The origins of cardiac surgery
Surgery on the heart and the great vessels has made enormous progress from its humble beginnings in the 19th century to the sophisticated and life-saving procedures of today.
Over the last one hundred years, cardiac surgery has evolved to address complex congenital and acquired cardiovascular diseases, driven by breakthroughs in data analysis, imaging technology, innovative surgical techniques, and a more detailed understanding of human anatomy and physiology.
The early attempts at heart surgery faced significant and understandable skepticism and risk. Dr Ludwig Rehn, Professor of Surgery at Frankfurt, reported the first successful heart surgical operation by repairing a stab wound in a patient’s heart, in 1896. By the end of his career, Ludwig Rehn had reported 124 cases of hear repair with 40% survival, a very good result for the time.
Around the turn of the century, the development of antiseptic techniques and anaesthesia laid the foundation for more advanced procedures. By the 1920s and 1930s, improved surgical instruments and increased experience in operating allowed surgeons to develop more advanced techniques for managing traumatic injuries to the heart, and the concept of open-heart surgery began to take shape.
However, operations on the heart valves were unknown until 1925. In that year, Sir Henry Souttar, a British surgeon who also had degrees in mathematics and engineering, operated successfully on a young woman with mitral valve stenosis. The operation was performed on the beating heart by inserting a finger in order to widen the damaged mitral valve. The patient survived for several year and the operation is regarded as a seminal event in cardiac surgery.
Alfred Blalock, Helen Taussig, and Vivien Thomas performed the first successful palliative pediatric cardiac operation at Johns Hopkins Hospital on 29 November 1944, in a one-year-old girl with Tetralogy of Fallot
Cardiac surgery began to change significantly after World War II. In 1947, Thomas Sellors of Middlesex Hospital in London operated on a Tetralogy of Fallot patient with pulmonary stenosis and successfully divided the stenosed pulmonary valve.
Some of the early heart operations were carried out in hypothermia, a technique involving the lowering of the patient’s body temperature. The modern era of heart surgery truly started with the development of the heart-lung machine, also known as cardio-pulmonary bypass machine. Complex intracardiac repairs take time, and the patient needs blood flow to the body (particularly to the brain), as well as heart and lung function.
A major turning point came in 1953 when Dr. John Gibbon, Professor of Surgery at Jefferson Medical College in Pennsylvania, successfully used the first heart-lung machine during surgery, allowing surgeons to operate on a stopped heart while maintaining circulation. This innovation paved the way for open-heart surgery, making previously unimaginable procedures possible.
Commonly performed cardiac surgical procedures in adults
Cardiac surgery involves procedures on the coronary arteries, cardiac valves, aorta as well as other less commonly performed operations. This is a brief summary on the development surgery of the coronary arteries and the aortic valve.
Coronary Artery Bypass Grafting
The aim of Coronary artery bypass grafting (CABG) is to improve blood flow to the heart muscle in patients with coronary artery disease. The surgeon bypasses the narrowings in coronary arteries by using the patients own arteries and veins.
The first anastomosis of the internal mammary artery to a coronary artery using a standard suturing technique was reported by the Soviet surgeon Vasillii Kolesov in 1964.
Building upon these developments, Argentine surgeon Dr. René Favaloro, working at the Cleveland Clinic, used the saphenous vein to bypass blocked coronary arteries in 1967.
The left internal mammary artery remains the preferred type of graft for the left anterior descending artery (LAD) offering the best option for durable outcomes and improved survival.
The great saphenous vein is still the most commonly used vessel for bypassing coronary arteries other than the LAD.
Throughout the 1970s and 1980s, CABG techniques were refined with the introduction of cardioplegia to protect the heart during surgery and the adoption of arterial grafts, such as the radial artery, to improve long-term outcomes. Today, CABG remains a cornerstone in the treatment of complex coronary artery disease, offering improved survival and quality of life for many patients.
Aortic valve replacement
The aortic valve at the ‘exit’ of the left ventricle allowing the heart to propel blood into the aorta. The commonest pathological conditions requiring intervention on the aortic valve are stenosis, usually due to calcific degeneration, and regurgitation or insufficiency. Aortic valve replacement (AVR) has evolved significantly since its inception. The first successful open-heart AVR was performed in 1960 using a mechanical ball-and-cage valve (Starr-Edwards valve), marking a major milestone in cardiac surgery. Mechanical valves became standard through the 1960s and 1970s. They are very durable although they have the disadvantage of requiring lifelong anticoagulation.
Donald Ross, a South African born London surgeon, replaced a diseased aortic valve with a human aortic valve from a cadaver, known as homograft, in 1962. In 1967, the same surgeon took the normal pulmonary valve of a patient with aortic valve disease and placed it in the aortic valve position while the missing pulmonary valve was replaced with an aortic valve homograft.
In the 1970s, bioprosthetic (tissue) valves were introduced, offering an alternative without long-term anticoagulation, especially beneficial for older patients.
Surgical techniques and cardiopulmonary bypass methods improved outcomes over time. Minimally invasive surgical approaches emerged in the 1990s, reducing recovery time and complications. A groundbreaking shift occurred in 2002 with the first transcatheter aortic valve implantation (TAVI or TAVR), a catheter-based technique that allowed valve replacement without open-heart surgery. Initially reserved for high-risk patients, TAVR’s indications expanded rapidly due to advancements in device design and clinical outcomes.
Conclusion
Cardiac surgery emerged over a century ago and has evolved dramatically, driven by scientific curiosity and technological advancements. Cardiac surgery interventions have become more complex and are associated with increasingly improved outcomes.
Author’s biography
Mr George Asimakopoulos
Consultant Cardiothoracic Surgeon
Mr George Asimakopoulos is a leading consultant cardiac surgeon based in London. His specialist interests include aortic root surgery, aortic valve replacement, surgery for endocarditis, Coronary Artery Bypass Grafting (CABG) and surgery for atrial fibrillation. He subspecialises in complex problems of the aortic valve, aortic root, ascending aorta and arch. He also has extensive experience in treating endocarditis and operating on patients who have had previous cardiac surgery.
In 1992, Mr Asimakopoulos qualified in medicine at The University of Hamburg, Germany. From 1999 to 2006, he trained on the West London rotation in cardiothoracic surgery. He went on to spend a year as a fellow in heart and lung transplantation at The Harefield Hospital.
Mr Asimakopoulos spent seven years working as a consultant cardiac surgeon at The University Hospitals Bristol NHS Foundation Trust. During his time at Bristol, Mr Asimakopoulos was one of the busiest cardiac surgeons in the UK. He performs more than 230 cardiac surgery operationsevery year. He also joined The Royal Brompton Hospital and Harefield Hospital in February 2014 as an aortic surgeon and continues to see patients at this highly regarded centre.
Mr Asimakopoulos is also an educational supervisor for trainee doctors in adult cardiac surgery. He regularly supervises medical students and sits on selection and interview panels for the national selection of surgical trainees.
He’s published over 80 peer-reviewed scientific articles. Currently, he is taking part in ongoing research on the performance of sutureless aortic valves, outcomes of surgery for aortic dissection and training in cardiac surgery.
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