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Origins of Cardiovascular Surgery at the Mayo Clinic
Author’s Accepted Manuscript Origins of Cardiovascular Surgery at the Mayo Clinic Arman Arghami, Joseph A. Dearani, Hartzell V. Schaff, Francisco J. Puga, Richard C. Daly www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1043-0679(16)30141-1 http://dx.doi.org/10.1053/j.semtcvs.2016.10.012 YSTCS915
To appear in: Seminars in Thoracic and Cardiovascular Surgery Cite this article as: Arman Arghami, Joseph A. Dearani, Hartzell V. Schaff, Francisco J. Puga and Richard C. Daly, Origins of Cardiovascular Surgery at the Mayo Clinic, Seminars in Thoracic and Cardiovascular Surgery, http://dx.doi.org/10.1053/j.semtcvs.2016.10.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Origins of Cardiovascular Surgery at the Mayo Clinic
Authors: Arman Arghami, MD, Joseph A. Dearani, MD, Hartzell V. Schaff, MD, Francisco J. Puga, MD, Richard C. Daly, MD Department of cardiovascular surgery, Mayo Clinic, Rochester, MN
Corresponding Author: Joseph A. Dearani, MD Email: [email protected] Department of cardiovascular surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905
Keywords: Mayo Clinic, cardiac surgery, history, Kirklin, Mayo heart lung machine
Abstract Sixty years ago, an ambitious group of pioneers lead by Dr. John W. Kirklin, supported by a multidisciplinary team of physicians and technicians at the Mayo Clinic in Rochester, Minnesota, embarked on a planned series of surgical cases using a heart-lung machine to allow direct visualization of the inside of the opened human heart to repair otherwise fatal congenital intracardiac defects. Their success sparked the beginning of a new era of open heart surgery. In this historical article we discuss the contributions of a few key figures of this revolution and also share the story of the first successful cardiac surgery operation using cardiopulmonary bypass performed at Mayo Clinic.
Introduction In 1864, Dr. William Worrall Mayo and his family settled in Rochester and opened a medical practice. In 1883 a tornado struck Rochester causing 37 deaths and many injured. After the crisis subsided, the Sisters of Saint Francis (a teaching order) approached W.W. Mayo about establishing a hospital in Rochester. On September 30, 1889, Saint Marys Hospital was opened. Soon thereafter W.W. Mayo’s two sons, Will and Charlie joined the medical practice (Figure 1). The founders of Mayo Clinic were the Mayo brothers and Drs. Stinchfield, Graham, Plummer, Millet, Judd, and Balfour. In 1919, the founders, with the exception of Dr. Graham, created the Mayo Properties Association, and their private practice became a not-for-profit entity that would develop into the Mayo Clinic. Cardiovascular surgery emerged in this environment from the efforts of four pioneers who are discussed below.
Background O.T. (Jim) Clagett, was born in Jamesport, Missouri, attended the University Of Colorado School Of Medicine and interned at Colorado General Hospital (Figure 2). He entered private practice in Glenwood Springs but then returned to residency to further continue his education. In 1935, he became a Mayo Clinic surgical fellow, spending much of his time with Dr. Waltman Walters and Stuart Harrington and was appointed to the staff in 1940. After sustaining a lower spine herniated disc, Dr. Clagett was denied active duty in World War II. As a result of many surgeons leaving Mayo due to military obligations, he was performing a large number of intraabdominal and intra-thoracic operations every day. The surgical treatment of postpneumonectomy empyema also known as the “Clagett Procedure” was one of his many
ingenious contributions(1). Although later on he focused his practice on thoracic surgery, he had many contributions in the cardiovascular field. He had a special interest in coarctation of aorta. Six years after Crafoord and Gross first described surgical correction of coarctation Clagett published his first 70 cases coarctation operation.(2) He studied the hemodynamic effects of coarctation and changes after surgical correction.(3) He described correction of double aortic arch and many other unique operations. (4) As he changed his focus to general thoracic surgery he appointed Dr. Kirklin, Dwight McGoon, Robert Wallace and Gordon Danielson to focus on cardiac surgery. He was the president of the Western Surgical Association, the American Association of Thoracic Surgery (AATS), and was a Director on the American Board of Thoracic Surgery for 14 years. He was President of the Mayo Clinic Staff and Chair of the Mayo Foundation Board of Development. In 1948, Dr. Clagett, who had performed Blalock-Taussig shunts in addition to coarctation repairs recognized the importance of the emerging technology for cardiac surgery under cardio-pulmonary bypass and urged the Mayo leadership to assemble a committee “to study the problems associated with cardiovascular disease and it’s surgical treatment”. The Mayo Board of Governors approved this in the fall of 1948 with Dr. Arlie Barnes, a cardiologist, as the Chair of the Board. The initial team included cardiologist Howard Burchell, physiologist Earl Wood, pathologist Jesse Edwards, radiologist David Pugh, and surgeon William Seybold. John W. Kirklin was chosen to lead Mayo’s intracardiac surgery program.
John W. Kirklin was born in 1917 in Muncie, Indiana. He moved to Rochester in 1927 when his father was invited to become the Chair of the Department of Roentgenology at Mayo Clinic by
Dr. W J Mayo (Figure 3). He received his undergraduate degree from the University of Minnesota and earned his medical degree from Harvard Medical School. After finishing an internship at the University Hospital of Pennsylvania and the Mayo Clinic, he trained in neurosurgery at O’Reilly General Hospital in Missouri and then served 2½ years in the military as a neurosurgeon. After his discharge from the U.S. Army in 1946, Dr. Kirklin worked as assistant resident alongside the renowned pediatric surgeon, Dr. Robert Gross at Boston Children’s Hospital. It was there that Dr. Kirklin’s career interests shifted from neurosurgery to congenital heart disease, which became his lifelong field of expertise. Noting his interest in open heart surgery during his residency training period, Kirklin recalled, “my fellow residents and I filled pages of notebooks with drawings and plans of how we would close ventricular septal defects and repair the Tetralogy of Fallot once science gave us a method to get inside the heart”(5). Kirklin was performing intracardiac operations well before the heart-lung machine was developed. He mastered operation such as mitral valvotomy using Bailey and Glover’s commissurotomy technique and atrial septal defect closure using atrial well technique. (6) In 1952, Mayo lunched a program to develop a method for performing open-heart surgery after John Kirklin and Earl Wood met with Mayo’s Sciences Committee. Dr. Kirklin and his team visited John Gibbon in Philadelphia, Clarence Dennis in Brooklyn (where he had moved from Minneapolis), and Forest Dewey Dodrill in Detroit. Each of these men had attempted openheart surgery in humans using machines for extra-corporeal support that they and their collaborators had built and tested on animals. Dr. Gibbon had successfully operated on an atrial septal defect (ASD) in May of 1953. Unfortunately his next three cases died so he discontinued further intracardiac operations. When asked, Gibbon and IBM were happy to provide Mayo
Clinic with the blueprint of their machine with hope that “this original work will be of value in further effort towards the complete solution of this medical problem”(7). In 1953 Mayo formally approved “the heart-lung bypass project of Drs. Kirklin, Wood, Donald and Swan” (7). This cardiovascular team in conjunction with the Mayo Engineering Department and an estimated budget of $27,000 were able to build the heart-lung machine with an oxygenator similar to Gibbon’s machine over a one-year effort (Figure 4). They successfully tested the machine on 10 dogs; nine survived following 30-45 minutes of heart-lung bypass. (8, 9) The Mayo group then carefully selected 8 patients to undergo heart surgery using the Mayo enhanced Gibbon heart-lung machine. On March 22nd 1955 Dr. Kirklin and his team performed a successful operation on a 5-year old girl with large VSD (Figures 5, 6AB, 7, 8, 9). They continued to do the entire 8 patients of which 4 survived(10) (Figure 6C). This was the beginning of the new era of open-heart surgery. This was followed by an influx of numerous patients with congenital heart disease who traveled to Mayo for diagnosis and heart surgery treatment. In less than a year they were 26 cardiac catheterization procedures and 10 intracardiac operations performed each month at Mayo (7). This steady patient volume for Drs. Kirklin and Wood facilitated the development of world’s first cardiac surgery intensive care unit (Figure 10). The Mayo success was felt to be due in large part to the multidisciplinary approach that was embedded in the Mayo culture. This teamwork focused not only the help with building and testing the machine, but more importantly, patient selection with a correct diagnosis and an accurate cardiac operation. In addition, the Rochester community also played a large part of the cardiac program’s success by many local people being available at the hospital at 5:30 in the morning for blood donation that was required for each operation.
Cardiac surgery using mechanical circulatory support continued after Dr. Kirklin’s pioneering work and the program at Mayo Clinic is the longest continuously active cardiac surgery program in the world having started in 1955 (5) In 1966, Dr. Kirklin took the position of Chairman of the Department of Surgery at the University of Alabama at Birmingham (UAB), and his achievements in the surgical treatment of cardiovascular diseases earned him global recognition. He was elected to the National Academy of Sciences’ Institute of Medicine, and he served as president of the American Association for Thoracic Surgery from 1978 to 1979. He received many additional awards, including the American Heart Association Research Achievement Award, the American Surgical Association Medallion for Scientific Achievement, the Rudolph Matas Award in Vascular Surgery, and honorary degrees from several domestic and foreign universities. In 1977, Dr. Kirklin became the sixth recipient of the Ray C. Fish Award—the medal of the Texas Heart Institute. He was awarded the 1972 Lister Medal for his contributions to surgical science(11). He was widely considered an authority on complex congenital cardiac defects, and published more than 700 manuscripts and, with New Zealand surgeon Dr. Brian Barratt-Boyes, compiled the comprehensive textbook - Cardiac Surgery, first published in 1986 and is still considered the authoritative reference today.
Dwight C. McGoon was recruited to the Mayo Clinic staff by Drs. Clagett and Kirklin in 1957. Dr. McGoon was born on March 24, 1925, in Marengo, Iowa (Figure 11) and attended Iowa State University in Ames, Iowa, and then St. Ambrose College in Davenport. He received his medical degree from the Johns Hopkins University in 1948. His general postgraduate training
began at the Johns Hopkins Hospital under Dr. Alfred Blalock until 1954. Like many other surgeons from his generation, Dr. McGoon served in the military, spending much of his stint in the U.S. Air Force from 1954 to 1956. Dr. Clagett, following the recommendation of Dr. Blalock made arrangements for Dr. McGoon to spend one year at Mayo Clinic as a surgical fellow as a prelude to any final staff commitments elsewhere. As expected, his year at Mayo went well and Dr. McGoon joined the surgical staff at the Mayo Clinic on July 1, 1957. Dr. McGoon made many contributions in the field of congenital cardiac surgery. Early series of atrioventricular canal repair, left ventricular and biventricular extracardiac conduits, treatment of pulmonary stenosis and pulmonary atresia, transposition of great arteries.(12-15) His innovation was not limited to congenital defects, he was the first to describe repair of mitral valve regurgitation due to ruptures chordae, also performed a successful repair of a ruptured aortic sinus.(16, 17) Dr. McGoon was an exceptional talented surgeon, in the days that cardiac surgery was associated with high mortality, he published his 100 consecutive aortic valve surgery patient with no hospital death which cut the surgical community by surprise.(18) He served as head of the Section of Thoracic and Cardiovascular Surgery from 1968 through 1978, and was Vice President of the Mayo Clinic staff in 1968. He was elected President of the American Association for Thoracic Surgery from 1983 to 1984. He was subsequently elected to membership of the Johns Hopkins University Society of Scholars. He and Dr. Kirklin were the first to receive Mayo Foundation Distinguished Alumni Award. He served as Editor-in-Chief of the Journal of Thoracic and Cardiovascular Surgery from 1977 to 1987. Although his operating room career was cut short in 1979 by the effects of Parkinson’s disease, McGoon continued to be involved in Mayo Clinic affairs until he formally retired in 1990 (19).
Gian Carlo Rastelli, graduated from the University of Parma, Italy (cum laude) in July 1957, and in 1961, he moved to the Mayo Clinic (Figure 12). His name is recognized worldwide for the classification of the atrioventricular (AV) canal defect and for the procedure (Rastelli Procedure) for the anatomical repair of transposition of the great arteries (TGA) with ventricular septal defect (VSD) and pulmonary stenosis (PS) that he devised in 1969 (20). This operation included patch closure of the VSD and placement of an extracardiac conduit from the right ventricle to the pulmonary artery.(21) He received the Annual Golden Medal for Research of the American Medical Association award for two consecutive years for his work in this field. With the advancements of surgical technique based on the Rastelli classification for AV canal defect, Kirklin and McGoon obtained extraordinary results with operations repairing the AV canal defect, with a reduction in mortality from 60 to 5% (12). The most extraordinary aspect of his successful research career was that it was mostly accomplished during the five years when Dr. Rastelli was battling lymphoma, the illness that took his life at the young age of 36 years.
Culture Mayo Clinic has over 56,000 employees at three large campuses in Rochester, Minnesota; Scottsdale, Arizona; Jacksonville, Florida; and throughout the Midwest in the Mayo Clinic Health System. It operates as one institution with a single governing board. The Mayo Clinic Model of Care (MCMC) is providing patient care in concert with its mission — Mayo Clinic will provide the best care to every patient every day through integrated clinical practice, education and research (the “three shields”). It is the set of objectives that addresses the core principle for practice — to practice medicine as an integrated team of compassionate, multi-disciplinary
physicians, scientists and allied-health professionals who are focused on the needs of patients from our communities, regions, the nation and the world.
Current status/structure The Mayo Clinic Cardiovascular Center was formulated in 2016 and includes an Enterprise-wide Department of Cardiovascular Surgery in parallel with an Enterprise-wide Department of Cardiovascular Diseases. The Department of Cardiovascular Surgery consists of 11 staff surgeons in Rochester, MN, 2 in Eau Claire, WI, 6 in Scottsdale, Arizona, and 4 in Jacksonville, Florida. The Rochester campus has had an ABTS accredited thoracic surgery residency with 2 graduates each year since 1970. In addition, Mayo Rochester has had a non-accredited 1-2 year fellowship for 6-8 trainees from abroad since 1966. The Department of Cardiovascular Surgery performs approximately 4,000 cardiac operations annually and publishes more than 100 scientific articles each year. Since training programs were formalized, Mayo Clinic has trained more than 372 residents and fellows in cardiothoracic surgery (157 accredited and 215 nonaccredited) of which many are world renowned for their contributions in this field.
Acknowledgments Department of cardiovascular surgery gratefully acknowledges the tremendous efforts of Jennifer Daley for locating and collecting the historical material and images. We are also delighted to announce that the first cardiac surgery patient of the Mayo Clinic is healthy at age 65 and has kindly accepted that her operative story be shared in this article.
Figure Captions: Figure 1 – From left to right, Charles H (Charlie), William Worrall, and William J (Will) Mayo Figure 2 – Dr. O. Theron Clagett, was instrumental in assembling a research team to study cardiovascular disease and their surgical treatment. Figure 3- Dr. John W Kirklin, lead a group of experts who successfully developed the heart lung machine and utilized it intracardiac operations. Figure 4- Mayo-Gibbon heart-lung machine. Figure 5 - The original operative report of the first cardiac surgeries using the Mayo-Gibbon heart lung machine. It is interesting that there was arterial cannula dislodgement meticulously described in the operative report Figure 6A - Punch card of the first cardiac operation on heart lung machine. Figure 6B - David Donald a skilled veterinary surgeon and physiologist’s perfusion Log book of the first cardiac surgery patient. Figure 6C - Report of the first eight open heart operations using the Mayo-Gibbon heart lung machine 1955(10) Figure 7 - Operative photos of Dr. Kirklin and his team. Figure 8 – First cardiac surgery patient few months later, having her 6th birthday. Figure 9 - Thank you letter from the first patient’s mother to Dr. Kirklin
Figure 10 – Mayo pioneered one of the first cardiac intensive care units in the United States. The photo and the floor plan shows one of the later build dedicated ICUs with centralized nursing station to facilitate patient access and care. Figure 11 - Dr. Dwight McGoon Figure 12 - (A) Dr Rastelli upon arrival to Mayo Clinic in 1961. (B) Dr Giancarlo Rastelli, Dwight C. McGoon, and Jack L. Titus discussing Rastelli's operation in front of their exhibit at the American Medical Association meeting in 1969. (C) A poster signed by all Italian children operated on at the Mayo Clinic in the late 1960s that Dr Rastelli kept in his office. The Italian inscription on the poster says, “Love always wins.”
References: 1. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg. 1963;45:141-5. 2. Clagett OT, Jampolis RW. Coarctation of the aorta; a study of 70 cases in which surgical exploration was performed. AMA Arch Surg. 1951;63(3):337-48. 3. Hallenbeck GA, Wood EH, Clagett OT. Changes in radial arterial blood pressure during surgical resection of coarctation of the aorta. Fed Proc. 1948;7(1 Pt 1):49. 4. Dry TJ, Clagett OT, Saxon RF, Jr., Pugh DG, Edwards JE. Double aortic arch associated with coarctation of the aorta; surgically treated patient. Dis Chest. 1953;23(1):36-42. 5. Daly RC, Dearani JA, McGregor CG, Mullany CJ, Orszulak TA, Puga FJ, et al. Fifty years of open heart surgery at the Mayo Clinic. Mayo Clin Proc. 2005;80(5):636-40. 6. Barrattboyes BG, Ellis FH, Jr., Kirklin JW. Technique for repair of atrial septal defect using the atrial well. Surg Gynecol Obstet. 1956;103(5):646-9. 7. Fye B. Caring for the heart : Mayo Clinic and the rise of specialization. Oxford ; New York: Oxford University Press; 2015. xxiv, 672 pages p. 8. Jones RE, Donald DE, Swan HJ, Harshbarger HG, Kirklin JW, Wood EH. Apparatus of the Gibbon type for mechanical bypass of the heart and lungs; preliminary report. Proc Staff Meet Mayo Clin. 1955;30(6):105-13. 9. Donald DE, Harshbarger HG, Hetzel PS, Patrick RT, Wood EH, Kirklin JW. Experiences with a heartlung bypass (Gibbon type) in the experimental laboratory; preliminary report. Proc Staff Meet Mayo Clin. 1955;30(6):113-5. 10. Kirklin JW, Dushane JW, Patrick RT, Donald DE, Hetzel PS, Harshbarger HG, et al. Intracardiac surgery with the aid of a mechanical pump-oxygenator system (gibbon type): report of eight cases. Proc Staff Meet Mayo Clin. 1955;30(10):201-6. 11. Lister Medal. Annals of The Royal College of Surgeons of England. 1972;50(6):382. 12. McGoon DC, McMullan MH, Mair DD, Danielson GK. Correction of complete atrioventricular canal in infants. Mayo Clin Proc. 1973;48(11):769-72. 13. McGoon DC. Left ventricular and biventricular extracardiac conduits. J Thorac Cardiovasc Surg. 1976;72(1):7-14. 14. McGoon DC. Surgery for transposition of the great arteries. Circulation. 1972;45(6):1147-9. 15. McGoon DC, Rastelli GC, Ongley PA. An operation for the correction of truncus arteriosus. JAMA. 1968;205(2):69-73. 16. Mc GD. Repair of mitral insufficiency due to ruptured chordae tendineae. J Thorac Cardiovasc Surg. 1960;39:357-62. 17. Mc GD, Edwards JE, Kirklin JW. Surgical treatment of ruptured aneurysm of aortic sinus. Ann Surg. 1958;147(3):387-92. 18. McGoon DC, Pestana C, Moffitt EA. Decreased risk of aortic valve surgery. Arch Surg. 1965;91(5):779-86. 19. McKellar SH, Cassivi SD. Historical perspectives of The American Association for Thoracic Surgery: Dwight C. McGoon (1925-1999). J Thorac Cardiovasc Surg. 2012;144(4):759-61. 20. Rastelli GC, Wallace RB, Ongley PA. Complete repair of transposition of the great arteries with pulmonary stenosis. A review and report of a case corrected by using a new surgical technique. Circulation. 1969;39(1):83-95. 21. Konstantinov IE, Rosapepe F, Dearani JA, Alexi-Meskishvili VV, Li J. A tribute to Giancarlo Rastelli. Ann Thorac Surg. 2005;79(5):1819-23.
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PII: DOI: Reference:
S1043-0679(16)30141-1 http://dx.doi.org/10.1053/j.semtcvs.2016.10.012 YSTCS915
To appear in: Seminars in Thoracic and Cardiovascular Surgery Cite this article as: Arman Arghami, Joseph A. Dearani, Hartzell V. Schaff, Francisco J. Puga and Richard C. Daly, Origins of Cardiovascular Surgery at the Mayo Clinic, Seminars in Thoracic and Cardiovascular Surgery, http://dx.doi.org/10.1053/j.semtcvs.2016.10.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Origins of Cardiovascular Surgery at the Mayo Clinic
Authors: Arman Arghami, MD, Joseph A. Dearani, MD, Hartzell V. Schaff, MD, Francisco J. Puga, MD, Richard C. Daly, MD Department of cardiovascular surgery, Mayo Clinic, Rochester, MN
Corresponding Author: Joseph A. Dearani, MD Email: [email protected] Department of cardiovascular surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905
Keywords: Mayo Clinic, cardiac surgery, history, Kirklin, Mayo heart lung machine
Abstract Sixty years ago, an ambitious group of pioneers lead by Dr. John W. Kirklin, supported by a multidisciplinary team of physicians and technicians at the Mayo Clinic in Rochester, Minnesota, embarked on a planned series of surgical cases using a heart-lung machine to allow direct visualization of the inside of the opened human heart to repair otherwise fatal congenital intracardiac defects. Their success sparked the beginning of a new era of open heart surgery. In this historical article we discuss the contributions of a few key figures of this revolution and also share the story of the first successful cardiac surgery operation using cardiopulmonary bypass performed at Mayo Clinic.
Introduction In 1864, Dr. William Worrall Mayo and his family settled in Rochester and opened a medical practice. In 1883 a tornado struck Rochester causing 37 deaths and many injured. After the crisis subsided, the Sisters of Saint Francis (a teaching order) approached W.W. Mayo about establishing a hospital in Rochester. On September 30, 1889, Saint Marys Hospital was opened. Soon thereafter W.W. Mayo’s two sons, Will and Charlie joined the medical practice (Figure 1). The founders of Mayo Clinic were the Mayo brothers and Drs. Stinchfield, Graham, Plummer, Millet, Judd, and Balfour. In 1919, the founders, with the exception of Dr. Graham, created the Mayo Properties Association, and their private practice became a not-for-profit entity that would develop into the Mayo Clinic. Cardiovascular surgery emerged in this environment from the efforts of four pioneers who are discussed below.
Background O.T. (Jim) Clagett, was born in Jamesport, Missouri, attended the University Of Colorado School Of Medicine and interned at Colorado General Hospital (Figure 2). He entered private practice in Glenwood Springs but then returned to residency to further continue his education. In 1935, he became a Mayo Clinic surgical fellow, spending much of his time with Dr. Waltman Walters and Stuart Harrington and was appointed to the staff in 1940. After sustaining a lower spine herniated disc, Dr. Clagett was denied active duty in World War II. As a result of many surgeons leaving Mayo due to military obligations, he was performing a large number of intraabdominal and intra-thoracic operations every day. The surgical treatment of postpneumonectomy empyema also known as the “Clagett Procedure” was one of his many
ingenious contributions(1). Although later on he focused his practice on thoracic surgery, he had many contributions in the cardiovascular field. He had a special interest in coarctation of aorta. Six years after Crafoord and Gross first described surgical correction of coarctation Clagett published his first 70 cases coarctation operation.(2) He studied the hemodynamic effects of coarctation and changes after surgical correction.(3) He described correction of double aortic arch and many other unique operations. (4) As he changed his focus to general thoracic surgery he appointed Dr. Kirklin, Dwight McGoon, Robert Wallace and Gordon Danielson to focus on cardiac surgery. He was the president of the Western Surgical Association, the American Association of Thoracic Surgery (AATS), and was a Director on the American Board of Thoracic Surgery for 14 years. He was President of the Mayo Clinic Staff and Chair of the Mayo Foundation Board of Development. In 1948, Dr. Clagett, who had performed Blalock-Taussig shunts in addition to coarctation repairs recognized the importance of the emerging technology for cardiac surgery under cardio-pulmonary bypass and urged the Mayo leadership to assemble a committee “to study the problems associated with cardiovascular disease and it’s surgical treatment”. The Mayo Board of Governors approved this in the fall of 1948 with Dr. Arlie Barnes, a cardiologist, as the Chair of the Board. The initial team included cardiologist Howard Burchell, physiologist Earl Wood, pathologist Jesse Edwards, radiologist David Pugh, and surgeon William Seybold. John W. Kirklin was chosen to lead Mayo’s intracardiac surgery program.
John W. Kirklin was born in 1917 in Muncie, Indiana. He moved to Rochester in 1927 when his father was invited to become the Chair of the Department of Roentgenology at Mayo Clinic by
Dr. W J Mayo (Figure 3). He received his undergraduate degree from the University of Minnesota and earned his medical degree from Harvard Medical School. After finishing an internship at the University Hospital of Pennsylvania and the Mayo Clinic, he trained in neurosurgery at O’Reilly General Hospital in Missouri and then served 2½ years in the military as a neurosurgeon. After his discharge from the U.S. Army in 1946, Dr. Kirklin worked as assistant resident alongside the renowned pediatric surgeon, Dr. Robert Gross at Boston Children’s Hospital. It was there that Dr. Kirklin’s career interests shifted from neurosurgery to congenital heart disease, which became his lifelong field of expertise. Noting his interest in open heart surgery during his residency training period, Kirklin recalled, “my fellow residents and I filled pages of notebooks with drawings and plans of how we would close ventricular septal defects and repair the Tetralogy of Fallot once science gave us a method to get inside the heart”(5). Kirklin was performing intracardiac operations well before the heart-lung machine was developed. He mastered operation such as mitral valvotomy using Bailey and Glover’s commissurotomy technique and atrial septal defect closure using atrial well technique. (6) In 1952, Mayo lunched a program to develop a method for performing open-heart surgery after John Kirklin and Earl Wood met with Mayo’s Sciences Committee. Dr. Kirklin and his team visited John Gibbon in Philadelphia, Clarence Dennis in Brooklyn (where he had moved from Minneapolis), and Forest Dewey Dodrill in Detroit. Each of these men had attempted openheart surgery in humans using machines for extra-corporeal support that they and their collaborators had built and tested on animals. Dr. Gibbon had successfully operated on an atrial septal defect (ASD) in May of 1953. Unfortunately his next three cases died so he discontinued further intracardiac operations. When asked, Gibbon and IBM were happy to provide Mayo
Clinic with the blueprint of their machine with hope that “this original work will be of value in further effort towards the complete solution of this medical problem”(7). In 1953 Mayo formally approved “the heart-lung bypass project of Drs. Kirklin, Wood, Donald and Swan” (7). This cardiovascular team in conjunction with the Mayo Engineering Department and an estimated budget of $27,000 were able to build the heart-lung machine with an oxygenator similar to Gibbon’s machine over a one-year effort (Figure 4). They successfully tested the machine on 10 dogs; nine survived following 30-45 minutes of heart-lung bypass. (8, 9) The Mayo group then carefully selected 8 patients to undergo heart surgery using the Mayo enhanced Gibbon heart-lung machine. On March 22nd 1955 Dr. Kirklin and his team performed a successful operation on a 5-year old girl with large VSD (Figures 5, 6AB, 7, 8, 9). They continued to do the entire 8 patients of which 4 survived(10) (Figure 6C). This was the beginning of the new era of open-heart surgery. This was followed by an influx of numerous patients with congenital heart disease who traveled to Mayo for diagnosis and heart surgery treatment. In less than a year they were 26 cardiac catheterization procedures and 10 intracardiac operations performed each month at Mayo (7). This steady patient volume for Drs. Kirklin and Wood facilitated the development of world’s first cardiac surgery intensive care unit (Figure 10). The Mayo success was felt to be due in large part to the multidisciplinary approach that was embedded in the Mayo culture. This teamwork focused not only the help with building and testing the machine, but more importantly, patient selection with a correct diagnosis and an accurate cardiac operation. In addition, the Rochester community also played a large part of the cardiac program’s success by many local people being available at the hospital at 5:30 in the morning for blood donation that was required for each operation.
Cardiac surgery using mechanical circulatory support continued after Dr. Kirklin’s pioneering work and the program at Mayo Clinic is the longest continuously active cardiac surgery program in the world having started in 1955 (5) In 1966, Dr. Kirklin took the position of Chairman of the Department of Surgery at the University of Alabama at Birmingham (UAB), and his achievements in the surgical treatment of cardiovascular diseases earned him global recognition. He was elected to the National Academy of Sciences’ Institute of Medicine, and he served as president of the American Association for Thoracic Surgery from 1978 to 1979. He received many additional awards, including the American Heart Association Research Achievement Award, the American Surgical Association Medallion for Scientific Achievement, the Rudolph Matas Award in Vascular Surgery, and honorary degrees from several domestic and foreign universities. In 1977, Dr. Kirklin became the sixth recipient of the Ray C. Fish Award—the medal of the Texas Heart Institute. He was awarded the 1972 Lister Medal for his contributions to surgical science(11). He was widely considered an authority on complex congenital cardiac defects, and published more than 700 manuscripts and, with New Zealand surgeon Dr. Brian Barratt-Boyes, compiled the comprehensive textbook - Cardiac Surgery, first published in 1986 and is still considered the authoritative reference today.
Dwight C. McGoon was recruited to the Mayo Clinic staff by Drs. Clagett and Kirklin in 1957. Dr. McGoon was born on March 24, 1925, in Marengo, Iowa (Figure 11) and attended Iowa State University in Ames, Iowa, and then St. Ambrose College in Davenport. He received his medical degree from the Johns Hopkins University in 1948. His general postgraduate training
began at the Johns Hopkins Hospital under Dr. Alfred Blalock until 1954. Like many other surgeons from his generation, Dr. McGoon served in the military, spending much of his stint in the U.S. Air Force from 1954 to 1956. Dr. Clagett, following the recommendation of Dr. Blalock made arrangements for Dr. McGoon to spend one year at Mayo Clinic as a surgical fellow as a prelude to any final staff commitments elsewhere. As expected, his year at Mayo went well and Dr. McGoon joined the surgical staff at the Mayo Clinic on July 1, 1957. Dr. McGoon made many contributions in the field of congenital cardiac surgery. Early series of atrioventricular canal repair, left ventricular and biventricular extracardiac conduits, treatment of pulmonary stenosis and pulmonary atresia, transposition of great arteries.(12-15) His innovation was not limited to congenital defects, he was the first to describe repair of mitral valve regurgitation due to ruptures chordae, also performed a successful repair of a ruptured aortic sinus.(16, 17) Dr. McGoon was an exceptional talented surgeon, in the days that cardiac surgery was associated with high mortality, he published his 100 consecutive aortic valve surgery patient with no hospital death which cut the surgical community by surprise.(18) He served as head of the Section of Thoracic and Cardiovascular Surgery from 1968 through 1978, and was Vice President of the Mayo Clinic staff in 1968. He was elected President of the American Association for Thoracic Surgery from 1983 to 1984. He was subsequently elected to membership of the Johns Hopkins University Society of Scholars. He and Dr. Kirklin were the first to receive Mayo Foundation Distinguished Alumni Award. He served as Editor-in-Chief of the Journal of Thoracic and Cardiovascular Surgery from 1977 to 1987. Although his operating room career was cut short in 1979 by the effects of Parkinson’s disease, McGoon continued to be involved in Mayo Clinic affairs until he formally retired in 1990 (19).
Gian Carlo Rastelli, graduated from the University of Parma, Italy (cum laude) in July 1957, and in 1961, he moved to the Mayo Clinic (Figure 12). His name is recognized worldwide for the classification of the atrioventricular (AV) canal defect and for the procedure (Rastelli Procedure) for the anatomical repair of transposition of the great arteries (TGA) with ventricular septal defect (VSD) and pulmonary stenosis (PS) that he devised in 1969 (20). This operation included patch closure of the VSD and placement of an extracardiac conduit from the right ventricle to the pulmonary artery.(21) He received the Annual Golden Medal for Research of the American Medical Association award for two consecutive years for his work in this field. With the advancements of surgical technique based on the Rastelli classification for AV canal defect, Kirklin and McGoon obtained extraordinary results with operations repairing the AV canal defect, with a reduction in mortality from 60 to 5% (12). The most extraordinary aspect of his successful research career was that it was mostly accomplished during the five years when Dr. Rastelli was battling lymphoma, the illness that took his life at the young age of 36 years.
Culture Mayo Clinic has over 56,000 employees at three large campuses in Rochester, Minnesota; Scottsdale, Arizona; Jacksonville, Florida; and throughout the Midwest in the Mayo Clinic Health System. It operates as one institution with a single governing board. The Mayo Clinic Model of Care (MCMC) is providing patient care in concert with its mission — Mayo Clinic will provide the best care to every patient every day through integrated clinical practice, education and research (the “three shields”). It is the set of objectives that addresses the core principle for practice — to practice medicine as an integrated team of compassionate, multi-disciplinary
physicians, scientists and allied-health professionals who are focused on the needs of patients from our communities, regions, the nation and the world.
Current status/structure The Mayo Clinic Cardiovascular Center was formulated in 2016 and includes an Enterprise-wide Department of Cardiovascular Surgery in parallel with an Enterprise-wide Department of Cardiovascular Diseases. The Department of Cardiovascular Surgery consists of 11 staff surgeons in Rochester, MN, 2 in Eau Claire, WI, 6 in Scottsdale, Arizona, and 4 in Jacksonville, Florida. The Rochester campus has had an ABTS accredited thoracic surgery residency with 2 graduates each year since 1970. In addition, Mayo Rochester has had a non-accredited 1-2 year fellowship for 6-8 trainees from abroad since 1966. The Department of Cardiovascular Surgery performs approximately 4,000 cardiac operations annually and publishes more than 100 scientific articles each year. Since training programs were formalized, Mayo Clinic has trained more than 372 residents and fellows in cardiothoracic surgery (157 accredited and 215 nonaccredited) of which many are world renowned for their contributions in this field.
Acknowledgments Department of cardiovascular surgery gratefully acknowledges the tremendous efforts of Jennifer Daley for locating and collecting the historical material and images. We are also delighted to announce that the first cardiac surgery patient of the Mayo Clinic is healthy at age 65 and has kindly accepted that her operative story be shared in this article.
Figure Captions: Figure 1 – From left to right, Charles H (Charlie), William Worrall, and William J (Will) Mayo Figure 2 – Dr. O. Theron Clagett, was instrumental in assembling a research team to study cardiovascular disease and their surgical treatment. Figure 3- Dr. John W Kirklin, lead a group of experts who successfully developed the heart lung machine and utilized it intracardiac operations. Figure 4- Mayo-Gibbon heart-lung machine. Figure 5 - The original operative report of the first cardiac surgeries using the Mayo-Gibbon heart lung machine. It is interesting that there was arterial cannula dislodgement meticulously described in the operative report Figure 6A - Punch card of the first cardiac operation on heart lung machine. Figure 6B - David Donald a skilled veterinary surgeon and physiologist’s perfusion Log book of the first cardiac surgery patient. Figure 6C - Report of the first eight open heart operations using the Mayo-Gibbon heart lung machine 1955(10) Figure 7 - Operative photos of Dr. Kirklin and his team. Figure 8 – First cardiac surgery patient few months later, having her 6th birthday. Figure 9 - Thank you letter from the first patient’s mother to Dr. Kirklin
Figure 10 – Mayo pioneered one of the first cardiac intensive care units in the United States. The photo and the floor plan shows one of the later build dedicated ICUs with centralized nursing station to facilitate patient access and care. Figure 11 - Dr. Dwight McGoon Figure 12 - (A) Dr Rastelli upon arrival to Mayo Clinic in 1961. (B) Dr Giancarlo Rastelli, Dwight C. McGoon, and Jack L. Titus discussing Rastelli's operation in front of their exhibit at the American Medical Association meeting in 1969. (C) A poster signed by all Italian children operated on at the Mayo Clinic in the late 1960s that Dr Rastelli kept in his office. The Italian inscription on the poster says, “Love always wins.”
References: 1. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg. 1963;45:141-5. 2. Clagett OT, Jampolis RW. Coarctation of the aorta; a study of 70 cases in which surgical exploration was performed. AMA Arch Surg. 1951;63(3):337-48. 3. Hallenbeck GA, Wood EH, Clagett OT. Changes in radial arterial blood pressure during surgical resection of coarctation of the aorta. Fed Proc. 1948;7(1 Pt 1):49. 4. Dry TJ, Clagett OT, Saxon RF, Jr., Pugh DG, Edwards JE. Double aortic arch associated with coarctation of the aorta; surgically treated patient. Dis Chest. 1953;23(1):36-42. 5. Daly RC, Dearani JA, McGregor CG, Mullany CJ, Orszulak TA, Puga FJ, et al. Fifty years of open heart surgery at the Mayo Clinic. Mayo Clin Proc. 2005;80(5):636-40. 6. Barrattboyes BG, Ellis FH, Jr., Kirklin JW. Technique for repair of atrial septal defect using the atrial well. Surg Gynecol Obstet. 1956;103(5):646-9. 7. Fye B. Caring for the heart : Mayo Clinic and the rise of specialization. Oxford ; New York: Oxford University Press; 2015. xxiv, 672 pages p. 8. Jones RE, Donald DE, Swan HJ, Harshbarger HG, Kirklin JW, Wood EH. Apparatus of the Gibbon type for mechanical bypass of the heart and lungs; preliminary report. Proc Staff Meet Mayo Clin. 1955;30(6):105-13. 9. Donald DE, Harshbarger HG, Hetzel PS, Patrick RT, Wood EH, Kirklin JW. Experiences with a heartlung bypass (Gibbon type) in the experimental laboratory; preliminary report. Proc Staff Meet Mayo Clin. 1955;30(6):113-5. 10. Kirklin JW, Dushane JW, Patrick RT, Donald DE, Hetzel PS, Harshbarger HG, et al. Intracardiac surgery with the aid of a mechanical pump-oxygenator system (gibbon type): report of eight cases. Proc Staff Meet Mayo Clin. 1955;30(10):201-6. 11. Lister Medal. Annals of The Royal College of Surgeons of England. 1972;50(6):382. 12. McGoon DC, McMullan MH, Mair DD, Danielson GK. Correction of complete atrioventricular canal in infants. Mayo Clin Proc. 1973;48(11):769-72. 13. McGoon DC. Left ventricular and biventricular extracardiac conduits. J Thorac Cardiovasc Surg. 1976;72(1):7-14. 14. McGoon DC. Surgery for transposition of the great arteries. Circulation. 1972;45(6):1147-9. 15. McGoon DC, Rastelli GC, Ongley PA. An operation for the correction of truncus arteriosus. JAMA. 1968;205(2):69-73. 16. Mc GD. Repair of mitral insufficiency due to ruptured chordae tendineae. J Thorac Cardiovasc Surg. 1960;39:357-62. 17. Mc GD, Edwards JE, Kirklin JW. Surgical treatment of ruptured aneurysm of aortic sinus. Ann Surg. 1958;147(3):387-92. 18. McGoon DC, Pestana C, Moffitt EA. Decreased risk of aortic valve surgery. Arch Surg. 1965;91(5):779-86. 19. McKellar SH, Cassivi SD. Historical perspectives of The American Association for Thoracic Surgery: Dwight C. McGoon (1925-1999). J Thorac Cardiovasc Surg. 2012;144(4):759-61. 20. Rastelli GC, Wallace RB, Ongley PA. Complete repair of transposition of the great arteries with pulmonary stenosis. A review and report of a case corrected by using a new surgical technique. Circulation. 1969;39(1):83-95. 21. Konstantinov IE, Rosapepe F, Dearani JA, Alexi-Meskishvili VV, Li J. A tribute to Giancarlo Rastelli. Ann Thorac Surg. 2005;79(5):1819-23.
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