associate Professor, Division of Thoracic Surgery

Department of Surgery Cape Cod Hospital
Ohio State University Hyannis, Massachusetts
Wexner Medical Center Associate Surgeon
m

Columbus, Ohio Brigham and Women’s Hospital

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Boston, Massachusetts
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co
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fre
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Contributors

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Ourania Preventza, MD Matthew A. Romano, MD
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Associate Professor of Surgery Assistant Professor

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Division of Cardiothoracic Surgery Department of Cardiac Surgery
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Michael E DeBakey Department of Surgery University of Michigan
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Baylor College of Surgery Ann Arbor, Michigan
Attending Cardiac and Endovascular Surgeon
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Texas Heart Institute Christian T. Ruff, MD, MPH
Baylor St Luke’s Medical Center Assistant Professor of Medicine
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Houston, Texas Cardiovascular Medicine Division
Brigham and Women’s Hospital
John D. Puskas, MD Harvard Medical School
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Chair, Cardiovascular Surgery Boston, Massachusetts
Mount Sinai St. Luke’s, Mount Sinai Beth Israel, and
co

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Mount Sinai West Frank J. Rybicki, MD, PhD

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New York, New York Professor, Chair and Chief, Department of Radiology
The University of Ottawa
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T. Konrad Rajab, MD Faculty of Medicine and The Ottawa Hospital
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Clinical Fellow in Surgery Ottawa, Ontario, Canada
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Harvard Medical School
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Resident in Cardiothoracic Surgery Arash Salemi, MD
Brigham and Women’s Hospital Associate Professor of Cardiothoracic Surgery
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Boston, Massachusetts Department of Cardiothoracic Surgery
Weill Cornell Medical College
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Basel Ramlawi, MD, FACC, FACS New York-Presbyterian Hospital
Chairman, Heart & Vascular Center New York, New York
Director, Advanced Valve & Aortic Center Valley Health System
Winchester, Virginia Edward B. Savage, MD
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Clinical Professor
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James G. Ramsay, MD Cleveland Clinic Lerner College of Medicine
Professor Anesthesiology Chairman
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Director of Cardiothoracic Intensive Care Unit Department of Cardiothoracic Surgery
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University of California Director
San Francisco, California Heart and Vascular Institute
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Cleveland Clinic Florida
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James D. Rawn, MD Weston, Florida
Director, Cardiac Surgery Intensive Care Unit
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Instructor in Surgery, Harvard Medical School Hartzell Schaff, MD
Cardiac Surgery Professor of Surgery, College of Medicine
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Boston, Massachusetts Department of Cardiovascular Surgery
Mayo Clinic
Michael J. Reardon, MD, FACS, FACC Rochester, Minnesota
Professor of Cardiothoracic Surgery
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Allison Family Distinguished Chair of Cardiovascular Research Frederick J. Schoen, MD, PhD
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Department of Cardiovascular Surgery Executive Vice Chairman
Houston Methodist DeBakey Heart & Vascular center Department of Pathology
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Houston, Texas Brigham and Women’s Hospital
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Kent Rehfeldt, MD, FASE

Professor of Pathology and Health Sciences and Technology (HST),
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Harvard Medical School

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Associate Professor of Anesthesiology Boston, Massachusetts
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Mayo Clinic
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Rochester, Minnesota Claudio J. Schonholz, MD

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Department of Surgery, Division of Cardiothoracic Surgery

Robert C. Robbins, MD Department of Radiology, Division of Interventional Radiology
m

President and CEO Medical University of South Carolina

Texas Medical Center Charleston, South Carolina
Houston, Texas
Jacob N. Schroder, MD
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Barbara Robinson, MD, MS, FACS, FAHA, FACC Assistant Professor of Surgery
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Division of Cardiothoracic Surgery Co-Director, Cardiothoracic Intensive Care Unit

Department of Cardiovascular Sciences Duke University School of Medicine
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East Carolina Heart Institute Durham, North Carolina

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Brody School of Medicine at East Carolina University

Greenville, North Carolina
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Contributors

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Pinak Shah, MD Larry W. Stephenson, MD
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Associate Professor of Medicine Professor Emeritus

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Division of Cardiology Ford Webber Professor of Surgery
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Department of Medicine Department of Surgery
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Brigham and Women’s Hospital Wayne State University
Harvard Medical School Detroit, Michigan
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Boston, Massachusetts
Thoralf M. Sundt, MD
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Prem S. Shekar, MD Edward D. Churchill Professor of Surgery
Assistant Professor of Surgery Harvard Medical School
Harvard Medical School Chief, Division of Cardiac Surgery
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Chief, Division of Cardiac Surgery Massachusetts General Hospital
Brigham and Women’s Hospital Boston, Massachusetts
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Boston, Massachusetts

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Rakesh Mark Suri, MD, D.Phil
Richard J. Shemin, MD Cleveland Clinic Foundation
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Robert and Kelly Day Professor and Chief Department of Thoracic and Cardiovascular Surgery
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Division of Cardiac Surgery Cleveland, Ohio
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Vice Chairman, Department of Surgery
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Co-director, Cardiovascular Center at UCLA Lars G. Svensson, MD, PhD
David Geffen School of Medicine at UCLA Chairman, Heart and Vascular Institute
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Los Angeles, California Cleveland Clinic
Cleveland, Ohio
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Stanton K. Shernan, MD, FAHA, FASE
Professor of Anesthesia Vakhtang Tchantchaleishvili, MD
Department of Anesthesiology, Perioperative and Pain Medicine Cardiothoracic Surgery
Brigham and Women’s Hospital University of Rochester Medical Center
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Harvard Medical School Rochester, New York
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Boston, Massachusetts
Usha Tedrow, MD
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Tarang Sheth, MD, FRCPC Assistant Professor of Medicine
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Cardiovascular Radiologist Division of Cardiology
Director of Cardiac CT and MR Department of Medicine
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Department of Diagnostic Imaging Brigham and Women’s Hospital
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Trillium Health Partners Harvard Medical School
Mississauga, Ontario, Canada Boston, Massachusetts
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Deane E. Smith III, MD Eliza P. Teo, MBBS
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Assistant Professor of Cardiothoracic Surgery Clinical and Research Fellow in Medicine
NYU School of Medicine Massachusetts General Hospital
New York, New York Research Fellow
Harvard Medical School
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Philip J. Spencer, MD Boston, Massachusetts
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Department of Surgery
Massachusetts General Hospital Tom P. Theruvath, MD, PhD
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Boston, Massachusetts Department of Surgery, Division of Cardiothoracic Surgery
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Michelle D. Spotnitz, MD
Department of Radiology, Division of Interventional Radiology
Medical University of South Carolina fre
sf

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Cardiologist Charleston, South Carolina
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EHE International
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New York, New York George Tolis, Jr., MD

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Assistant Professor of Surgery

Henry M. Spotnitz, MD Harvard Medical School
m

George H. Humphreys, II, Professor of Surgery Boston, Massachusetts

Department of Surgery
Columbia University Robin Varghese, MD, MS, FRCSC
New York, New York Associate Professor
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Department of Cardiovascular Surgery

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Paul Stelzer, MD Icahn School of Medicine at Mount Sinai

Professor New York, New York
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Department of Cardiovascular Surgery

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Icahn School of Medicine at Mount Sinai

New York, New York
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Contributors

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Subodh Verma, MD, PhD, FRCSC Mathew R. Williams, MD
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Cardiac Surgeon Associate Professor of Cardiothoracic Surgery & Medicine

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St Michael’s Hospital Chief, Division of Adult Cardiac Surgery
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Professor of Surgery & Pharmacology and Toxicology Director, CVI Structural Heart Program
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University of Toronto Director, Interventional Cardiology
Canada Research Chair in Atherosclerosis NYU School of Medicine
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Toronto, Ontario New York, New York
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Rochus K. Voeller, MD James M. Wilson, MD
Cardiovascular Surgeon Director, Cardiology Education
Fairview Health System Texas Heart Institute
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Fairview Southdale Hospital Houston, Texas
Edina, Minnesota
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Maroun Yammine, MD

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Jennifer D. Walker, MD Division of Cardiac Surgery
Professor and Chief Brigham and Women’s Hospital
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Division of Cardiac Surgery Boston, Massachusetts
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Surgical Director
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Heart & Vascular Center of Excellence Bobby Yanagawa, MD, PhD, FRCSC
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UMass Memorial Medical Center Assistant Professor
Worcester, Massachusetts Division of Cardiac Surgery
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St Michael’s Hospital
Toni B. Walzer, MD, FACOG Toronto, Canada
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Assistant Professor, Part-Time, of Obstetrics, Gynecology, and
Reproductive Biology Farhang Yazdchi, MD, MS
Harvard Medical School Clinical Fellow in Surgery (EXT)
Department of Obstetrics and Gynecology Brigham and Women’s Hospital Surgery
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Brigham and Women’s Hospital Brigham and Women’s Hospital
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Assistant in Healthcare Education Cardiac Surgery
Department of Anesthesia, Critical Care, and Pain Medicine Boston, Massachusetts
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Massachusetts General Hospital
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Director, Labor and Delivery Program
Center for Medical Simulation
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Boston, Massachusetts
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James T. Willerson, MD, FACC
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President and Medical Director
Texas Heart Institute
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Houston, Texas
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FUNDAMENTALS

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History of Cardiac Surgery
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Larry W. Stephenson • Frank A. Baciewicz, Jr.
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The development of major surgery was retarded for centu- man was stabbed in the heart and collapsed. The police found
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ries by a lack of knowledge and technology. Significantly, the him pale, covered with cold sweat, and extremely short of
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general anesthetics ether and chloroform were not developed breath. His pulse was irregular and his clothes were soaked
until the middle of the nineteenth century. These agents with blood. By September 9, his condition was worsening, as
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made major surgical operations possible, which created an shown in Dr. Rehn’s case notes:
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interest in repairing wounds to the heart, leading some inves-
tigators in Europe to conduct studies in the animal laboratory
on the repair of heart wounds. The first simple operations in
humans for heart wounds soon were reported in the medical
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Pulse weaker, increasing cardiac dullness on percussion, res-
piration 76, further deterioration during the day, diagnostic
tap reveals dark blood. Patient appears moribund. Diagno-
sis: increasing hemothorax. I decided to operate entering

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literature. the chest through the left fourth intercostal space, there is
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massive blood in the pleural cavity. The mammary artery is
not injured. There is continuous bleeding from a hole in the
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HEART WOUNDS pericardium. This opening is enlarged. The heart is exposed.
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On July 10, 1893, Dr. Daniel Hale Williams (Fig. 1-1), a Old blood and clots are emptied. There is a 1.5 cm gaping
surgeon from Chicago, successfully operated on a 24-year-old right ventricular wound. Bleeding is controlled with finger
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pressure. …
man who had been stabbed in the heart during a fight. The
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stab wound was slightly to the left of the sternum and dead
center over the heart. Initially, the wound was thought to be
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I decided to suture the heart wound. I used a small intes-
tinal needle and silk suture. The suture was tied in diastole.

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Bleeding diminished remarkably with the third suture, all
superficial, but during the night the patient experienced per- bleeding was controlled. The pulse improved. The pleural
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sistent bleeding, pain, and pronounced symptoms of shock.
Williams opened the patient’s chest and tied off an artery and
vein that had been injured inside the chest wall, likely causing
the blood loss. Then he noticed a tear in the pericardium and
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cavity was irrigated. Pleura and pericardium were drained
with iodoform gauze. The incision was approximated, heart
rate and respiratory rate decreased and pulse improved post-
operatively.

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a puncture wound to the heart “about one-tenth of an inch … Today the patient is cured. He looks very good. His
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in length.”1 heart action is regular. I have not allowed him to work
physically hard. This proves the feasibility of cardiac
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The wound in the right ventricle was not bleeding, so
suture repair without a doubt! I hope this will lead to more
Williams did not place a stitch through the heart wound.
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He did, however, stitch closed the hole in the pericardium.

investigation regarding surgery of the heart. This may save
many lives. fre
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Williams reported this case 4 years later.1 This operation,
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which is referred to frequently, is probably the first suc- Ten years after Rehn’s initial repair, he had accumulated a
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cessful surgery involving a documented stab wound to the series of 124 cases with a mortality of only 60%, quite a feat
at that time.3
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heart. At the time Williams’ surgery was considered bold

and daring, and although he did not actually place a stitch Dr. Luther Hill was the first American to report the suc-
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through the wound in the heart, his treatment seems to have
been appropriate. Under the circumstances, he most likely
saved the patient’s life.
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cessful repair of a cardiac wound, in a 13-year-old boy who
was a victim of multiple stab wounds.4 When the first doctor
arrived, the boy was in profound shock. The doctor remem-
bered that Dr. Luther Hill had spoken on the subject of repair

A few years after Williams’ case, a couple of other surgeons

actually sutured heart wounds, but the patients did not sur- of cardiac wounds at a local medical society meeting in Mont-
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vive. Dr. Ludwig Rehn (Fig. 1-2), a surgeon in Frankfurt, gomery, Alabama. With the consent of the boy’s parents,
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Germany, performed what many consider the first success- Dr. Hill was summoned. He arrived sometime after midnight
with six other physicians. One was his brother. The surgery
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ful heart operation.2 On September 7, 1896, a 22-year-old

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Part I Fundamentals

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FIGURE 1-2 Ludwig Rehn, a surgeon from Frankfurt, Germany,
FIGURE 1-1 Daniel Hale Williams, a surgeon from Chicago, who who performed the first successful suture of a human heart wound.
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successfully operated on a patient with a wound to the chest involving (Reproduced with permission from Mead R: A History of Thoracic
the pericardium and the heart. (Reproduced with permission from Surgery. Springfield: Charles C Thomas; 1961.)
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Organ CH Jr., Kosiba MM: The Century of the Black Surgeons: A
USA Experience. Norman, OK: Transcript Press, 1937; p 312.)
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Rapid blood infusion consisted of pumping air into glass
bottles of blood.
took place on the patient’s kitchen table in a rundown shack.
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Lighting was provided by two kerosene lamps borrowed from
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neighbors. One physician administered chloroform anesthe- OPERATIVE MANAGEMENT OF
sia. The boy was suffering from cardiac tamponade as a result PULMONARY EMBOLI
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of a stab wound to the left ventricle. The stab wound to the
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ventricle was repaired with two catgut sutures. Although the Martin Kirschner reported the first patient who recovered
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early postoperative course was stormy, the boy made a com- fully after undergoing pulmonary embolectomy in 1924.6
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In 1937, John Gibbon estimated that nine of 142 patients
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plete recovery. That patient, Henry Myrick, eventually moved

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to Chicago, where, in 1942, at the age of 53, he got into a who had undergone the procedure worldwide left the hospi-
heated argument and was stabbed in the heart again, very tal alive.7 These dismal results were a stimulus for Gibbon to
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close to the original stab wound. This time, Henry was not as start work on a pump oxygenator that could maintain the cir-
culation during pulmonary embolectomy. Sharp was the first
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lucky and died from the wound.

Another milestone in cardiac surgery for trauma to perform pulmonary embolectomy using cardiopulmonary
occurred during World War II when Dwight Harken, then bypass, in 1962.8
a U.S. Army surgeon, removed 134 missiles from the medi-
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astinum, including 55 from the pericardium and 13 from

SURGERY OF THE PERICARDIUM
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cardiac chambers, without a death.5 It is hard to imagine

this type of elective (and semielective) surgery taking place Pericardial resection was introduced independently by Rehn9
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without sophisticated indwelling pulmonary artery cath- and Sauerbruch.10 Since Rehn’s report, there have been few
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eters, blood banks, and electronic monitoring equipment. advances in the surgical treatment of constrictive pericarditis.
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Chapter 1 History of Cardiac Surgery

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Some operations are now performed with the aid of cardio- dilators and various approaches to dilate stenotic aortic valves
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pulmonary bypass. In certain situations, radical pericardiec- in patients. Mortality for these procedures, which was often

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tomy that removes most of the pericardium posterior to the done in conjunction with mitral commissurotomy, was high.

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phrenic nerves is done. Elliott Cutler worked for 2 years on a mitral valvulotomy
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procedure in the laboratory. His first patient underwent suc-
cessful valvulotomy on May 20, 1923, using a tetrasomy
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CATHETERIZATION OF THE RIGHT knife.19 Unfortunately, most of Cutler’s subsequent patients
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SIDE OF THE HEART
Although cardiac catheterization is not considered heart sur-
gery, it is an invasive procedure, and some catheter procedures
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died because he created too much regurgitation with his val-
vulotome, and he soon gave up the operation.
In Charles Bailey’s 1949 paper entitled, “The Surgical
Treatment of Mitral Stenosis,” he states, “After 1929 no more

om
have replaced heart operations. Werner Forssmann is credited
surgical attempts [on mitral stenosis] were made until 1945.
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with the first heart catheterization. He performed the proce-
Dr. Dwight Harken, Dr. Horace Smithy, and the author

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dure on himself and reported it in Klrinische Wochenschrift.11
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recently made operative attempts to improve mitral stenosis.
In 1956 Forssmann shared the Nobel Prize in Physiology
Our clinical experience with the surgery of the mitral valves
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or Medicine with Andre F. Cournand and Dickenson W.
has been five cases to date.” He then describes his five patients,
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Richards, Jr. His 1929 paper states, “One often hesitates to
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four of whom died and only one of whom lived a long life.20,21
use intercardiac injections promptly, and often, time is wasted
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A few days after Bailey’s success, on June 16 in Boston, Dr.

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with other measures. This is why I kept looking for a differ-
Dwight Harken successfully performed his first valvulotomy
ent, safer access to the cardiac chambers: the catheterization
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for mitral stenosis.22
of the right heart via the venous system.”
The first successful pulmonary valvulotomy was performed
In this report by Forssmann, a photograph of the x-ray
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by Thomas Holmes Sellers on December 4, 1947.23
taken of Forssmann with the catheter in his own heart is pre-
Charles Hufnagel reported a series of 23 patients starting
sented. Forssmann, in that same report, goes on to present
September 1952 who had operation for aortic insufficiency.24
the first clinical application of the central venous catheter for
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There were four deaths among the first 10 patients and two
a patient in shock with generalized peritonitis. Forssmann
deaths among the next 13. Hufnagel’s caged-ball valve, which
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concludes his paper by stating, “I also want to mention that
used multiple-point fixation rings to secure the apparatus to
this method allows new options for metabolic studies and
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the descending aorta, was the only surgical treatment for aor-
studies about cardiac physiology.”
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tic valvular incompetence until the advent of cardiopulmo-
In a 1951 lecture Forssmann discussed the tremendous
nary bypass and the development of heart valves that could
resistance he faced during his initial experiments.12 “Such
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be sewn into the aortic annulus position.
methods are good for a circus, but not for a respected hospi-
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tal” was the answer to his request to pursue physiologic stud-
ies using cardiac catheterization. His progressive ideas pushed
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him into the position of an outsider with ideas too crazy to CONGENITAL CARDIAC SURGERY
BEFORE THE HEART-LUNG
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give him a clinical position. Klein applied cardiac catheteriza-
tion for cardiac output determinations using the Fick method MACHINE ERA
a half year after Forssmann’s first report.13 In 1930, Forss-
mann described his experiments with catheter cardiac angi- Congenital cardiac surgery began when John Strieder at Mas-
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ography.14 Further use of this new methodology had to wait sachusetts General Hospital first successfully interrupted a
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until Cournand’s work in the 1940s. ductus on March 6, 1937. The patient was septic and died
on the fourth postoperative day. At autopsy, vegetations filled
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the pulmonary artery down to the valve.25 On August 16,
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HEART VALVE SURGERY BEFORE 1938, Robert Gross, at Boston Children’s Hospital, operated
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THE ERA OF CARDIOPULMONARY on a 7-year-old girl with dyspnea after moderate exercise.26
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The ductus was ligated and the patient made an uneventful
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BYPASS
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recovery.
The first clinical attempt to open a stenotic valve was car- Modifications of the ductus operation soon followed. In
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ried out by Theodore Tuffier on July 13, 1912.15 Tuffier used 1944, Dr. Gross reported a technique for dividing the duc-
tus successfully. The next major congenital lesion to be over-
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his finger to reach the stenotic aortic valve. He was able to

dilate the valve supposedly by pushing the invaginated aortic come was coarctation of the aorta. Dr. Clarence Crafoord,
wall through the stenotic valve. The patient recovered, but in Stockholm, Sweden, successfully resected a coarctation of
one must be skeptical as to what was accomplished. Russell the aorta in a 12-year-old boy on October 19, 1944.27 Twelve
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Brock attempted to dilate calcified aortic valves in humans days later he successfully resected the coarctation of a 27-year-
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in the late 1940s by passing an instrument through the valve old patient. Dr. Gross first operated on a 5-year-old boy with
from the innominate or another artery.16 His results were this condition on June 28, 1945.28 After he excised the coarc-
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poor, and he abandoned the approach. During the next sev- tation and rejoined the aorta, the patient’s heart stopped sud-
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eral years, Brock17 and Bailey and colleagues18 used different denly. The patient died in the operating room. One week
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Part I Fundamentals

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later, however, Dr. Gross operated on a second patient, a THE DEVELOPMENT OF
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12-year-old girl. This patient’s operation was successful. Dr. CARDIOPULMONARY BYPASS

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Gross had been unaware of Dr. Crafoord’s successful surgery

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several months previously, probably because of World War II. The development of the heart-lung machine made repair
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In 1945, Dr. Gross reported the first successful case of sur- of intracardiac lesions possible. To bypass the heart, one
gical relief for tracheal obstruction from a vascular ring.29 In needs a basic understanding of the physiology of the circu-
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the 5 years that followed Gross’s first successful operation, he lation, a method of preventing the blood from clotting, a
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reported 40 more cases.
The famous Blalock-Taussig operation also was first
reported in 1945. The first patient was a 15-month-old
girl with a clinical diagnosis of tetralogy of Fallot with a
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mechanism to pump blood, and finally, a method to ven-
tilate the blood.
One of the key requirements of the heart-lung machine
was anticoagulation. Heparin was discovered in 1915 by a

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severe pulmonary stenosis.30 At age 8 months, the baby medical student, Jay McLean, working in the laboratory of
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had her first cyanotic spell, which occurred after eating. Dr. William Howell, a physiologist at Johns Hopkins.37

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Dr. Helen Taussig, the cardiologist, followed the child John Gibbon contributed more to the success of the devel-
for 3 months, and during that time, cyanosis increased, opment of the heart-lung machine than anyone else.
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and the child failed to gain weight. The operation was Gibbon’s work on the heart-lung machine took place over
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performed by Dr. Alfred Blalock at Johns Hopkins Uni- 20 years in laboratories at Massachusetts General Hospital,
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versity on November 29, 1944. The left subclavian artery the University of Pennsylvania, and Thomas Jefferson
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was anastomosed to the left pulmonary artery in an end- University. In 1937, Gibbon reported the first successful
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to-side fashion. The postoperative course was described demonstration that life could be maintained by an artificial
as stormy; the patient was discharged 2 months postoper- heart and lung and that the native heart and lungs could
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atively. Two additional successful cases were done within
3 months of that first patient.
Thus, within a 7-year period, three congenital cardiovascu-
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resume function. Unfortunately, only three animals recov-
ered adequate cardiorespiratory function after total pulmo-
nary artery occlusion and bypass, and even they died a few

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lar defects, patent ductus arteriosus, coarctation of the aorta, hours later.38 Gibbon’s work was interrupted by World War
and vascular ring, were attacked surgically and treated suc- II; afterward, he resumed his work at Thomas Jefferson Medi-
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cessfully. However, the introduction of the Blalock-Taussig cal College in Philadelphia (Table 1-1).
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shunt probably was the most powerful stimulus to the devel- Forest Dodrill and colleagues used the mechanical blood
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opment of cardiac surgery because this operation palliated pump they developed with General Motors on a 41-year-
a complex intracardiac lesion and focused attention on the old man43 (Fig. 1-3). The machine was used to substitute
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pathophysiology of cardiac disease. for the left ventricle for 50 minutes while a surgical proce-
Anomalous coronary artery in which the left coronary dure was carried out to repair the mitral valve; the patient’s
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artery communicates with the pulmonary artery was the own lungs were used to oxygenate the blood. This, the
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next surgical conquest. The surgery was performed on July first clinically successful total left-sided heart bypass in a
22, 1946, and was reported by Gunnar Biorck and Clarence human, was performed on July 3, 1952, and followed from
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Crafoord.31 The anomalous coronary artery was identified
and doubly ligated. The patient made an uneventful recovery.
Muller32 reported successful surgical treatment of trans-
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Dodrill’s experimental work with a mechanical pump for
univentricular, biventricular, or cardiopulmonary bypass.
Although Dodrill and colleagues had used their pump with

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position of the pulmonary veins in 1951, but the operation an oxygenator for total heart bypass in animals,54 they felt
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addressed a partial form of the anomaly. Later in the 1950s, that left-sided heart bypass was the most practical method
Gott, Varco, Lillehei, and Cooley reported successful opera- for their first clinical case.
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tive variations for anomalous pulmonary veins. Later, on October 21, 1952, Dodrill and colleagues used
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Another of Gross’s pioneering surgical procedures was their machine in a 16-year-old boy with congenital pulmo-
nary stenosis to perform a pulmonary valvuloplasty under fre
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surgical closure of an aortopulmonary window on May 22,

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1948.33 Cooley and colleagues34 were the first to report on direct vision; this was the first successful right-sided heart
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the use of cardiopulmonary bypass to repair this defect and bypass.44 Between July 1952 and December 1954, Dodrill
converted a difficult and hazardous procedure into a relatively performed approximately 13 clinical operations on the
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straightforward one. heart and thoracic aorta using the Dodrill—General Motors
Glenn35 reported the first successful clinical application machine, with at least five hospital survivors.55 Although he
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of the cavopulmonary anastomosis in the United States in used this machine with an oxygenator in the animal labora-
1958 for what has been termed the Glenn shunt. Similar tory, he did not start using an oxygenator with the Dodrill—
work was done in Russia during the 1950s by several investi- General Motors mechanical heart clinically until early 1955.
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gators. On January 3, 1957, Galankin,36 a Russian surgeon, Hypothermia was another method to stop the heart and
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performed a cavopulmonary anastomosis in a 16-year-old allow it to be opened.44

patient with tetralogy of Fallot. The patient made a good John Lewis closed an atrial septal defect (ASD) in a
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recovery with significant improvement in exercise tolerance 5-year-old girl on September 2, 1952 using a hypothermic
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and cyanosis. technique.44

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Chapter 1 History of Cardiac Surgery

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TABLE 1-1: Twilight Zone: Clinical Status of Open-Heart Surgery, 1951–1955

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1951 April 6: Clarence Dennis at the University of Minnesota used a heart-lung machine to repair an ostium primum or AV canal defect in

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a 5-year-old girl. Patient could not be weaned from cardiopulmonary bypass.39
May 31: Dennis attempted to close an atrial septal defect using heart-lung machine in a 2-year-old girl who died intraoperatively of a
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massive air embolus.40
August 7: Achille Mario Digliotti at the University of Turino, Italy, used a heart-lung machine of his own design to partially support
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the circulation (flow at 1 L/min for 20 minutes) while he resected a large mediastinal tumor compressing the right side of the
heart.41 The cannulation was through the right axillary vein and artery. The patient survived. This was the first successful clinical use
of a heart-lung machine, but the machine was not used as an adjunct to heart surgery.
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1952 February (1952 or 1953 John Gibbon; see February 1953)
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March: John Gibbon used his heart-lung machine for right-sided heart bypass only while surgeon Frank Allbritten at Pennsylvania

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Hospital, Philadelphia, operated to remove a large clot or myxomatous tumor suspected by angiography.42 No tumor or clot was
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found. The patient died of heart failure in the operating room shortly after discontinuing right-sided heart bypass.
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April 3: Helmsworth in Cincinnati used a pump oxygenator of his own design connecting it in a veno-veno bypass mode to temporarily
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treat a patient with end-stage lung disease. The patients symptoms improved but recurred shortly after bypass was discontinued.60
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July 3: Dodrill used the Dodrill-GMR pump to bypass the left side of the heart while he repaired a mitral valve.43 The patient survived.
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This was the first successful use of a mechanical pump for total substitution of the left ventricle in a human being.
September 2: John Lewis, at the University of Minnesota, closed an atrial septal defect under direct vision in a 5-year-old girl. The
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patient survived. This was the first successful clinical heart surgery procedure using total-body hypothermia. A mechanical pump
and an oxygenator were not used. Others, including Dodrill, soon followed, using total-body hypothermia techniques to close atrial
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septal defects (ASDs) and perform pulmonary valvulotomies. By 1954, Lewis reported on 11 ASD closures using hypothermia with
two hospital deaths.44 He also operated on two patients with ventricular septal defect (VSD) in early 1954 using this technique.
Both resulted in intraoperative deaths.
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October 21: Dodrill performed pulmonary valvulotomy under direct vision using Dodrill-GMR pump to bypass the right atrium,
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ventricle, and main pulmonary artery.45 The patient survived.
Although Dr. William Mustard in Toronto would describe a type of “corrective” surgical procedure for transposition of the great arteries
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(TGA) in 1964, which, in fact, for many years, would become the most popular form of surgical correction of TGA, his early results
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with this lesion were not good. In 1952, he used a mechanical pump coupled to the lung that had just been removed from a monkey
to oxygenate the blood in seven children while attempts were made to correct their TGA defect.46 There were no survivors.
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1953 February (or 1952): Gibbon at Jefferson Hospital in Philadelphia operated to close an ASD. No ASD was found. The patient died
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intraoperatively. Autopsy showed a large patent ductus arteriosus.47
May 6: Gibbon used his heart-lung machine to close an ASD in an 18-year-old woman with symptoms of heart failure.47,57 The
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patient survived the operation and became the first patient to undergo successful open-heart surgery using a heart-lung machine.
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July: Gibbon used the heart-lung machine on two 5-year-old girls to close atrial septal defects.47 Both died intraoperatively. Gibbon was
extremely distressed and declared a moratorium on further cardiac surgery at Jefferson Medical School until more work could be done to
solve problems related to heart-lung bypass. These were probably the last heart operation he performed using the heart-lung machine.
1954 March 26: C. Walton Lillehei and associates at the University of Minnesota closed a VSD under direct vision in a 15-month-old boy using a
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technique to support the circulation that they called controlled cross-circulation. An adult (usually a parent) with the same blood type was
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used more or less as the heart-lung machine. The adult’s femoral artery and vein were connected with tubing and a pump to the patient’s
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circulation. The adult’s heart and lungs were oxygenated and supported the circulation while the child’s heart defect was corrected. The first
patient died 11 days postoperatively from pneumonia, but six of their next seven patients survived.48 Between March 1954 and the end of
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1955, 45 heart operations were performed by Lillehei on children using this technique before it was phased out. Although controlled cross-
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circulation was a short-lived technique, it was an important stepping stone in the development of open-heart surgery.
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July: Clarence Crafoord and associates at the Karolinska Institute in Stockholm, Sweden, used a heart-lung machine of their own
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design coupled with total-body hypothermia (patient was initially submerged in an ice-water bath) to remove a large atrial myxoma
in a 40-year-old woman.49 She survived.
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1955 March 22: John Kirklin at the Mayo Clinic used a heart-lung machine similar to Gibbon’s, but with modifications his team had
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worked out over 2 years in the research laboratory, to successfully close a VSD in a 5-year-old patient. By May of 1955, they had
operated on eight children with various types of VSDs, and four were hospital survivors. This was the first successful series of
patients (ie, more than one) to undergo heart surgery using a heart-lung machine.50
May 13: Lillehei and colleagues began using a heart-lung machine of their own design to correct intracardiac defects. By May of
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1956, their series included 80 patients.48 Initially they used their heart-lung machine for lower-risk patients and used controlled
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cross-circulation, with which they were more familiar, for the higher-risk patients. Starting in March 1955, they also tried other
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techniques in patients to oxygenate blood during heart surgery, such as canine lung, but with generally poor results.48
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(Continued )
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Part I Fundamentals

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TABLE 1-1: Twilight Zone: Clinical Status of Open-Heart Surgery, 1951–1955 (Continued )

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1955 Dodrill had been performing heart operations with the GM heart pump since 1952 and used the patient’s own lungs to oxygenate

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the blood. Early in the year 1955, he attempted repairs of VSDs in two patients using the heart pump, but with a mechanical
oxygenator of his team’s design both died. On December 1, he closed a VSD in a 3-year-old girl using his heart-lung machine. She
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survived. In May 1956 at the annual meeting of the American Association for Thoracic Surgery, he reported on six children with
VSDs, including one with tetralogy of Fallot, who had undergone open-heart surgery using his heart-lung machine. All survived at
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least 48 hours postoperatively.51 Three were hospital survivors, including the patient with tetralogy of Fallot.
June 30: Clarence Dennis, who had moved from the University of Minnesota to the State University of New York, successfully closed
an ASD in a girl using a heart-lung machine of his own design.52
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Mustard successfully repaired a VSD and dilated the pulmonary valve in a 9-month-old with a diagnosis of tetralogy of Fallot using
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a mechanical pump and a monkey lung to oxygenate the blood.53 He did not give the date in 1955, but the patient is listed as

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Human Case 7. Unfortunately, in the same report, cases 1–6 and 8–15 operated on between 1951 and the end of 1955 with
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various congenital heart defects did not survive the surgery using the pump and monkey lung, nor did another seven children in
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1952, all with TGA (see timeline for 1952) using the same bypass technique.
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Note: This list is not all-inclusive but likely includes most of the historically significant clinical open-heart events in which a blood pump was used to support the circulation
during this period. (A twilight zone can mean an ill-defined area between two distinct conditions, such as the area between darkness and light.)
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The use of systemic hypothermia for open intracardiac sur- cardiopulmonary bypass were poor. In 1967, Hikasa and
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gery was relatively short-lived; after the heart-lung machine
was introduced clinically, it appeared that deep hypothermia
was obsolete. However, during the 1960s it became appar-
ent that operative results in infants under 1 year of age using
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colleagues,56 from Kyoto, Japan, published an article that
reintroduced profound hypothermia for cardiac surgery in
infants and used the heart-lung machine for rewarming.
Their technique involved surface cooling to 20°C, cardiac

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FIGURE 1-3 Blueprints by General Motors engineers of the Dodrill-GMR mechanical heart. (Used with permission from Calvin Hughes.)
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Chapter 1 History of Cardiac Surgery

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surgery during circulatory arrest for 15 to 75 minutes, and The patient recovered, and several months later the defect was
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rewarming with cardiopulmonary bypass. At the same time, confirmed closed at cardiac catheterization.57 Unfortunately,

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other groups reported using profound hypothermia with Gibbon’s next two patients did not survive intracardiac pro-

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circulatory arrest in infants with the heart-lung machine for cedures when the heart-lung machine was used. These failures
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cooling and rewarming. Results were much improved, and distressed Dr. Gibbon, who declared a 1-year moratorium for
subsequently the technique also was applied for resection of the heart-lung machine until more work could be done to
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aortic arch aneurysms. solve the problems causing the deaths.
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After World War II, John Gibbon resumed his research.
He eventually met Thomas Watson, chairman of the board
of the International Business Machines (IBM) Corporation.
Watson was fascinated by Gibbon’s research and promised
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During this period, C. Walton Lillehei and colleagues at
the University of Minnesota studied a technique called con-
trolled cross-circulation.58 With this technique, the circulation
of one dog was used temporarily to support that of a second

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help. Soon afterward, six IBM engineers arrived and built a dog while the second dog’s heart was stopped temporarily and
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machine that was similar to Gibbon’s earlier machine, which opened. After a simulated repair in the second dog, the ani-

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contained a rotating vertical cylinder oxygenator and a modi- mals were disconnected and allowed to recover.
fied DeBakey rotary pump. Gibbon operated on a 15-month- Lillehei and colleagues58 used their technique at the Uni-
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old girl with severe congestive heart failure (CHF). The versity of Minnesota to correct a ventricular septal defect
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preoperative diagnosis was ASD, but at operation, none (VSD) in a 12-month-old infant on March 26, 1954
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was found. She died, and a huge patent ductus was found (Fig. 1-4). Either a parent or a close relative with the same
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at autopsy. The next patient was an 18-year-old girl with blood type was connected to the child’s circulation. In Lille-
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CHF owing to an ASD. This defect was closed successfully hei’s first clinical case, the patient made an uneventful recov-
on May 6, 1953, with the Gibbon-IBM heart-lung machine. ery until death on the eleventh postoperative day from a
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FIGURE 1-4 A depiction of the method of direct-vision intracardiac surgery using extracorporeal circulation by controlled cross-circulation. (A)
The patient, showing sites of arterial and venous cannulations. (B) The donor, showing sites of arterial and venous (superficial femoral and great
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saphenous) cannulations. (C) The Sigma motor pump controlling precisely the reciprocal exchange of blood between the patient and donor. (D)
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Close-up of the patient’s heart, showing the vena caval catheter positioned to draw venous blood from both the superior and inferior venae cavae
during the cardiac bypass interval. The arterial blood from the donor circulated to the patient’s body through the catheter that was inserted into
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the left subclavian artery. (Reproduced with permission from Lillehei CW, Cohen M, Warden HE, et al: The results of direct vision closure of
ventricular septal defects in eight patients by means of controlled cross circulation, Surg Gynecol Obstet. 1955 Oct;101(4):446-466.)
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Part I Fundamentals

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rapidly progressing tracheal bronchitis. At autopsy, the VSD Kirklin continued:61
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was closed, and the respiratory infection was confirmed as the Four of our first eight patients survived, but the press of the

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cause of death. Two weeks later, the second and third patients clinical work prevented our ever being able to return to the

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had VSDs closed by the same technique 3 days apart. Both laboratory with the force that we had planned. By now, Walt
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remained long-term survivors with normal hemodynamics Lillehei and I were on parallel, but intertwined paths.
confirmed by cardiac catheterization.
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In 1955, Lillehei and colleagues59 published a report of By the end of 1956, many university groups around the
world had launched into open-heart programs. Currently, it
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32 patients that included repairs of VSDs, tetralogy of Fallot,
and atrioventricularis communis defects. By May of 1955,
the blood pump used for systemic cross-circulation by Lillehei
and colleagues was coupled with a bubble oxygenator devel-
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is estimated that more than 1 million cardiac operations are
performed each year worldwide with use of the heart-lung
machine. In most cases, the operative mortality is quite low,

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oped by Drs. DeWall and Lillehei, and cross-circulation was approaching 1% for some operations. Little thought is given
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soon abandoned after use in 45 patients during 1954 and to the courageous pioneers in the 1950s whose monumental

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contributions made all this possible.
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1955. Although its clinical use was short-lived, cross-circula-
tion was an important steppingstone in the development of
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cardiac surgery. Extracorporeal Life Support
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Meanwhile, at the Mayo Clinic only 90 miles away, John
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W. Kirklin and colleagues launched their open-heart program Extracorporeal life support (ECLS) is an extension of cardio-
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on March 5, 1955.50 They used a heart-lung machine based pulmonary bypass. Cardiopulmonary bypass was limited ini-
tially to no more than 6 hours. The development of membrane
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on the Gibbon-IBM machine but with their own modifica-
tions. Kirklin wrote:61 oxygenators in the 1960s permitted longer support. Donald
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We investigated and visited the groups working intensively
with the mechanical pump oxygenators. We visited Dr.
Gibbon in his laboratories in Philadelphia, and Dr. Forest
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Hill and colleagues in 1972 treated a 24-year-old man who
developed shock lung after blunt trauma.62 The patient was
supported for 75 hours using a heart-lung machine with a
membrane oxygenator, cannulated via the femoral vein and

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Dodrill in Detroit, among others. The Gibbon pump oxy-
artery. The patient was weaned and recovered. Hill’s second
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genator had been developed and made by the International
Business Machine Corporation and looked quite a bit like a patient was supported for 5 days and recovered. This led to
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computer. Dr. Dodrill’s heart-lung machine had been devel- a randomized trial supported by the National Institutes of
Health to determine the efficacy of this therapy for adults
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oped and built for him by General Motors and it looked a
great deal like a car engine. We came home, reflected and with respiratory failure. The study was conducted from 1972
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decided to try to persuade the Mayo Clinic to let us build a to 1975 and showed no significant difference in survival
pump oxygenator similar to the Gibbon machine, but some- between patients managed by ECLS (9.5%) and those who
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what different. We already had had about a year’s experience received conventional ventilatory therapy (8.3%).63 Because
in the animal laboratory with David Donald using a simple
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of these results, most U.S. centers abandoned efforts to sup-
pump and bubble oxygenator when we set about very early in
1953, the laborious task of building a Mayo-Gibbon pump
port adult patients using ECLS, also known as extracorporeal
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oxygenator and continuing the laboratory research.
Most people were very discouraged with the laboratory
progress. The American Heart Association and the National
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membrane oxygenation (ECMO).
One participant in the adult trial decided to study neo-
nates. The usual causes of neonatal respiratory failure have

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Institutes of Health had stopped funding any projects for in common abnormal postnatal blood shunts known as per-
the study of heart-lung machines, because it was felt that the sistent fetal circulation (PFC). This is a temporary, reversible
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problem was physiologically insurmountable. David Donald phenomenon. In 1976, Bartlett and colleagues at the Univer-
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and I undertook a series of laboratory experiments lasting sity of Michigan were the first to treat a neonate successfully
about 1½ years during which time the engineering shops at
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the Mayo Clinic constructed a pump oxygenator based on

using ECLS. More than 8000 neonatal patients have been
treated using ECLS worldwide, with a survival rate of 82% fre
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the Gibbon model.
(ELSO registry data).
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… In the winter of 1954 and 1955 we had nine sur-

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viving dogs out of 10 cardiopulmonary bypass runs. With

my wonderful colleague and pediatric cardiologist, Jim
MYOCARDIAL PROTECTION
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DuShane, we had earlier selected eight patients for intra-

cardiac repair. Two had to be put off because two babies Melrose and colleagues64 in 1955 presented the first experi-
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with very serious congenital heart disease came along and mental study describing induced arrest by potassium-based
we decided to fit them into the schedule. We had deter-
cardioplegia. Blood cardioplegia was used “to preserve
mined to do all eight patients even if the first seven died. All
myocardial energy stores at the onset of cardiac ischemia.”
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of this was planned with the knowledge and approval of the

governance of the Mayo Clinic. Our plan was then to return Unfortunately, the Melrose solution proved to be toxic to the
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to the laboratory and spend the next 6 to 12 months solv- myocardium, and as a result cardioplegia was not used widely
for several years.
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ing the problems that had arisen in the first planned clinical
trial of a pump oxygenator. … We did our first open-heart Gay and Ebert65 and Tyres and colleagues66 demonstrated
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operation on a Tuesday in March 1955. that cardioplegia with lower potassium concentrations was
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11
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Chapter 1 History of Cardiac Surgery

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safe. Studies by Kirsch and colleagues,67 Bretschneider and col- By 1967, nearly 2000 Starr-Edwards valves had been
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leagues,68 and Hearse and colleagues69 demonstrated the effec- implanted, and the caged-ball-valve prosthesis was established

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tiveness of cardioplegia with other constituents and renewed as the standard against which all other mechanical prostheses

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interest in this technique. Gay and Ebert in 1973 demonstrated would be compared.
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a significant reduction in myocardial oxygen consumption In 1964, Starr and colleagues reported 13 patients who
during potassium-induced arrest when compared with that of had undergone multiple valve replacement.93 One patient
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the fibrillating heart.65 They also showed that the problems in had the aortic, mitral, and tricuspid valves replaced on Feb-
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the use of the Melrose solution in the early days of cardiac sur-
gery probably were caused by its hyperosmolar properties and
perhaps not the high potassium concentration.
In a 1978 publication by Follette and colleagues,70 the
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ruary 21, 1963. Cartwright and colleagues, however, on
November 1, 1961, were the first to replace both the aortic
and mitral valves successfully with ball-valve prostheses that
they had developed.94 Knott-Craig and colleagues,95 from the

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technique of blood cardioplegia was reintroduced. In experi- Mayo Clinic, successfully replaced all four heart valves in a
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mental and clinical studies, these authors demonstrated that patient with carcinoid involvement.

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hypothermic, intermittent blood cardioplegia provided bet- In 1961, Andrew Morrow and Edwin Brockenbrough96
ter myocardial protection than normothermic, continuous reported a treatment for idiopathic hypertrophic subaortic
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coronary perfusion and/or hypothermic, intermittent blood stenosis by resecting a portion of the thickened ventricular
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perfusion without cardioplegia solution. The composition of septum. They referred to this as subaortic ventriculomyotomy.
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the best cardioplegia solution remains controversial, and new They gave credit to William Cleland and H.H. Bentall in
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formulations, methods of delivery, and recommended tem- London, who had encountered this condition unexpectedly
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peratures continue to evolve. at operation and resected a small portion of the ventricular
mass. The patient improved, but no postoperative hemody-
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namic studies had been reported. The subaortic ventriculo-
EVOLUTION OF CONGENITAL myotomy became the standard surgical treatment for this
CARDIAC SURGERY DURING THE ERA cardiac anomaly, although in some patients systolic anterior
OF CARDIOPULMONARY BYPASS
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motion (SAM) of the anterior leaflet of the mitral valve neces-
sitates mitral valve replacement with a low-profile mechanical
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With the advent of cardiopulmonary bypass using either the valve.
cross-circulation technique of Lillehei and colleagues or the ver-
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An aortic homograft valve was used clinically for the first
sion of the mechanical heart-lung machine used by Kirklin and
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colleagues, the two groups led the way for intracardiac repairs
for many of the commonly occurring congenital heart defects.
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time by Heimbecker and colleagues in Toronto for replace-
ment of the mitral valve in one patient and an aortic valve

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in another.97 Survival was short, 1 day in one patient and 1
Because of the morbidity associated with the heart-lung machine, month in the other. Donald Ross reported on the first success-
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palliative operations also were developed to improve circulatory ful aortic valve placement with an aortic valve homograft.98
physiology without directly addressing the anatomic pathology.
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He used a technique of subcoronary implantation developed
These palliative operations included the Blalock-Taussig subcla- in the laboratory by Carlos Duran and Alfred Gunning in
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vian–pulmonary arterial shunt30 with modifications by Potts and Oxford.
colleagues71 and Waterston,72 the Blalock-Hanlon operation to The technique of AVR with a pulmonary autograft
create an ASD,73 and the Galankin-Glenn superior vena cava– described initially by Ross in 1967 is advocated by some
right pulmonary arterial shunt.35,36
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groups for younger patients who require AVR.99 An aortic or
As the safety of cardiopulmonary bypass improved steadily,
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pulmonary valve homograft is used to replace the pulmonary
surgeons addressed more and more complex abnormalities of the valve that has been transferred to the aortic position.
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heart in younger and younger patients. Some of the milestones Other autogenous materials that have been used to manu-
in the development of operations to correct congenital heart
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defects using cardiopulmonary bypass appear in Table 1-2.

facture valve prostheses include pericardium, fasciae latae,
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and dura mater. In the 1960s, Binet and colleagues100 began

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to develop and test tissue valves. In 1964, Duran and Gun-
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VALVULAR SURGERY: ning in England replaced an aortic valve in a patient using a

xenograft porcine aortic valve. Early results with formalde-
CARDIOPULMONARY BYPASS ERA
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hyde-fixed xenografts were good,100 but in a few years these

Cardiac valve repair or replacement under direct vision valves began to fail because of tissue degeneration and cal-
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awaited the development of the heart-lung machine. The first cification.101 Carpentier and colleagues revitalized interest in
successful aortic valve replacement (AVR) in the subcoronary xenograft valves by fixating porcine valves with glutaralde-
position was performed by Dr. Dwight Harken and associ- hyde. Carpentier also mounted his valves on a stent to pro-
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ates.91 A caged-ball valve was used. Many of the techniques duce a bioprosthesis. Carpentier-Edwards porcine valves and
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described in Harken’s 1960 report are similar to those used Hancock and Angell-Shiley bioprostheses became popular
today for AVR. and were implanted in large numbers of patients.102,103
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That same year, Starr and Edwards92 successfully replaced With the development of cardiopulmonary bypass, valves
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the mitral valve using a caged-ball valve of their own design. could be approached under direct vision, and for the first
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12
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Part I Fundamentals

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TABLE 1-2: First Successful Intracardiac Repairs Using Cardiopulmonary Bypass or

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Cross-Circulation
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Lesion Year Reference Comment
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Atrial septal defect 1953 Gibbon57 May 6, 1953
Ventricular septal defect 1954 Lillehei et al58 Cross-circulation
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Complete atrioventricular canal 1954 Lillehei et al59 Cross-circulation
Tetralogy of Fallot 1954 Lillehei et al58 Cross-circulation
Tetralogy of Fallot 1955 Kirklin50 Cardiopulmonary bypass (CPB)
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Total anomalous pulmonary veins 1956 Burroughs and Kirklin74
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Congenital aneurysm sinus of Valsalva 1956 McGoon et al75

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Congenital aortic stenosis 1956 Ellis and Kirklin76 First direct visual correction
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Aortopulmonary window 1957 Cooley et al77 First closure using CPB
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Double outlet right ventricle 1957 Kirklin et al78 Extemporarily devised correction
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Corrected transposition great arteries 1957 Anderson et al79
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Transposition of great arteries: 1959 Senning80 Physiologic total correction
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atrial switch
Coronary arteriovenous fistula 1959 Swan et al81
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Ebstein’s anomaly 1964 Hardy et al82 Repair of atrialized tricuspid valve
Tetralogy with pulmonary atresia 1966 Ross and Somerville83 Used aortic allograft
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Truncus arteriosus 1967 McGoon et al84 Used aortic allograft
Tricuspid atresia 1968 Fontan and Baudet85 Physiologic correction
Single ventricle 1970 Horiuchi et al86
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Subaortic tunnel stenosis 1975 Konno et al87
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Transposition of great arteries: 1975 Jatene et al88 Anatomic correction
arterial switch
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Hypoplastic left heart syndrome 1983 Norwood et al89 Two-stage operation
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Pediatric heart transplantation 1985 Bailey et al90
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time, mitral insufficiency could be attacked by reparative tech- April 16, 2002.110 Prospective clinical trials soon followed,
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niques. Techniques for mitral annuloplasty were described by
Wooler and colleagues,104 Reed and colleagues,105 and Kay
and colleagues.106 The next step forward was development of
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which demonstrated that percutaneous aortic valve inser-
tion improved 1 year survival compared to medically treated
patients with critical aortic stenosis, and that this procedure

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annuloplasty rings by Carpentier and Duran. In the 1970s, had similar 30-day and 1-year mortalities when compared
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few groups were involved in valve repairs. Slowly, techniques to the standard surgical procedure. There was, however, an
evolved, were tested clinically, and were followed over the increased rate of stroke/transient ischemic attack (TIA) with
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years. Carpentier led the field by establishing the importance percutaneous approach.111, 112
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of careful analysis of valve pathology, describing in detail

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several techniques of valve repair, and reporting good results

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CORONARY ARTERY SURGERY
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after early and late follow-up, especially with concomitant use

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of annuloplasty rings.107 Selective coronary angiography was developed by Sones and

From 1966 to 1968, a small epidemic of infective endo- Shirey at the Cleveland Clinic and reported in their 1962
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carditis in Detroit among heroin addicts broke out. Patients classic paper entitled, “Cine Coronary Arteriography.”113
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were dying of intractable gram-negative tricuspid valve endo-
carditis, often caused by Pseudomonas aeruginosa. Long-term
antibiotic administration in combination with tricuspid valve
replacement was 100% fatal. Starting in 1970, Arbulu oper-
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They used a catheter to inject contrast material directly into
the coronary artery ostia. This technique gave a major impe-
tus to direct revascularization of obstructed coronary arteries.
From 1960 to 1967, several sporadic instances of coronary

ated on 55 patients; in 53, the tricuspid valve was removed grafting were reported. All were isolated cases and, for uncer-
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without replacing it.108,109 At 25 years, the actuarial survival tain reasons, were not reproduced. None had an impact on
is 61%. the development of coronary surgery. Dr. Robert H. Goetz
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Alan Cribier in Rouen France was first to successfully performed what appears to be the first clearly documented
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perform a transcatheter aortic valve insertion in a patient on coronary artery bypass operation in a human, which was
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13
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Chapter 1 History of Cardiac Surgery

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successful. The surgery took place at Van Etten Hospital in of the coronary artery. In an addendum to that paper, 55
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New York City on May 2, 1960.114 He operated on a 38-year- patients were added, 52 for segmental occlusion of the right

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old man who was severely symptomatic and used a nonsuture coronary and 3 others for circumflex disease.

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technique to connect the right internal mammary artery to a The contributions by Favalaro, Kolessov, Green and col-
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right coronary artery. It took him 17 seconds to join the two leagues, and Bailey and Hirose all were important, but
arteries using a hollow metal tube. The right internal mam- arguably the official start of coronary bypass surgery as we
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mary artery–coronary artery connection was confirmed pat- know it today happened in 1969 when W. Dudley Johnson
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ent by angiography performed on the 14th postoperative day.
The patient remained asymptomatic for about a year and then
developed recurrent angina and died of a myocardial infarc-
tion on June 23, 1961. Goetz was severely criticized by his
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and coworkers from Milwaukee reported their series of 301
patients who had undergone various operations for coro-
nary artery disease (CAD) since February of 1967.122 In that
report, the authors presented their results with direct coro-

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medical and surgical colleagues for this procedure, although nary artery surgery during a 19-month period. They state:
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he had performed it successfully many times in the animal

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After two initial and successful patch grafts, the vein bypass
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laboratory. He never attempted another coronary bypass technique has been used exclusively. Early results were so
operation in a human.
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encouraging that last summer the vein graft technique was
Another example involved a case of autogenous saphenous expanded and used to all major branches. Vein grafts to the
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vein bypass grafting performed on November 23, 1964, in a left side of the arteries run from the aorta over the pulmo-
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42-year-old man who was scheduled to have endarterectomy nary artery and down to the appropriate coronary vessel.
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of his left coronary artery.115 Because the lesion involved the Right-sided grafts run along the atrioventricular groove and
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entire bifurcation, endarterectomy with venous patch graft also attach directly to the aorta. There is almost no limit of
was abandoned as too hazardous. The authors, Garrett, Dennis, potential (coronary) arteries to use. Veins can be sutured to
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and DeBakey, however, did not report this case until 1973. the distal anterior descending or even to posterior marginal
branches. Double vein grafts are now used in more than 40%
The patient was alive at that time, and angiograms showed
of patients and can be used to any combination of arteries.
the vein graft to be patent.
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Shumaker116 credits Longmire with the first internal mam- Johnson goes on to say:
mary–coronary artery anastomosis. “It was almost surely
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Longmire, long-time chairman at UCLA, and his associate, Our experience indicates that five factors are important to
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Jack Cannon, who first performed an anastomosis between direct surgery. One: Do not limit grafts to proximal portions
of large arteries. … Two: Do not work with diseased arteries.
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the internal mammary artery and a coronary branch, prob-
ably in early 1958.” Vein grafts can be made as long as necessary and should be
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The reference that Shumaker gives for this quotation from
Longmire is a personal communication to Shumaker in 1990,
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inserted into distal normal arteries. Three: Always do end-
to-side anastomoses. … Four: Always work on a dry, quiet

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field. Consistently successful fine vessel anastomoses cannot
which was 32 years after the fact! be done on a moving, bloody target. … Five: Do not allow
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As early as 1952, Vladimir Demikhov, the renowned the hematocrit to fall below 35.
Soviet surgeon, was anastomosing the internal mammary
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artery to the left coronary artery in dogs.117 In 1967, at the
height of the Cold War, a Soviet surgeon from Leningrad,
V. I. Kolessov, reported his experience with mammary artery–
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In discussing Dr. Johnson’s presentation, Dr. Frank Spen-
cer commented:
I would like to congratulate Dr. Johnson very heartily. We may

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coronary artery anastomoses for the treatment of angina pec- have heard a milestone in cardiac surgery today. Because for years,
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toris in six patients in an American surgical journal.118 The pathologists, cardiologists, and many surgeons have repeatedly
first patient in that series was done in 1964. Operations were stated that the pattern of coronary artery disease is so exten-
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performed through a left thoracotomy without extracorporeal sive that direct anastomosis can be done in only 5 to 7% of
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circulation or preoperative coronary angiography. The fol- patients. If the exciting data by Dr. Johnson remain valid and
the grafts remain patent over a long period of time, a total
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lowing year, Green and colleagues119 and Bailey and Hirose120

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revision of thinking will be required regarding the feasibility
separately published reports in which the internal mammary
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of direct arterial surgery for CAD.122

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artery was used for coronary artery bypass in patients.

Rene Favalaro from the Cleveland Clinic used saphenous The direct anastomosis between the internal mammary
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vein for bypassing coronary obstructions.121 Favalaro’s 1968 artery and the coronary artery was not as popular initially as
article focused on 15 patients, who were part of a larger series the vein-graft technique; however, owing to the persistence of
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of 180 patients who had undergone the Vineberg procedure. Drs. Green, Loop, Grondin, and others, internal mammary
In these 15 patients with occlusion of the proximal right cor- artery grafts eventually became the conduit of choice when
onary artery, an interpositional graft of saphenous vein also their superior long-term patency became known.123
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was placed between the ascending aorta and the right coro- Andreas Gruntzig working in Zurich, Switzerland, was
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nary artery distal to the blockage. The right coronary artery the first to successfully dilate a stenotic coronary artery in a
was divided, and the vein graft was anastomosed end to end. patient, percutaneously and used a balloon-tip catheter he had
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Favalaro states that this procedure was done because of the developed. The procedure was performed on September 16,
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unfavorable results with pericardial patch reconstruction 1977, on a 38-year-old woman with an 85% stenosis of the
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14
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Part I Fundamentals

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left anterior descending coronary artery. In 1979, he reported all refractory clinical cases now are treated successfully by
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on the first 50 patients to undergo percutaneous transluminal nonsurgical means.132

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coronary angioplasty (PTCA).124 However despite the almost Ross and colleagues133 in Sydney, Australia, and Cox and

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instant popularity of this procedure in the Western world, colleagues134 in St. Louis, Missouri, used cryosurgical treat-
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it was soon found that the restenosis rate was relatively high ment of atrial ventricular node re-entry tachycardia. Sub-
when compared with that of coronary bypass surgery, and sequently, James L. Cox, after years of laboratory research,
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there was also risk of sudden closure of the artery in the area developed the Maze operation for atrial fibrillation.135 That
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that had been dilated.
Research in the animal laboratory with stents was carried
out in the hope of solving these problems.
Jacque Puel in Toulouse, France, and shortly afterward,
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technique, with his subsequent modifications, is now known
as the Cox Maze procedure and has become the world standard
with which other techniques used to treat atrial fibrillation,
either surgically or with catheters, are compared.136

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Ulrich Sigwart in Lausanne, Switzerland, were first to Guiraudon and colleagues,136 from Paris, reported their
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implant stents in patient’s coronary arteries in the spring of results with an encircling endomyocardial ventriculotomy for

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1986.125–128 Although stents improved the results of PTCA the treatment of malignant ventricular arrhythmias. The fol-
and significantly decreased the incidence of acute coronary lowing year, in 1979, Josephson and colleagues137 described
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closure, the long-term patency rates in general were not as a more specific procedure for treatment of malignant ven-
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good as those in coronary bypass surgery. Therefore, stents tricular arrhythmias. After endocardial mapping, the endo-
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that were impregnated with drugs or other chemicals were cardial source of the arrhythmia was excised. Although the
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developed, which would be slowly released with hopes of Guiraudon technique usually isolated the source of the
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decreasing the restenosis rate. Clinical trials with these drug- arrhythmia, the incision also devascularized healthy myocar-
eluting types of stents began in 2003 and indicate they are dium and was associated with high mortality. Endocardial
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associated with a decrease in restenosis rates.
Denton Cooley and colleagues made two important con-
tributions to the surgery for ischemic heart disease.129 In
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resection was safer and more efficacious and became the basis
of all approaches for the treatment of ischemic ventricular
tachycardia.137

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1956, with the use of cardiopulmonary bypass, they were the Stimulated by the death of a close personal friend from
first to repair a ruptured interventricular septum following ventricular arrhythmias, Dr. Mirowski developed a proto-
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acute myocardial infarction. The patient did well initially but type defibrillator over a 3-month period in 1969. In 1980,
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died of complications 6 weeks after the operation. Cooley Mirowski and colleagues described three successful cases using
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and colleagues also were the first to report the resection of a their implantable myocardial stimulator at Johns Hopkins.138
left ventricular aneurysm with the use of cardiopulmonary Soon a version of Mirowski’s defibrillator was commer-
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bypass.130 cially available. Initially centers implanting them were part
of the clinical trials being conducted and required Food and
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ARRHYTHMIC SURGERY Drug Administration (FDA) approval. The chest needed
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to be opened to place the relatively large electrodes directly
Cobb and colleagues at Duke University developed the first on the ventricles. The battery used to power the device and
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successful surgical treatment for cardiac arrhythmias.131 A
32-year-old fisherman was referred for symptomatic episodes
of atrial tachycardia that caused CHF. On May 2, 1968, after
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generate the electrical shock was also large and was usually
placed in the abdominal wall. Within 10 years, smaller, more
advanced ventricular leads were developed and inserted per-

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epicardial mapping, a 5- to 6-cm cut was made extending cutaneously through the venous system. The battery was
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from the base of the right atrial appendage to the right border made much smaller in size. During the 1990s, clinical trials
of the right atrium during cardiopulmonary bypass. The inci- were conducted, which showed the automatic implantable
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sion transected the conduction pathway between the atrium cardiac defibrillators decreased mortality when compared to
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and ventricle. Subsequent epicardial mapping indicated erad-

ication of the pathway. Six weeks after the operation, heart
medically treated patients in subsets of patients prone to ven-
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tricular tachycardia and fibrillation. As a result of these find-

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size had decreased and lung fields had cleared. The patient ings, the use of these devices has increased significantly.139, 140
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eventually returned to work.

A year earlier, Dr. Dwight McGoon at the Mayo Clinic
PACEMAKERS
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closed an ASD in a patient who also had Wolff-Parkinson-

White (WPW) syndrome.132 At operation, Dr. Birchell In 1952, Paul Zoll applied electric shocks 2 ms in duration
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mapped the epicardium of the heart and localized the that were transmitted through the chest wall at frequencies
accessory pathway to the right atrioventricular groove. from 25 to 60 per minute and increased the intensity of the
Lidocaine was injected into the site, and the delta wave shock until ventricular responses were observed. However,
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disappeared immediately. Unfortunately, conduction after 25 minutes of intermittent stimulation the patient
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across the pathway reappeared a few hours later. This prob- died, although many subsequent patients recovered.141
ably was the first attempt to treat the WPW syndrome The next step came when Lillehei and colleagues reported
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surgically. As a result of knowledge gained from the sur- a series of patients who had external pacing after open-
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gical treatment for WPW syndrome, more than 95% of heart surgery during the 1950s.142 The field of open-heart
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Chapter 1 History of Cardiac Surgery

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surgery gave a major impetus to the development of pace- other until he had the donor heart functioning in the appro-
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makers because there was a high incidence of heart block priate position and the native heart removed. One of his dogs

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following many intracardiac repairs. The major difference climbed the steps of the Kremlin on the sixth postoperative

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between Zoll’s pacing and that of Lillehei and colleagues day but died shortly afterward of rejection.
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was that Zoll used external electrodes placed on the chest Richard Lower and Norman Shumway established
wall, whereas Lillehei and colleagues attached electrodes the technique for heart transplantation as it is performed
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directly to the heart at operation. Lillehei and colleagues today.147 Preservation of the cuff of recipient left and right
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used a relatively small external pacemaker to stimulate the
heart and much less electric current. This form of heart
pacing was better tolerated by the patient and was a more
efficient way to stimulate the heart. The survival rate of
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atria with part of the atrial septum was described earlier by
Brock148 in England and Demikhov117 in Russia,149 but it
became popular only after Shumway and Lower reported it
in their 1960 paper.

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Lillehei’s patients with surgically induced heart block was The first attempt at human heart transplantation was made
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improved significantly. by Hardy and colleagues150 at the University of Mississippi.

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During this period, progress was made toward a totally Because no human donor organ was available at the time, a
implantable pacemaker. Elmquist and Senning143 developed a large chimpanzee’s heart was used; however, it was unable to
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pacer battery that was small enough for an epigastric pocket support the circulation because of hyperacute rejection.
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with electrodes connected to the heart. They implanted the The first human-to-human heart transplant occurred
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unit in a patient with atrioventricular block in 1958. Just on December 3, 1967, in Capetown, South Africa.151 The
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before implantation, the patient had 20 to 30 cardiac arrests surgical team, headed by Christiaan Barnard, transplanted
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a day. The first pacemaker that was implanted functioned the heart of a donor who had been certified dead after the
only 8 hours; the second pacemaker implanted in the same electrocardiogram showed no activity for 5 minutes into a
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patient had better success. The patient survived until January
2002 and had many additional pacemakers. Chardack and
colleagues are perhaps better known for their development of
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54-year-old man whose heart was irreparably damaged by
repeated myocardial infarctions. The second human heart
transplant using a human donor was performed on a child

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the totally implantable pacemaker.144 In 1961, they reported 3 days after the first on December 6, 1967, by Adrian Kantrowitz
a series of 15 patients who had pacemakers that they had in Brooklyn, New York. Dr. Kantrowitz’s patient died of a
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developed implanted. bleeding complication within the first 24 hours.152 Barnard’s
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Early implantable pacemakers were fixed-rate, asynchro- patient, Lewis Washkansky, died on the 18th postoperative
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nous devices that delivered an impulse independent of the day. At autopsy, the heart appeared normal, and there was no
underlying cardiac rhythm. During the past 40 years, enor- evidence of chronic liver congestion, but bilateral pneumo-
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mous progress has been made in the field of pacing technol- nia was present, possibly owing to severe myeloid depression
ogy. The number of individuals with artificial pacemakers is from immunosuppression.153
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unknown; however, estimates indicate that approximately On January 2, 1968, Barnard performed a second heart
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500,000 Americans are living with a pacemaker and that each transplant on Phillip Blaiberg, 12 days after Washkansky’s
year another 100,000 or more patients require permanent death.154 Blaiberg was discharged from the hospital and
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pacemakers in the United States. became a celebrity during the several months he lived after
the transplant. Blaiberg’s procedure indicated that a heart
transplant was an option for humans suffering from end-stage
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HEART, HEART-LUNG, AND LUNG heart disease. Within a year of Barnard’s first heart transplant,
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99 heart transplants had been performed by cardiac surgeons
TRANSPLANTATION around the world. However, by the end of 1968, most groups
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Alexis Carrel and Charles Guthrie reported transplantation abandoned heart transplantation because of the extremely
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of the heart and lungs while at the University of Chicago in high mortality related to rejection. Shumway and Lower,
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1905.145 The heart of a small dog was transplanted into the Barnard, and a few others persevered both clinically and in
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neck of a larger one by anastomosing the caudad ends of the the laboratory. Their efforts in discovering better drugs for
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jugular vein and carotid artery to the aorta and pulmonary immunosuppression eventually established heart transplanta-
artery. The animal was not anticoagulated, and the experi- tion as we know it today.
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ment ended about 2 hours after circulation was established A clinical trial of heart-lung transplantation was com-
because of blood clot in the cavities of the transplanted heart. menced at Stanford University in 1981 by Reitz and col-
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Vladimir Demikhov, from Russia, described more than leagues.155 Their first patient was treated with a combination
20 different techniques for heart transplantation in 1950.146 of cyclosporine and azathioprine. The patient was discharged
He also published various techniques for heart and lung from the hospital in good condition and was well more than
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transplantation. He was even able to perform an orthotopic 5 years after the transplant.
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heart transplant in a dog before the heart-lung machine was The current success with heart, heart-lung, and lung trans-
developed. This was accomplished by placing the donor heart plantation is related in part to the discovery of cyclosporine
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above the dog’s own heart, and then with a series of tubes by workers at the Sandoz Laboratory in Basel, Switzerland,
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and connections, he rerouted the blood from one heart to the in 1970. In December of 1980, cyclosporine was introduced
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Part I Fundamentals

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at Stanford for cardiac transplantation. The incidence of at almost the same time and in the same location by different
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rejection was not reduced, nor was the incidence of infec- groups. On September 5, 1984, in San Francisco,164 Donald

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tion. However, these two major complications of cardiac Hill implanted a Pierce-Donachy LVAD in a patient in car-

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transplantation were less severe when cyclosporine was used. diogenic shock. The patient received a successful transplant
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Availability of cyclosporine stimulated many new programs 2 days later and was discharged subsequently. The assist device
across the United States in the mid-1980s. used by Hill was developed at Pennsylvania State University by
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The first human lung transplant was performed by Hardy Pierce and Donachy. Phillip Oyer and colleagues at Stanford
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and colleagues156 at the University of Mississippi on June 11,
1964. The patient died on the 17th postoperative day. In
1971, a Belgian surgeon, Fritz Derom, achieved a 10-month
survival in a patient with pulmonary silicosis.157
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University placed an electrically driven Novacor LVAD in a
patient in cardiogenic shock on September 7, 1984.165 The
patient was transplanted successfully and survived beyond
3 years. The device used by the Stanford group was developed

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Much of the credit, however, for the success of lung trans- by Peer Portner.
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plantation belongs to the Toronto group, whose efforts were The first implantation of a permanent totally artificial

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headed by Joel Cooper. Their successes were based on labora- heart (Jarvik-7) was performed by DeVries and colleagues
tory experimentation and the discovery of cyclosporine. After at the University of Utah in 1982.166 By 1985, they had
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losing an early patient to bronchial anastomotic dehiscence implanted the Jarvik in four patients, and one survived for
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in 1978, the group substituted cyclosporine for cortisone and 620 days after implantation. This initial clinical experience
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wrapped the bronchial suture line with a pedicle of omentum. was based heavily on the work of Kolff and colleagues.
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They also developed a comprehensive preoperative preparation
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program that increased the strength and nutritional status of
the recipients. In 1986, Cooper and associates presented their
THORACIC AORTA SURGERY
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first two successful patients, who had returned to normal activ-
ities and were alive 14 and 26 months after operation.158
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Alexis Carrel was responsible for one of the great surgical
advances of the twentieth century: techniques for suturing
and transplanting blood vessels.167 Although Carrel initially

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developed his methods of blood vessel anastomosis in Lyon,
HEART ASSIST AND ARTIFICIAL France, his work with Charles Guthrie in Chicago led to many
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major advances in vascular, cardiac, and transplantation sur-
HEARTS
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gery. In a short period of time, these investigators perfected
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In 1963, Kantrowitz and colleagues reported the first use of techniques for blood vessel anastomoses and transposition
the intra-aortic balloon pump (IABP) in three patients.159 of arterial and venous segments using both fresh and frozen
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All were in cardiogenic shock but improved during balloon grafts. After leaving Chicago, Carrel continued to expand his
pumping. One survived to leave the hospital. work on blood vessels and organ transplantation and in 1912
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In 1963, Liotta and colleagues reported a 42-year-old man received the Nobel Prize. Interestingly, Carrel’s work did not
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who had a stenotic aortic valve replaced but suffered a cardiac receive immediate clinical application.
arrest the following morning.160 The patient was resuscitated Rudolph Matas pioneered clinical vascular surgery. Matas’
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but developed severe ventricular failure. An artificial intratho-
racic circulatory pump was implanted. The patient’s pulmo-
nary edema cleared, but he died 4 days later with the pump
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work took place before drugs were available to prevent blood
clotting, before antibiotics, and without reliable blood ves-
sel substitutes.168 Matas performed 620 vascular operations

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working continuously. In 1966, the same group used a newer between 1888 and 1940. Only 101 of these were attempts to
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intrathoracic pump to support another patient who could not repair arteries; most involved ligation. Matas developed three
be weaned from cardiopulmonary bypass. This pump main- variations of his well-known endoaneurysmorrhaphy proce-
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tained the circulation. The patient eventually died before the dure. The most advanced was to reconstruct the wall of the
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pump could be removed.161 Later that year, the same group

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blood vessel from within while using a rubber tube as a stent.
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used a left ventricular assist device (LVAD) in a woman who Vascular surgery advanced tentatively during World War II
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could not be weaned from cardiopulmonary bypass after dou- as traumatic injuries to major blood vessels were repaired in
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ble valve replacement.162 After 10 days of circulatory assistance, some soldiers with results significantly better than with the
the patient was weaned successfully from the device and recov- standard treatment of ligation.169 The successful treatment of
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ered. This woman was probably the first patient to be weaned coarctation of the aorta by Crafoord and Gross added a major
from an assist device and leave the hospital. boost to the reconstructive surgery of arteries.
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The first human application of a totally artificial heart was Shumaker reported the excision of a small descending
by Denton Cooley and colleagues as a “bridge” to transplan- thoracic aortic aneurysm with reanastomosis of the aorta in
tation.163 They implanted a totally artificial heart in a patient 1948.170 Swan and colleagues171 repaired a complex aneurys-
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who could not be weaned from cardiopulmonary bypass. mal coarctation and used aortic homograft for reconstruc-
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After 64 hours of artificial heart support, heart transplan- tion in 1950. Gross172 reported a series of similar cases using
tation was performed, but the patient died of Pseudomonas homograft replacement. In 1951, DuBost and colleagues173
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pneumonia 32 hours after transplantation. The first two in Paris resected an intra-abdominal aortic aneurysm with
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patients bridged successfully to transplantation were reported homograft replacement.

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Chapter 1 History of Cardiac Surgery

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In 1953, Henry Bahnson,174 from Johns Hopkins, suc- the aortic prosthesis into the tube graft and used the Wheat
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cessfully resected six saccular aneurysms of the aorta in eight technique for implanting the coronary arteries into the com-

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patients. In the same year, DeBakey and Cooley175 reported posite graft.

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a 46-year-old man who had resection of a huge aneurysm of Since the early 1990s, stents also have been used for the
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the descending thoracic aorta that measured approximately treatment of aneurysms in both the descending aorta and the
20 cm in length and in greatest diameter. The aneurysm was abdominal aortas.187, 188
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resected and replaced with an aortic homograft approximately The first thoracic stent placed in a patient’s thoracic aorta
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15 cm in length.
During the Korean War, the arterial homograft and autog-
enous vein graft were used to reconstruct battlefield arterial
injuries and reduce the overall amputation rate to 11.1%176
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was performed to treat a false aneurysm after a coarcta-
tion of the aorta repair.189 The procedure was carried out at
Stanford University Hospital in July 1992 by Michael Drake
and D. Craig Miller. Since then, the indications for using

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compared with the rate of 49.6% reported in World War II. thoracic stent grafts have gradually expanded and include
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Although the vein autograft remains the first-choice periph- transected aortas, aneurysms, penetrating atherosclerotic

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eral vascular conduit today, the arterial homograft was super- ulcers, and intramural hematomas of the descending aorta.
seded by the development of synthetic vascular grafts by The long-term follow-up with these stents still needs to be
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Arthur Voorhees at Columbia University in 1952. Voorhees better defined.190–193
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and colleagues developed Vinyon-N cloth tubes to substitute
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for diseased arterial segments.177

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Another advance in aortic surgery appeared in 1955 when REFERENCES
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DeBakey and colleagues178 reported six cases of aortic dissec- 1. Williams DH: Stab wound of the heart, pericardium—Suture of the
tion treated by aggressive surgery. Because mortality of opera- pericardium—Recovery—Patient alive three years afterward. Med Rec
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tion for acute dissections remained high, Myron Wheat Jr. 1897;1.
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Michael DeBakey, Denton Cooley, Stanley Crawford, and 1907;83:723. Quoted from Beck CS: Wounds of the heart: the technic
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4. Hill LL: A report of a case of successful suturing of the heart, and table
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descending aorta, and thoracoabdominal aorta.181 Cardiopul- terminations, and the conclusions drawn. Med Rec 1902;2:846.
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monary bypass was used for the ascending aortic resections.
The high risk of paraplegia highlighted a major complica-
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5. Harken DE: Foreign bodies in and in relation to the thoracic blood
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bodies from the chambers of the heart. Surg Gynecol Obstet 1946;83:117.

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tion of thoracoabdominal aortic resections. The Houston 6. Kirschner M: Ein durch die Trendelenburgische operation geheiter fall
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von embolie der art. pulmonalis. Arch Klin Chir 1924;133:312.
cardiopulmonary bypass in 1957 and replace the arch with 7. Gibbon JH: Artificial maintenance of circulation during experimental
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a reconstituted aortic arch homograph.182 More interesting is
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occlusion of pulmonary artery. Arch Surg 1937;34:1105.
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large aortic arch aneurysm that also involved a portion of the report. Ann Surg 1962;156:1.
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bypass, by first sewing in a temporary graft from the ascend- 11. Forssmann W: Catheterization of the right heart. Klin Wochenshr
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ing aorta to the distal descending aorta and sewing in two 1929;8:2085.
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more temporary limbs off that graft, which were anastomosed
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Dtsch Ges Kreislaufforschung 1951;17:1.
to the left and right carotid arteries, while the aneurysm was 13. Klein O: Zur bestimmung des zirkulatorischen minutenvoumnens
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resected and a permanent graft was placed.183 beim menschen nach dem fisckschen prinzip. Meunsch Med Wochenschr
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In 1968, Bentall and De Bono184 introduced replacement

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rechten herzens and der lungenschlagader. Muensch Med Wochenschr

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the coronary ostia to the replacement graft. They described 1931;78:489.

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1913 (London, 1914), 7; Surgery 1914;2:249.

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Part I Fundamentals

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of the Heart
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Michael R. Mill • Robert H. Anderson • Lawrence H. Cohn
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A thorough knowledge of the anatomy of the heart is a pre- to the heart during blunt trauma and is aided by the cushion-
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requisite for the successful completion of the myriad proce- ing effects of the lungs.
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dures performed by the cardiothoracic surgeon. This chapter
describes the normal anatomy of the heart, including its
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position and relationship to other thoracic organs. It also The Pericardium and Its Reflections
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describes the incisions used to expose the heart for various
operations and discusses in detail the cardiac chambers and
valves, coronary arteries and veins, and the important but
surgically invisible conduction tissues.
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The heart lies within the pericardium, which is attached to the
walls of the great vessels and the diaphragm. The pericardium
can be visualized best as a bag into which the heart has been

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placed apex first. The inner layer, in direct contact with the
heart, is the visceral epicardium, which encases the heart and
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OVERVIEW extends several centimeters back onto the walls of the great
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vessels. The outer layer forms the parietal pericardium, which
Location of the Heart Relative to
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lines the inner surface of the tough fibrous pericardial sack. A
Surrounding Structures thin film of lubricating fluid lies within the pericardial cavity
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between the two serous layers. Two identifiable recesses lie
The overall shape of the heart is that of a three-sided pyra- within the pericardium and are lined by the serous layer. The
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mid located in the middle mediastinum (Fig. 2-1). When first is the transverse sinus, which is delineated anteriorly by
viewed from the heart’s apex, the three sides of the ventricu-
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the posterior surface of the aorta and pulmonary trunk and
lar mass are readily apparent (Fig. 2-2). Two of the edges are posteriorly by the anterior surface of the interatrial groove.
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named. The acute margin lies inferiorly and describes a sharp
angle between the sternocostal and diaphragmatic surfaces.
The obtuse margin lies superiorly and is much more diffuse.
The posterior margin is unnamed but is also diffuse in its
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The second is the oblique sinus, a cul-de-sac located behind
the left atrium, delineated by serous pericardial reflections
from the pulmonary veins and the inferior vena cava.

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transition.
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One-third of the cardiac mass lies to the right of the mid- Mediastinal Nerves and Their
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line and two-thirds to the left. The long axis of the heart is
oriented from the left epigastrium to the right shoulder. The
Relationships to the Heart
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short axis, which corresponds to the plane of the atrioven- The vagus and phrenic nerves descend through the mediasti- fre
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tricular groove, is oblique and is oriented closer to the vertical num in close relationship to the heart (Fig. 2-3). They enter
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than the horizontal plane (see Fig. 2-1). through the thoracic inlet, with the phrenic nerve located
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Anteriorly, the heart is covered by the sternum and the anteriorly on the surface of the anterior scalene muscle and
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costal cartilages of the third, fourth, and fifth ribs. The lungs lying just posterior to the internal thoracic artery (internal
contact the lateral surfaces of the heart, whereas the heart mammary artery) at the thoracic inlet. In this position, the
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abuts onto the pulmonary hila posteriorly. The right lung phrenic nerve is vulnerable to injury during dissection and
overlies the right surface of the heart and reaches to the midline. preparation of the internal thoracic artery for use in coro-
In contrast, the left lung retracts from the midline in the area nary arterial bypass grafting. On the right side, the phrenic
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of the cardiac notch. The heart has an extensive diaphragmatic nerve courses on the lateral surface of the superior vena cava,
surface inferiorly. Posteriorly, the heart lies on the esophagus again in harm’s way during dissection for venous cannula-
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and the tracheal bifurcation and bronchi that extend into the tion for cardiopulmonary bypass. The nerve then descends
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lung. The sternum lies anteriorly and provides rigid protection anterior to the pulmonary hilum before reflecting onto the
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Cohn_ch02_p0021-0042.indd 21 08/05/17 5:26 pm

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Part I Fundamentals

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subclavian artery before ascending out of the thoracic cavity.
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The right vagus nerve continues posterior to the pulmonary

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hilum, gives off branches of the right pulmonary plexus, and

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exits the thorax along the esophagus. On the left, the vagus
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nerve crosses the aortic arch, where it gives off the recur-
rent laryngeal branch. The recurrent nerve passes around the
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arterial ligament before ascending in the tracheoesophageal
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groove. The vagus nerve continues posterior to the pulmo-
nary hilum, gives rise to the left pulmonary plexus, and then
continues inferiorly out of the thorax along the esophagus.
A delicate nerve trunk known as the subclavian loop carries
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fibers from the stellate ganglion to the eye and head. This
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branch is located adjacent to the subclavian arteries bilater-

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ally. Excessive dissection of the subclavian artery during shunt
procedures may injure these nerve roots and cause Horner
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syndrome.
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SURGICAL INCISIONS
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FIGURE 2-1 This diagram shows the heart within the middle medi-
astinum with the patient supine on the operating table. The long axis
Median Sternotomy
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lies parallel to the interventricular septum, whereas the short axis is
perpendicular to the long axis at the level of the atrioventricular valves.
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The most common approach for operations on the heart
and aortic arch is the median sternotomy. The skin incision
is made from the jugular notch to just below the xiphoid

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process. The subcutaneous tissues and presternal fascia are
right diaphragm, where it branches to provide its innerva- incised to expose the periostium of the sternum. The sternum
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tion. In the presence of a left-sided superior vena cava, the is divided longitudinally in the midline. After placement of
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left phrenic nerve is applied directly to its lateral surface. The a sternal spreader, the thymic fat pad is divided up to the
nerve passes anterior to the pulmonary hilum and eventually
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level of the brachiocephalic vein. An avascular midline plane
branches on the surface of the diaphragm. The vagus nerves is identified easily but is crossed by a few thymic veins that
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enter the thorax posterior to the phrenic nerves and course are divided between fine silk ties or hemoclips. Either the left
along the carotid arteries. On the right side, the vagus gives or right or, occasionally, both lobes of the thymus gland are
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off the recurrent laryngeal nerve that passes around the right removed in infants and young children to improve exposure
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FIGURE 2-2 This diagram shows the surfaces and margins of the heart as viewed anteriorly with the patient supine on the operating table (left)
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and as viewed from the cardiac apex (right).

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Cohn_ch02_p0021-0042.indd 22 08/05/17 5:27 pm

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Chapter 2 Surgical Anatomy of the Heart

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FIGURE 2-3 Diagram of the heart in relation to the vagus and phrenic nerves as viewed through a median sternotomy.
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and minimize compression on extracardiac conduits. If a through the pectoralis major muscles to enter the hemithora-
portion of the thymus gland is removed, excessive traction ces through the appropriate intercostal space. The right and
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may result in injury to the phrenic nerve. The pericardium is
opened anteriorly to expose the heart. Through this incision,
operations within any chamber of the heart or on the surface
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left internal thoracic arteries are dissected and ligated proxi-
mally and distally prior to transverse division of the sternum.
Electrocautery dissection of the pleural reflections behind

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of the heart and operations involving the proximal aorta, pul- the sternum allows full exposure of both hemithoraces and
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monary trunk, and their primary branches can be performed. the entire mediastinum. Bilateral chest spreaders are placed
Extension of the superior extent of the incision into the neck to maintain exposure. Morse or Haight retractors are par-
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along the anterior border of the right sternocleidomastoid ticularly suitable with this incision. The pericardium may be
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muscle provides further exposure of the aortic arch and its

branches for procedures involving these structures. Exposure fre
opened anteriorly to allow access to the heart for intracardiac
procedures. When required, standard cannulation for cardio-
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of the proximal descending thoracic aorta is facilitated by pulmonary bypass is achieved easily. This incision is popular
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a perpendicular extension of the incision through the third for bilateral sequential double-lung transplants and heart-
intercostal space. lung transplants because of enhanced exposure of the apical
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pleural spaces. When made in the fourth intercostal space,

the incision is useful for access to the ascending aorta, aortic
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Bilateral Transverse Thoracosternotomy arch, and descending thoracic aorta.

(Clamshell Incision)
The bilateral transverse thoracosternotomy (clamshell incision)
Anterolateral Thoracotomy
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is an alternative incision for exposure of the pleural spaces and

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heart. This incision may be made through either the fourth or The right side of the heart can be exposed through a right
fifth intercostal space, depending on the intended procedure. anterolateral thoracotomy. The patient is positioned supine,
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After identifying the appropriate interspace, a bilateral sub- with the right chest elevated to approximately 30 degrees by
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mammary incision is made. The incision is extended down a roll beneath the shoulder. An anterolateral thoracotomy
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Cohn_ch02_p0021-0042.indd 23 08/05/17 5:27 pm

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Part I Fundamentals

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incision can be made that can be extended across the midline junction is oriented obliquely, lying much closer to the verti-
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by transversely dividing the sternum if necessary. With the cal than to the horizontal plane. This plane can be viewed

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lung retracted posteriorly, the pericardium can be opened just from its atrial aspect (Fig. 2-4) if the atrial mass and great

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anterior to the right phrenic nerve and pulmonary hilum to arteries are removed by a parallel cut just above the junction.
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expose the right and left atria. The incision provides access The tricuspid and pulmonary valves are widely separated by
to both the tricuspid and mitral valves and the right coro- the inner curvature of the heart lined by the transverse sinus.
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nary artery. Cannulation may be performed in the ascend- Conversely, the mitral and aortic valves lie adjacent to one
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ing aorta and the superior and inferior venae cavae. Aortic
cross-clamping, administration of cardioplegia, and removal
of air from the heart after cardiotomy are difficult with this
approach. This incision is particularly useful nonetheless for
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another, with fibrous continuity of their leaflets. The aortic
valve occupies a central position, wedged between the tricus-
pid and pulmonary valves. Indeed, there is fibrous continuity
between the leaflets of the aortic and tricuspid valves through

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performance of the Blalock-Hanlon atrial septectomy or valve the central fibrous body.
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replacement after a previous procedure through a median With careful study of this short axis, several basic rules of

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sternotomy. A left anterolateral thoracotomy performed in a cardiac anatomy become apparent. First, the atrial chambers
similar fashion to that on the right side may be used for iso- lie to the right of their corresponding ventricles. Second, the
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lated bypass grafting of the circumflex coronary artery or for right atrium and ventricle lie anterior to their left-sided coun-
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left-sided exposure of the mitral valve. terparts. The septal structures between them are obliquely ori-
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ented. Third, by virtue of its wedged position, the aortic valve

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Posterolateral Thoracotomy is directly related to all the cardiac chambers. Several other
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significant features of cardiac anatomy can be learned from
A left posterolateral thoracotomy is used for procedures the short-axis section. The position of the aortic valve mini-
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involving the distal aortic arch and descending thoracic aorta.
With left thoracotomy, cannulation for cardiopulmonary
bypass must be done through the femoral vessels. A number
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mizes the area of septum where the mitral and tricuspid valves
attach opposite to each other. Because the tricuspid valve is
attached to the septum further toward the ventricular apex

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of variations of these incisions have been used for minimally than the mitral valve, it seems that a muscular atrioventricu-
invasive cardiac surgical procedures. These include partial ster- lar septum interposes between the right atrium and the left
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notomies, parasternal incisions, and limited thoracotomies. ventricle. We now know that a continuation of the inferior
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atrioventricular groove interposes between the atrial and ven-
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tricular walls in this area, so that it is a sandwich rather than
RELATIONSHIP OF THE CARDIAC a true septum, with the fibro-adipose tissue of the atrioven-
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tricular groove forming the “meat” in the sandwich. The cen-
CHAMBERS AND GREAT ARTERIES tral fibrous body, where the leaflets of the aortic, mitral, and
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The surgical anatomy of the heart is best understood when the tricuspid valves all converge, lies cephalad and anterior to the
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position of the cardiac chambers and great vessels is known muscular atrioventricular sandwich. The central fibrous body
in relation to the cardiac silhouette. The atrioventricular is the main component of the fibrous skeleton of the heart
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FIGURE 2-4 This dissection of the cardiac short axis, seen from its atrial aspect, reveals the relationships of the cardiac valves.
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Cohn_ch02_p0021-0042.indd 24 08/05/17 5:27 pm

Another random document with
no related content on Scribd:
ricondurla a bordo quando non poteva accompagnarla lei stessa o
quando il padre non poteva venirla a prendere.
Qual cambiamento nella signora Agnese! Non serbava la minima
traccia di quell’alterigia che i miei colleghi le rimproveravano ad una
voce; non aveva più quell’aria tra uggita e sprezzante che io pure
avevo notata in lei; era affabile, espansiva, sempre dolce di modi,
spesso col sorriso sul labbro. Ed ella era la prima a riconoscere
questa sua trasformazione, e ne dava il merito all’Ofelia. — È così
buona, — diceva, — che si diventa buoni a starle insieme. Già i
bambini sono una gran benedizione del cielo.... È incomprensibile
che ci sia della gente che non li può soffrire, o che tutt’al più li tollera
come una molestia necessaria.... Ah se non ci fossero, sarebbe pur
triste il mondo!
Non duravo fatica a darle ragione.
Ed ella seguitava: — Anche a lei, Ceriani, piacciono i bambini.... Si
vede subito.... E non è mai sprecato l’affetto che si ha per loro.... Li
dicono interessati, egoisti.... Non è vero.... Son meglio di noi
grandi.... Noi altri invece ripaghiamo spesso l’amore con
l’indifferenza, l’indifferenza con l’amore.... A loro ciò non accade....
Essi amano chi li ama.... L’Ofelia le vuol bene, sa?
Di tratto in tratto la signora Agnese sospirava: — Se avessi avuto
figliuoli...!
Un giorno mi arrischiai a dirle! — Ne avrà.... È tanto giovine.
Ella tentennò tristamente il capo e i suoi occhi s’inumidirono.
Io assistevo a un dramma domestico, a un dramma semplice e
toccante, quantunque non vi fosse in gioco nessuna di quelle che si
ha l’abitudine di chiamar forti passioni. Non l’adulterio con le sue
febbri, non la gelosia co’ suoi furori, non l’ambizione con le sue
inquietudini. Due persone nel fiore degli anni, certo con diversità
notevoli d’aspetto e di carattere, ma tutte e due sane di corpo, e con
un gran fondo di rettitudine morale, due persone che s’erano unite
sotto gli auspici più lieti a cui un capriccio della sorte avvelenava
resistenza! Nella moglie un istinto esagerato della maternità che le
rendeva incomportabile il non aver prole; nel marito, che pur si
sarebbe rassegnato a questa sventura, un cruccio, un rodimento
continuo di saper infelice una sposa per la quale egli avrebbe
versato fin l’ultima goccia del proprio sangue, un’acuta mortificazione
di sentirla sempre più fredda, più riluttante fra le sue braccia di mano
in mano che s’affievoliva la speranza di ciò che agli occhi di lei
nobilitava l’amore.
Altri particolari non ricercati, non chiesti, ma sorpresi facilmente sulle
labbra di questo o di quello contribuivano a illuminarmi sullo stato
delle cose. Si alludeva a consulti medici fatti sino dal secondo anno
di matrimonio e ripetuti poi, a cure contradditorie qua e là, ora certi
bagni, ora certe acque, ora la doccia, o il ferro, o l’arsenico. E io mi
figuravo la signora Agnese, lei così poetica, così riservata nei modi,
me la figuravo sottoposta a interrogatorî delicatissimi, offesa ne’ suoi
pudori più intimi senza che il sacrifizio approdasse a nulla. Qual
maraviglia che l’amore non fosse sopravvissuto a queste prove
dolorose, o che almeno esso ne fosse uscito col germe di qualche
male organico ed insanabile?
— Sicuro, — mi diceva il dottor Gandolfi, medico dei Prosperi, —
sicuro, quella che i moralisti chiamano psicologia ha sempre una
base fisiologica. — Ed egli soggiungeva che quest’era veramente un
caso singolare. A nessuno dei due coniugi si poteva imputare la
sterilità del matrimonio. C’erano novanta probabilità su cento che il
marito avesse avuto figliuoli da un’altra moglie e la moglie ne avesse
avuti da un altro marito. A questo punto il dottore ch’era un uomo di
manica larga si divertiva a sciorinar delle teorie molto ardite e a citar
dei versi d’un poeta latino sugli effetti benefici di certi strappi alla
fede coniugale. — Guai però a chi osasse tener questi discorsi alla
signora Agnese! — egli si affrettava a concludere.
Fatto si è che comprendendo le pene, le delusioni della signora
Agnese, vedevo anch’io che era una crudeltà l’insidiarle i suoi pochi
momenti di gioia.
Adesso ell’era beata nella compagnia della gentile Ofelia. A poco a
poco era riuscita a tenersela seco dalla mattina alla sera, la colmava
di regali, la conduceva in gondola, a passeggio, tirandosi dietro, che
già s’intende, l’inseparabile cane di Terranuova. Se il capitano
Atkinson faceva qualche osservazione, ella gli dava sulla voce. —
Non sia cattivo, si tratta di pochi giorni. — E intanto lo invitava
spessissimo a colazione e a pranzo.
— Curioso tipo quella Prosperi, — dicevano i pettegoli di caffè. —
Sempre con quella bambina cascata dalle nuvole! E co’ suoi gusti
aristocratici, col suo fare schizzinoso, ha per unici commensali un
capitano mercantile e un semplice commesso.
Il commesso ero io. Quando c’era l’Ofelia, la signora Agnese mi
tratteneva sovente a desinare.
Una mattina ella mi pregò di fissarle un’ora dal fotografo. Voleva far
fare un gruppo dell’Ofelia e di Tom. Ma badassi di non parlare della
cosa nè con suo marito, nè con Master Atkinson, nè con altri.
Doveva essere un’improvvisata.
Poche sere dopo, a tavola, il capitano trovò sotto il tovagliuolo una
copia della bellissima fotografia, e fu una gradita sorpresa. La
signora Agnese magnificò la discrezione dell’Ofelia. Una bimba di
quell’età, non essersi lasciata scappare una parola! Era un prodigio.
E in un impeto di tenerezza si alzò dalla seggiola e andò ad
abbracciar la fanciulla. Nel tornar al suo posto aveva le lacrime agli
occhi; Prosperi, inquieto, non sapeva staccar lo sguardo da lei.
Gli è che l’idillio s’avvicinava alla fine. Eravamo al mercoledì e la
partenza del King Arthur era stabilita per sabato.
Ora la sera di quello stesso mercoledì, mentre il capitano Atkinson
stava per accommiatarsi, la signora Agnese, stringendogli forte la
mano, gli disse con una certa esaltazione: — Quanto durerà il suo
viaggio, fra andata e ritorno?
— Non più di cinque mesi, spero.
— Ebbene, vuol fare una bella cosa?... Affidi a noi l’Ofelia per questi
cinque mesi....
— Ma, Agnese.... — interruppe il signor Roberto. — come puoi
domandare a Master George di privarsi della sua figliuola?
— Oh lo sa anche lui che non potrà condurla sempre in giro pel
mondo....
— Appunto per questo la vorrà seco adesso, — replicò Prosperi, —
evidentemente infastidito dal ghiribizzo saltato in capo a sua moglie.
La signora Agnese insistette. — Non lo si sforza mica. Sentiamo
quel che ne pensa lui.... lui e l’Ofelia.
S’era chinata sulla bimba per agganciarle i bottoni del soprabitino e
le susurrava in tono carezzevole: — Non è vero, Ofelia, che
resteresti volentieri con la zia Agnese?
Per l’Ofelia il restar con la zia Agnese significava andar a spasso
ogni giorno, far baldoria con Tom in giardino, aver sempre nuovi
balocchi da ammirare e da rompere, tutte cose piene di attrattive per
lei. Ma l’idea di separarsi per un pezzo dal padre non entrava nella
sua testolina, ed ella espresse ingenuamente il suo pensiero: — Con
la zia Agnese, col babbo e con Tom.
Il capitano Atkinson frattanto ringraziava la signora Prosperi
dell’ospitalità ch’ella offriva all’Ofelia.... L’avrebbe affidata a lei come
a una seconda mamma.... e avrebbe viaggiato sicuro, tranquillo,
anche per qualche anno di seguito.... In quel momento però temeva
che quella compagnia gli fosse necessaria.... Non s’era rimesso
ancora dal dolore per la perdita della moglie, e la sua unica
consolazione era quella di aver presso di sè la soave creaturina che
nella voce, nei lineamenti gli ricordava la sua povera morta.
Parlava commosso, agitato, cercando con gli occhi l’Ofelia di cui la
signora Agnese era sempre occupata ad agganciare i bottoni con
mano incerta e febbrile.
Forse la bimba sentì quello sguardo appassionato che l’avvolgeva;
fatto si è ch’ella si staccò dolcemente dalla zia, dicendo: — Lascia
finire al babbo: ha più pratica....
La signora Agnese vedeva svanire il suo sogno.
— Capisco, — ella balbettò in risposta a Master Atkinson, —
capisco.... Ma non mi dia subito una negativa assoluta.... Rifletta fino
a domani.... La notte porta consiglio.
Ella diceva così, ma in fondo non sperava più nulla.
E quando il capitano e l’Ofelia furono usciti ella si abbandonò sulla
poltrona, con la faccia rivolta verso la spalliera e si mise a piangere
dirottamente.
A me parve delicato di lasciar soli marito e moglie e mi dileguai in
silenzio.

III.

Era destino però ch’io non potessi, neppur volendo, tenermi

estraneo alle faccende intime di casa Prosperi. Il giovedì mattina il
principale non venne in banco che tardi e mi chiamò subito nel suo
gabinetto. Era pallido, stravolto. — Ha fatto male ad andarsene
iersera, — egli mi disse. — Forse la sua presenza avrebbe evitato
una scena penosa.
Mi raccontò poi che sua moglie lo aveva investito fieramente perchè
con le sue parole aveva incoraggiato la risposta sfavorevole del
capitano Atkinson, il quale non poteva tener un altro linguaggio dal
momento che le prime difficoltà venivano da una delle persone che
avrebbero dovuto ospitar la sua figliuola.
— In verità, — soggiunse il signor Roberto, — a me sembrava di
avere il diritto di far ben maggiori lagnanze dell’Agnese. Ell’aveva
tirato in campo, senza essersi intesa meco, un argomento
gravissimo, aveva tentato di forzarmi la mano, di vincere per
sorpresa. Pur non le mossi rimprovero di sorta. Mi limitai a spiegarle
le ragioni per le quali io giudicavo assolutamente inopportuna la sua
proposta. È sempre un’immensa responsabilità l’incaricarsi dei
fanciulli che non ci appartengono, ma la cosa può passare quando
se ne conoscono a fondo l’indole, le abitudini, le disposizioni fisiche;
e sopratutto quando se ne conosce a fondo la famiglia. Ora l’Ofelia
si conosceva da pochi giorni, suo padre si conosceva ancora meno
di lei, e in quanto ad altri parenti, fuori della madre ch’era morta,
s’ignorava perfino s’esistessero. E se la bimba s’ammalava in questi
cinque mesi che, nella più favorevole ipotesi, sarebbe durato il
viaggio del capitano Atkinson? Se, con la volubilità dell’età sua,
domandava di tornar col suo babbo mentr’egli era lontano migliaia di
miglia?... Ma supposto invece che tutto andasse pel meglio, come
mai l’Agnese non aveva considerato che il separarsi dall’Ofelia dopo
cinque mesi di convivenza le sarebbe riuscito più grave che il
separarsene adesso? Poichè non si poteva supporre che il capitano
rinunziasse addirittura a sua figlia; e quand’egli vi avesse rinunziato
si sarebbe dovuto pensarci su molto da parte nostra prima di
risolverci a tenerla per un tempo indefinito....
Devo aver fatto un movimento inconsciente che il signor Roberto
prese per l’atto di chi si accinge a sollevare un’obbiezione. E
s’interruppe per dirmi: — Parli pure liberamente, Ceriani. Se ha
un’opinione diversa dalla mia, non abbia riguardo a
manifestarmela.... Le assicuro; quasi quasi vorrei aver torto.
Lo disingannai. I suoi argomenti mi parevano inappuntabili. — E la
signora? — chiesi.
— Ah, giovinotto mio, — egli rispose — le donne non discutono con
le ragioni, ma con le lacrime, ma con gli attacchi di nervi.... E questa
è la loro forza.... le ragioni di mia moglie erano deboli, ma il suo
pianto mi spezzava il cuore.... E al sentirla, in mezzo ai singhiozzi,
chiamar Dio in testimonio ch’ella non desiderava, nè aveva mai
desiderato nulla che non fosse onesto, a sentirla invidiar la sorte
della donnicciuola del popolo che tornando dal lavoro trova un bimbo
che le sorride e le stende le braccia e balbetta l’ineffabile parola
mamma, io provavo una gran tentazione di gettarmele ai piedi e di
domandarle perdono o di prometterle tutto quello che ella voleva.
Non lo feci per orgoglio, per puntiglio.... Ella stette male tutta la notte
cosicchè stamattina feci venire Gandolfi, il nostro dottore, e prima e
dopo la visita medica parlai con lui delle cause che avevano
provocato questa crisi, la quale, del rimanente, non ha nessuna
gravità. Ebbene, caro Ceriani, Gandolfi non è alieno dal credere che
la vicematernità, com’egli la chiama col suo frasario originale,
sarebbe forse il rimedio più efficace allo squilibrio nervoso della mia
Agnese. Anzi, nello stato presente delle cose, egli la ritiene
preferibile alla maternità vera che in un organismo già scosso porta
sempre gravi pericoli. Insomma, secondo lui, sarebbe stato miglior
consiglio non contraddire ai desideri di mia moglie e veder di
persuadere il capitano Atkinson a lasciar qui la bambina o durante
questo, o durante un suo prossimo viaggio.... Eccomi in un
bell’impiccio, perchè, lo confesso, le parole del dottore non mi hanno
convertito che a mezzo e i miei dubbi restano intatti.... Ma d’altra
parte se c’è un modo di ridar all’Agnese la serenità, la pace
dell’animo, mi è lecito ostinarmi nella mia negativa?... Chi sa?... La
soluzione intermedia accennata da Gandolfi, quella cioè di aver qui
l’Ofelia durante un prossimo viaggio, potrebb’esser la buona. Se
l’Agnese si acquetasse a una promessa formale del capitano in
questo senso?... Perchè già è chiaro che, subito, egli non ci
confiderebbe l’Ofelia quando pur gliela ridomandassimo.... Ah,
Ceriani, — conchiuse il signor Roberto con un sorriso triste —
prevedo che avrò bisogno dell’opera sua.
— Disponga — risposi. — Ma come?
— Per tasteggiare il capitano meglio che non possa farlo io col mio
sciagurato inglese.... e anche per dir qualche parolina all’Agnese ove
se ne presenti l’opportunità.... L’Agnese ha molta stima di lei.... E
tutti e due, sa, mia moglie ed io, la consideriamo ormai come uno di
famiglia....
Chinai il capo ringraziando.
Alle corte, non seppi esimermi da quest’ufficio di negoziatore che mi
piombava sulle spalle. E riuscii oltre all’aspettativa. Così parve allora
agli altri, così pareva a me stesso.... Più tardi, di fronte ad
avvenimenti imprevisti, si levarono in me degli scrupoli, dei rimorsi....
Usando una maggiore insistenza con Master Atkinson avrei forse
potuto ottenere.... quest’idea non mi vuole uscir dalla mente....
ch’egli aderisse alla primitiva richiesta della signora Agnese, nel qual
caso si sarebbero evitati dei grossi guai.... Basta; si rimase
d’accordo col capitano che se al suo ritorno dal Giappone i signori
Prosperi fossero stati ancora disposti a tenersi per qualche tempo
l’Ofelia egli l’avrebbe affidata a loro durante il nuovo viaggio da
Venezia a Singapore e da Singapore a Liverpool che secondo
l’ultima lettera de’ suoi armatori era definitivamente stabilito. I signori
Prosperi s’impegnavano poi, a viaggio compiuto, di riaccompagnare
o far riaccompagnare la bimba a Liverpool.
Quella clausola dubitativa se i signori Prosperi fossero stati ancora
disposti, destò l’ammirazione del signor Roberto. — È un tratto di
diplomazia sopraffina — egli esclamò. — In cinque mesi possono
succedere tante cose.... e va bene non aver legate le mani.
Non era presumibile che la signora Agnese facesse un’accoglienza
ugualmente festosa a questa specie di compromesso. Ciò ch’ella
desiderava era di non separarsi dall’Ofelia, le cui grazie ingenue
avevano conquistato il suo cuore. Invece le toccava separarsene
tosto per non riaverla che di lì ad alcuni mesi, e per alcuni mesi
soltanto, col patto espresso di restituirla al padre in un termine non
breve ma certo non lunghissimo. A ogni modo, sia ch’ella si fosse
convinta dell’impossibilità di ottener maggiori concessioni, sia che
sperasse di convertir l’atto della restituzione in una semplice visita
della figliuola al babbo, ella fu più ragionevole ch’io non avrei
creduto. Mi ringraziò della parte presa in questa faccenda e si
mostrò riconoscente anche al marito di ciò ch’egli aveva fatto per
compiacerla.
Giunse così il sabato, giorno della partenza. S’era convenuto di
recarci a bordo, i coniugi Prosperi ed io, la mattina per tempo, e di
trattenerci non solo finchè il King Arthur avesse levato le áncore, ma
finch’esso fosse arrivato a Malamocco. Là si sarebbe scesi per
tornare a Venezia col vapore che viene da Chioggia.
Il programma fu eseguito appuntino. Eravamo sul bastimento poco
dopo le otto antimeridiane, e mi par sempre di veder l’Ofelia correrci
incontro sul ponte co’ suoi bei capelli biondi che le ondeggiavano
sulle spalle e con Tom che le galoppava a fianco. Ell’aveva un
vestito di mussola bianca stretta alla vita da una cintura di seta nera
e con due nastri pur neri svolazzanti sugli omeri. Erano nere anche
le scarpine e le calze. Ella saltò al collo della signora Agnese
baciandola e ribaciandola, ma non perdendo d’occhio un
grossissimo involto che uno dei marinai aveva ricevuto da Beppi, il
gondoliere, e portava su per la scaletta. Quando poi l’involto fu
aperto e ne uscirono sei o sette scatole e scatolini, e quando il
prezioso contenuto delle scatole fu messo in mostra sulla coperta,
l’entusiasmo della bimba non ebbe confine. Erano balocchi d’ogni
specie che la signora Agnese regalava alla sua piccola amica, e fra
questi primeggiavano una magnifica bambola che chiamava mamma
e papà, e un can barbone che moveva la testa, apriva la bocca e
alzava le zampe anteriori, con grande ira di Tom, non ben sicuro se
avesse dinanzi a sè un fantoccio o un rivale in carne ed ossa.
Si fece colazione prima che il King Arthur si movesse dal Canale
della Giudecca, perchè il capitano voleva essere sul ponte del
comando al momento della partenza. Alle frutta Master Atkinson
bevette alla salute del signor Roberto e della signora Agnese
ringraziandoli dell’infinite cortesie usate a lui e all’Ofelia e pregandoli
di accettare un esemplare, uno dei due che gli restavano (l’altro era
quello che avevamo visto appeso nell’anticamera della sua cabina),
della fotografia del King Arthur fatta fare a Liverpool alla vigilia del
suo ultimo viaggio. Per lui quella fotografia aveva un pregio
singolarissimo. In un gruppo di figurine appena percettibili che si
vedevano raccolte sul castello di poppa c’era anche sua moglie.
Naturalmente egli solo sarebbe riuscito a distinguerla, ma forse
appunto per questo la fotografia gli era più cara. Pregava i signori
Prosperi di serbarla per ricordo suo. Rispose il signor Roberto nel
miglior inglese che gli fu possibile, accettando il dono con animo
riconoscente e augurando prosperi l’andata e il ritorno al King Arthur.
— Siamo al 5 di aprile, — egli disse. — Speriamo di trovarci qui uniti
di nuovo il 5 di settembre.
Durante questo scambio di brindisi la signora Agnese s’era presa
sulle ginocchia l’Ofelia e tenendosela stretta al cuore le susurrava
dolci parole e le discorreva di ciò che avrebbero fatto insieme
nell’autunno, a viaggio finito.
Risalimmo sopra coperta, e di lì a pochi minuti il King Arthur lasciò la
banchina e si diresse alla volta di Malamocco. Dietro di noi Venezia
s’impiccoliva e sfumava come un quadro dissolvente.
In vicinanza del porto il vapore rallentò la sua corsa, e una barca
s’avvicinò alla scaletta. Bisognava separarsi.
Ancora una volta l’Ofelia si aggrappò al collo della signora Agnese.
— Vieni con noi — le diceva — vieni con noi.... Noi dobbiamo
tornare.... Tornerai anche tu.
E poichè il signor Roberto si era accostato alla moglie per sollecitarla
— Va via tu solo — gridò la fanciulla. — Cattivo, che vorresti la zia
Agnese tutta per te.
Vi furono di nuovo baci, lacrime e strette di mano in quantità. Alla
fine noi prendemmo posto nella barca che ci attendeva, il vapore
ripigliò la sua rotta.
S’agitarono i fazzoletti; l’Ofelia, sollevata sulle braccia dal padre,
mandava baci alla zia; Tom girava su e giù pel ponte abbaiando. Il
King Arthur oltrepassò presto la diga e scomparve; per qualche
minuto si vide ancora una striscia di fumo nel cielo azzurro; si udì, o
si credette udire, il vocione di Tom; poi non si udì e non si vide più
nulla.

· · · · · · · · · · · · · · · ·

IV.

Se il signor Roberto sperava che con la partenza del King Arthur

sbollissero gli ardori di sua moglie per la figliuola del capitano
Atkinson, la sua era proprio una speranza campata in aria. L’Ofelia
non c’era, ma la signora Agnese ne parlava come d’un’assente che
non si sarebbe fatta aspettare troppo e a cui bisognava
apparecchiare gli alloggi. Ne aveva sempre sotto gli occhi la
fotografia, divisava seco medesima mille cose da effettuarsi al
ritorno della fanciulla, le modificazioni che avrebbe introdotte nella
distribuzione della giornata, la cameretta che le avrebbe assegnata,
la bambinaia che le avrebbe presa, le lezioni d’italiano che le
avrebbe date lei stessa. Non voleva più dubitare di nulla; nè
dell’assenso del capitano a rinunciare per sempre all’Ofelia, nè di
quello di suo marito a tenerla definitivamente presso di sè, nè della
buona riuscita ch’ella avrebbe fatto nelle sue mani. L’antico sogno, il
sogno dolcissimo di diventar madre davvero cedeva il posto alla
singolare fantasia di questa maternità fittizia.
Il signor Roberto tentennava il capo e si rimproverava la sua
debolezza. Quest’è il modo di disfar la famiglia — lo intesi dire un
giorno al dottor Gandolfi. — È già male che una donna trascuri il
marito per non pensare che ai propri figliuoli: peggio ancora che lo
trascuri pei figliuoli degli altri.
— In massima avete ragione — replicò quello scettico del dottore; —
ma in casa l’essenziale è di aver la pace.... Se vostra moglie ve la dà
a queste condizioni, accettatela con gratitudine; e tutt’al più....
cercatevi qualche svago.... Gli svaghi sono le valvole di sicurezza
del matrimonio....
Dal suo punto di vista medico, Gandolfi era contentissimo che la sua
cliente si fosse scossa dal torpore doloroso in cui era immersa da un
pezzo. Ed egli levava a cielo la combinazione da lui suggerita e in
virtù della quale la signora Agnese aveva cinque mesi da pregustar
la sua gioia. — E i beni che si sperano — notava il dottore filosofo —
ci danno sempre maggior voluttà dei beni che si hanno. Se quella
bimba fosse qui adesso, la signora Agnese comincierebbe già a
crucciarsi pensando al momento di perderla; invece ella è felice
pensando a quello di trovarla.
È innegabile che la signora Agnese, appunto facendo assegnamento
sul non lontano ritorno dell’Ofelia, s’era rimessa prestissimo dalla
commozione provata alla partenza del King Arthur. Era sempre in
moto, sempre vispa e gioviale. Cosa insolita, la vedevamo
spessissimo in banco. Ci veniva con mille pretesti, ma in fondo non
le stava a cuore che una cosa sola; saper s’erano giunte notizie del
capitano Atkinson, il quale aveva promesso di scrivere anche prima
del suo arrivo a Hiogo.
E scrisse in fatti da Suez parlando a lungo dell’Ofelia che aveva
continuamente in bocca la zia Agnese e dichiarava con grande
solennità di voler mandarle una lettera. A tal fine prendeva un pezzo
di carta, vi tracciava col lapis alcuni geroglifici, lo piegava in due e lo
consegnava al padre con l’incarico di spedirlo a Venezia. L’Ofelia,
seguitava il capitano, era buona e savia e consacrava ogni giorno
un’oretta a combinar le parole coi caratteri mobili, sperando di
ricevere e decifrare da sè qualche riga della zia Agnese. Alla quale
la bimba faceva sapere che Tom era in castigo perchè in un impeto
di gelosia aveva spezzato in due il cane barbone, credendolo vivo.
Infine, sempre per incarico della figliuola, il capitano assicurava la
signora che la puppatola era benissimo conservata; solo che la sua
voce cominciava a indebolirsi e diceva mamma e papà con meno
enfasi di prima.... forse, osservava l’Ofelia, per effetto del mal di
mare.
Si diede immediatamente comunicazione alla signora Agnese di
questa lettera che interessava più lei che la ditta Prosperi e si può
immaginarsi s’ella le facesse festosa accoglienza. Il giorno stesso
ella mi chiamò per consegnarmi un biglietto in nitido stampatello
destinato a
Miss Ophelia Atkinson
to the care of Master George Atkinson
of the english Steamer King Arthur.
Il biglietto venne inchiuso in una lettera nostra al capitano, impostata
la sera stessa per Hiogo.
Ora bisognava rassegnarsi a un lungo silenzio, perchè il King Arthur
proseguiva direttamente pel Giappone senza poggiare a nessun
punto intermedio.
Noi intanto avevamo sollecitato il nostro banchiere di Londra ad
assumere qualche informazione precisa sul conto del capitano
Atkinson, sul suo carattere, sulla sua famiglia, sulla malattia da cui
era morta sua moglie, eccetera, eccetera. La risposta non si fece
attender molto e le informazioni furono, nel complesso, assai
favorevoli. Il capitano Atkinson, nativo di Glasgow, era da otto anni al
servizio degli armatori del King Arthur, i quali non avevano che da
lodarsene. Era uomo probo, intelligente, marinaio arditissimo, più
colto di quello che non sogliono essere le persone della sua classe.
Non aveva parenti prossimi; la moglie gli era morta pochi mesi
addietro di tubercolosi acuta lasciandogli un’unica figliuola in tenera
età che adesso viaggiava con lui.
Il punto nero era questo: la moglie morta di tubercolosi. La possibilità
che la figliuola avesse ereditato i germi della malattia che aveva
ucciso la madre impensieriva il signor Roberto e lo raffermava nella
risoluzione di non permettere che l’Ofelia prendesse stabile dimora
nella sua casa.
Ma di tutto ciò alla signora Agnese non fu tenuta parola. Era inutile
affliggerla fuori di tempo.
In mezzo alle preoccupazioni di vario genere che l’amabile bambina
del capitano Atkinson destava nei coniugi Prosperi era sfumata via la
grande curiosità di saper eseguita dai signori Holiday la
commissione del salottino giapponese. Però, in attesa dei gingilli che
dovevano adornarlo, il salotto d’angolo aveva, per la servitù e pei
padroni, preso già questo nome. Si era ormai avvezzi, domandando
ove fosse la signora, a sentirsi rispondere: — Nel salottino
giapponese. — Ella aveva sempre avuto una predilezione per
questa stanza; adesso vi passava anche più ore del solito, perchè il
resto del palazzo era sossopra a cagione dei ristauri. Invece il
salotto d’angolo pel momento non si toccava, e l’unica novità che vi
fosse era quella delle due fotografie dell’Ofelia e del King Arthur che
la signora Agnese aveva provvisoriamente collocate sopra un
tavolino.
Povera signora Agnese! Me la ricordo seduta presso la finestra,
intenta a ricamare od a leggere. M’aveva incaricato di comperarle
qualche libro che trattasse del Giappone, e le avevo portato tre o
quattro volumi ch’ella sfogliava con avidità.
— Capisco che questo non diventerà mai un salottino giapponese
autentico — ella mi disse un giorno. — Prima di tutto è troppo
grande, e poi vedo qui che veri e propri mobili i giapponesi non ne
usano. Hanno un’infinità di gingilli e ninnoli graziosissimi e stuoie, e
paraventi, e carte colorate, e specchi dipinti, e vasi, e tappeti, ma
non hanno nè sedie, nè tavole, nè armadi, nè letti.... Basta; oggi le
do il tè alla nostra maniera — ella soggiunse sorridendo; —
nell’inverno prossimo le metterò davanti le tazzine e quel fornelletto
di bronzo che i Giapponesi chiamano tribacì e che serve per tenervi
in caldo l’acqua, e lei, accoccolato per terra che ben s’intende, si
leverà d’impiccio come potrà.
Di lì a poco cambiò argomento e mi chiese: — Dove sarà la nostra
piccola viaggiatrice?
— Ma! — risposi. — Non saprei.... A due terzi di cammino.... Nei
mari della China....
— Non vedo l’ora di ricevere l’annunzio telegrafico dell’arrivo a
Hiogo. Perchè il capitano telegraferà subito, non c’è dubbio.... L’ho
tanto pregato....
Io notai che in ogni caso avrebbero telegrafato i signori Holiday.
— Lo so, lo so — ella disse. — Ma non è la stessa cosa. I signori
Holiday non inseriranno nel dispaccio neanche una parola che si
riferisca all’Ofelia.... Questo non c’entra col vostro carico di riso.
Infatti, non c’entrava.
Dopo una breve pausa, la signora Agnese confessò che il suo
trasporto per quella fanciulla meravigliava lei stessa e che suo
marito aveva mille ragioni di rimproverarla di mancar di misura; ma
certe cose non si discutono.... L’Ofelia l’aveva ammaliata.
— E forse — ella continuava — anche Roberto finirà col subirne il
fascino, col desiderare ch’ella non vada più via. Si ha un bel dire:
“L’Ofelia è un’incognita.„ Ma tutti i bambini sono altrettante incognite,
persino i nostri quando ne abbiamo.... E se ci si decide a dare
ospitalità a quelli che non son nostri, il meglio si è che i genitori o
non ci siano, o siano lontani.... L’ho fatto l’esperimento dei figliuoli
dei parenti, degli amici; l’ho fatto nel terzo e quart’anno del mio
matrimonio.... C’era specialmente una bimbetta d’una mia cugina
che si lasciava da noi per due, tre mesi di fila.... Però la madre
veniva ogni tanto a vedersela e allora erano osservazioni su questo,
su quello.... La mia cugina andò a stabilirsi in Francia col marito e
con la figlia, e in quell’occasione io avevo giurato di non voler più
saperne nè di quella bimba, nè di nessun’altra.... Giuramenti da
marinaio.... Son nata mamma!
La signora Agnese si alzò e tendendomi la mano mi disse: — Sarà
mio alleato, non è vero? Patrocinerà la mia causa con mio marito e
col capitano Atkinson?
Balbettai qualche parola ch’ella interpretò nel senso più favorevole, e
m’allontanai col presentimento di essermi messo per una via irta di
triboli.
Questo colloquio era stato tenuto il lunedì o il martedì; la domenica,
almeno una settimana prima di quello che si sarebbe creduto,
giunsero due telegrammi da Hiogo, uno del capitano Atkinson che
avvisava del suo felice arrivo, l’altro dei signori James Holiday e C.,
in cifra, che davano anch’essi la stessa notizia, assicuravano che si
sarebbe posto mano al più presto alla caricazione del riso, e
confermavano una lettera spedita per la posta circa al salottino
giapponese. Non occorre dire che il capitano aveva introdotta nel
dispaccio la frase voluta dalla signora Agnese.
Era il 20 di maggio. Il King Arthur aveva compiuto il suo tragitto in
quarantacinque giorni. Se il ritorno si compiva con una celerità
uguale, accordato anche un mese per la caricazione, il bastimento si
sarebbe rivisto a Venezia ai primi di agosto.
Queste notizie e queste previsioni empirono d’allegria il banco e la
casa. Per la ditta Prosperi l’operazione non poteva presentarsi sotto
migliori auspici e c’era ormai la certezza di vendere tutta la partita
con un larghissimo margine sul prezzo di costo. Era inoltre una vera
compiacenza d’amor proprio l’aver iniziato un nuovo commercio con
quei lontani paesi. Gl’imitatori non sarebbero mancati, e già si
sapeva che i nostri rivali, i fratelli Gelardi, stavano trattando
l’acquisto d’un carico simile al nostro. Poco importava. Per presto
ch’essi facessero non avrebbero ricevuto la merce che un paio di
mesi dopo di noi, e a noi sarebbe sempre rimasto il merito di averli
preceduti.
La signora Agnese si curava mediocremente di tutto ciò; quello che
la colmava di gioia era l’avvicinarsi del momento che la piccola
Ofelia sarebbe stata a Venezia, sua certo per qualche mese, sua
forse per sempre. Per creanza, ella mostrava talvolta di prendere
interesse anche all’affare in sè e indirizzava al signor Roberto mille
domande a cui egli rispondeva evasivamente, con un sorrisetto
scettico. — Via via, — egli le diceva — vorresti negarmi che se il
King Arthur, invece di contenere nella capace sua stiva una
sessantina di mille sacchi di riso, contenesse soltanto una bionda
fanciulla di cinque anni chiamata Ofelia, per te sarebbe
precisamente lo stesso?
Ella protestava. — No, no, lo stesso, no....
— Quasi lo stesso allora — replicava il marito. — Sei contenta così?
Tre settimane dopo i dispacci annunzianti l’arrivo del bastimento ne
giunse un altro importantissimo dei signori Holiday. La caricazione
del riso era terminata; il salottino giapponese era stato incassato e
non mancava che di portarlo a bordo; il capitano si proponeva di
partire al più presto.
Quello fu un giorno di gran lavoro pel banco Prosperi. Si fece una
colossale rimessa di cambiali su Londra ai nostri banchieri Eliot
Green e C., per coprirli delle tratte che i signori Holiday avevano
certo spiccato sopra di loro, e si provvide senza ulteriori indugi alla
sicurtà che fu assunta da più Compagnie per la somma cumulativa
d’un milione di lire in cui era compreso anche l’utile probabile. Il
salottino giapponese venne assicurato a parte per 25 mila lire.
Infine il lunedì 18 giugno 1878 alle cinque pomeridiane (ricordo il
giorno e l’ora) capitò un nuovo e ultimo telegramma, brevissimo, dei
signori Holiday, avvisandoci che il King Arthur era uscito quella
mattina dal porto di Hiogo.
— Non sarebbe da stupirsi — disse qualcuno — se il carico fosse
qui prima delle polizze.
Intanto la posta, ora per la via di Hong-Kong, Singapore e il Mar
Rosso, ora per quella di San Francisco, Nuova York e l’Atlantico,
recò una serie di lettere che i fulminei telegrammi avevano
preceduto. Lettere dei signori Holiday, lettere del capitano Atkinson,
e persino un foglietto per la signora Agnese con tre parole
dell’Ofelia, della quale evidentemente s’era condotta la mano: Many
kisses-Ophelia. E il capitano Atkinson nell’inviar questo prezioso
autografo dava minuti ragguagli sulla sua figliuoletta che non aveva
sofferto nemmeno un’ora di mal di mare e non aveva avuto
nemmeno un capriccio; o a meglio dire ne aveva avuto uno solo,
quello di tener qualche volta il broncio al suo babbo perchè non
faceva venir la zia Agnese. Del resto la zia l’avrebbe trovata
cresciuta di statura e florida d’aspetto. Anche Tom, dopo quella sua
birichinata in principio del viaggio, s’era condotto benissimo. Non
solo aveva adempiuto scrupolosamente ai suoi due uffici di custodir
l’Ofelia e di dar la caccia ai topi, ma s’era altresì reso meritevole di
una decorazione salvando, con lo slanciarsi spontaneamente
nell’acqua, un mozzo che stava per affogare. Figuriamoci, scriveva il
capitano, ciò che farebbe quella buona bestia se, Dio guardi, l’Ofelia
avesse a correre un pericolo analogo!
Una delle lettere dei nostri corrispondenti di Hiogo conteneva un
lungo poscritto relativo al salottino giapponese, poscritto vergato
tutto quanto dalla mano di M. James Holiday in persona, il quale si
dichiarava lietissimo di rendere un piccolo servigio all’egregio signor
Prosperi e alla sua most gracious lady, da lui rammentata con
rispettosa ammirazione. Il detto signore confidava di poter
raccogliere in brevissimi giorni tutti gli oggetti necessari per l’arredo
del salottino, pagandone una somma inferiore a quello che i suoi
amici eran disposti a spendere. Egli si riprometteva eziandio, in un
suo futuro viaggio in Europa, di visitare questo salotto alla cui
formazione egli avrebbe contribuito e di prendervi una tazza di tè,
preparata dalle mani della più gentile signora ch’egli avesse avuto la
fortuna di conoscere ne’ suoi viaggi.
Queste galanterie dettele in faccia sarebbero parse alla signora
Agnese sciocche e dozzinali; avrebbero provocato sulle sue labbra
uno di quei motti freddi ed alteri con cui ella scoraggiava i
corteggiatori, e riusciva, lei, bella, ricca, elegante, a tenerne lontano
lo sciame importuno. Venute invece dal Giappone attraverso migliaia
e migliaia di miglia, esse lusingavano il suo amor proprio, la
empivano di gratitudine, la facevano arrossire di compiacenza.
Seguirono altre lettere di minor conto, finchè nella prima settimana
d’agosto ne capitò una portante la data dell’ultimo telegramma, 18
giugno. Essa confermava la partenza del King Arthur, conteneva le
polizze di carico, le fatture del riso, e la nota delle tratte emesse da
Hiogo sui banchieri Eliot, Collins e C. Nell’importo di queste tratte
era compreso anche il valore del salottino giapponese che
ammontava, se non mi falla la memoria, a qualcosa meno di 800 lire
sterline. I signori Holiday avvertivano di aver consegnato al capitano
la distinta particolare degli oggetti e dei prezzi.
Inchiuso nel foglio dei signori Holiday c’era pure un bigliettino di
Master Atkinson coi saluti e i baci dell’Ofelia per la zia Agnese.
La previsione che il bastimento arrivasse prima delle polizze di
carico, non s’era avverata. Ma in ciò non v’era nulla di straordinario,
tanto più che l’ultima posta aveva preso la via di San Francisco, la
quale, se si trovano le coincidenze esatte, porta sempre qualche
risparmio di tempo. Bisognava aspettare. E aspettammo.
 V.

Aspettammo per alcuni giorni con la massima calma e serenità. La

signora Agnese era di buonissimo umore e dava l’ultima mano alla
cameretta ch’ella aveva preparata per la piccina. Era tormentata,
pareva almeno, da un unico dubbio. Si doveva tenersi anche Tom?
E, in ogni caso, era probabile che il capitano volesse privarsene? E,
se non voleva, che dispiacere non sarebbe stato quello per l’Ofelia?
— Quando non ci fosse che questo, — replicava il signor Roberto
che aveva preoccupazioni d’altra natura, — le procureremo un cane
di Terranuova identico a Tom. I fanciulli si consolano presto.
I più impazienti erano i sensali a cui premeva di veder meglio che sui
campioni la qualità di questo riso, sconosciuto fino allora a Venezia.
Avevano già in serbo gli ordini dei loro clienti e anelavano d’eseguirli.
D’altra parte appunto per l’incertezza della qualità, nè essi si
credevano autorizzati, nè noi desideravamo di vender la merce
viaggiante. Si contentavano di prender, come si direbbe, una specie
di prenotazione. Taluno ci susurrava all’orecchio che non dovevamo
tener troppo alte le nostre pretese, che i fratelli Gelardi stavano
facendo anch’essi un carico a Hiogo e che questo solo annunzio
bastava a raffreddare il mercato. Spauracchi vani. A ora che il carico
dei Gelardi arrivasse, la nostra operazione sarebbe liquidata da un
pezzo.
Però, alla metà d’agosto il King Arthur non era ancora giunto.
Telegrafammo a Suez per sapere se esso fosse passato di là; ci si
rispose di no. Evidentemente la sollecitudine eccezionale del viaggio
di andata ci faceva troppo esigenti pel viaggio di ritorno.
E continuammo ad aspettare. Ma non più con la stessa tranquillità di
spirito.
Si capiva che la sorte del bastimento cominciava ad impensierir tutti.
Non potevamo andar alla Borsa senza che ci si domandasse: — E
questo King Arthur?
E si trovava stranissimo, non tanto il ritardo, quanto la mancanza
d’ogni notizia. Come mai il capitano, seppur costretto a ripararsi in
qualche porto per cagion d’avaria, non aveva spedito un dispaccio?
La signora Agnese aveva per un pezzo usato violenza a sè stessa,
s’era stordita proponendosi di dar la baia a Master Giorgio pel suo
ritardo e facendo mille castelli in aria sulla villeggiatura autunnale
con l’Ofelia; poi questa commedia era divenuta superiore alle sue
forze ed ella non dissimulava più la sua inquietudine. Scendeva,
saliva dalla casa al banco, dal banco alla casa; fissava addosso certi
occhi scrutatori; non aveva pace un minuto.
Prosperi invitava ogni giorno due o tre persone a desinare. —
Quando siamo soli a tavola, mia moglie ed io — egli diceva — o il
discorso cade fatalmente sul King Arthur, o si tace.... E se si tace, è
ancora peggio.... Quello sciagurato legno, è lì, in mezzo a noi.
Pur troppo esso era sempre lì, per quanti fossero i commensali, per
quanto svariati gli argomenti che si mettevano sul tappeto. Si vedeva
subito che non c’era rispondenza fra la parola e il pensiero, come
non c’è mai allorchè lo spirito è occupato da una cura più grave.
Dopo uno di questi lugubri pranzi al quale avevo partecipato anch’io,
la signora Agnese mi chiamò in disparte con un pretesto, e mi disse
a voce bassa ma vibrata: — Mi si nasconde qualche cosa. È
impossibile che non sia successa una disgrazia al King Arthur.
Le diedi la mia parola d’onore che non le si nascondeva nulla perchè
realmente non si sapeva nulla. Tentai quindi alla meglio di dissipare
le sue apprensioni. Certo il viaggio aveva una durata maggiore della
prevista, ma le combinazioni son tante: contrarietà di venti,
deficienza di combustibile, guasto alla macchina....
— Naufragi — soggiunse la signora Agnese guardandomi bene in
faccia.
— Sì, anche naufragi — risposi. — Ma questi si vengono a sapere.
— Sempre? — ella insistè.
— Quasi sempre — diss’io.