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The 25 Landmark ‘Milestone’ Papers Published by ASAIO

1955-2003

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Cardiac Devices

1. Cooley D, Liotta D, Hallman GL, Bloodwell RD, Leachman RD, Milan RC, "Discussion: First Human Implantation of Cardiac Prosthesis for Staged Total Replacement of the Heart," TASAIO 15:252-263 ( Discussion of Kwann-Gett et al.TASAIO 15:245-251) 1969.

Commentary: At the invitation of Dr Willem Kolff, and a late addition to the original program, this paper by Dr Denton A. Cooley reports on the historic first clinical application in 1969 of a total artificial heart (TAH). It describes the concept of two-staged cardiac transplantation (practiced widely as bridge-to-transplantation today) for the emergency setting of acute irreversible cardiac failure, precluding orderly donor organ procurement and elective transplantation.

The patient was a 47 year old male with severe diffuse coronary disease, complete heart block, extensive left ventricular fibrosis and a ten year history of myocardial infarctions, arrhythmia and congestive failure. The patient was opposed to cardiac transplantation, the procedure of choice, and opted for myocardial excision with ventriculoplasty – a procedure he had seen reported on the news. A wide resection of nonfunctional myocardium was carried out, but inadequate cardiac function prevented weaning from cardiopulmonary bypass, necessitating mechanical circulatory support. The pneumatic TAH employed, developed by Dr Domingo Liotta with the Baylor-Rice team and tested in a series of seven short-term bovine experiments, was ”covertly taken from the Baylor surgical laboratory to St Luke’s Hospital” (as reported by Dr Michael DeBakey). Implanted orthotopically, the Liotta TAH provided satisfactory circulatory support for 64 hours, although renal and respiratory function were marginal. Thirty-two hours following cardiac transplantation, the patient died of Pseudomonas pneumonia, likely related to the administration of azathioprine immunosuppression soon after TAH implant.

A second staged cardiac transplantation was carried out by Cooley some 12 years later, using the Akutsu III pneumatic TAH, but with a similar outcome. The first successful bridge to transplantation was not achieved until 1984 (Dr Philip Oyer, Novacor LVAS), and the first successful TAH bridge was accomplished a year later (Dr Jack Copeland, Jarvik 7 TAH). – Peer M. Portner Ph.D.

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2. Joyce LD, DeVries WC, Hastings WL, Olsen DB, Jarvik RK, Kolff WJ, "Response of the Human Body to the First Permanent Implant of the Jarvik-7 Total Artificial Heart," TASAIO 29:81-7, 1983.

Commentary: At the ASAIO meeting in 1982 Don Olsen chaired a panel conference describing the indications and plans for implantation of a total artificial heart (TASAIO, Vol 28, page 652). Later in 1982 the Utah team lead by surgeon William DeVries implanted a total artificial heart in patient Barney Clark. The case was reported in the lay press and at every scientific meeting. Barney Clark lived in the hospital with this total artificial heart for many months, finally succumbing to an embolic stroke. The first successful implantation of a total artificial heart was the subject of great excitement at the 1983 ASAIO meeting. This was the culmination of decades of research in dozens of laboratories, and the culmination of the NIH total artificial heart program. This landmark paper presented at the 1983 meeting, describes function of the artificial heart and physiologic responses to prolonged mechanical pumping. This paper is the most complete description of the course of Mr. Clark, and defines that normal organ function can be sustained indefinitely with a mechanical heart, and that thrombolic complications will be the subject of intense research while progress with implantable cardiac devices continues. -- Robert H. Bartlett, MD

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3. Portner PM, Oyer PE, Jassawalla JS, Miller PJ, Chen H, LaForge DH, Skytte KW, "An implantable permanent left ventricular assist system for man," Trans Am Soc Artif Intern Organs 24: 98-103, 1978.

Commentary: Dr. Peer M. Portner had been a principal investigator in the NHLBI permanently implantable LVAD development program since 1970 through Andros Inc., Berkeley, California and subsequently Novacor Medical Corporation and the Novacor Division of Baxter Healthcare, Oakland, California, while holding a faculty position in the Department of Cardiovascular Surgery at Stanford University School of Medicine. The first fully integrated system, his electromechanical LVAD is based upon a dual pusher plate sac-type pump with controlled deformation, activated by a unique spring-decoupled solenoid. Thus, this electromechanical LVAD has proven to be effective, safe, and durable.

This paper by Dr. Portner, chosen as one of the 25 key ASAIO publications, represents the first description of a permanently implantable electromechanical LVAD system in detail. This LVAD was first implanted in a 51 year-old patient in 1984, in the world’s first successful bridge to transplantation. To date, more than 1,500 such devices have been implanted in patients for durations up to more than six years. This paper supports the idea that the permanently implantable LVAD is not a dream; it is a therapeutically effective substitute for the natural heart. Currently this LVAD, recognized as the Novacor LVAS, is manufactured by WorldHeart Corporation, Ottawa, Canada and Oakland, California. It is one of the most effective, safe, reliable, and dependable LVADs in the world. After this Novacor LVAS system was introduced clinically, many other permanently implantable LVASs were introduced, including the Thoratec-TCI LVAS, the DeBakey MicroMed LVAS, and many others. -- Yukihiko Nosé, MD, PhD

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4. Kantrowitz, A., Tjonneland, S., Krakauer, J., Butner, A.N., Phillips, S.J., Yahr, W.Z., Sharpiro, M., Freed, P.S., Jaron, D., Sherman, J.S., Jr.: Clinical experience with cardiac assistance by means of intra-aortic phase-shift balloon pumping. Trans Amer Soc Artif Int Organs, 14:344-8, 1968.

Commentary: I was very fortunate to train with Dr. Adrian Kantrowitz. Dr Kantrowitz pioneered the development and implantation of temporary and permanent heart pumps - devices that, to date, have saved many thousands of lives. Dr. Adrian Kantrowitz also co-invented a plastic heart valve (1954), a heart-lung machine (1958), an internal pacemaker (1961) and an auxiliary left ventricle (1964). In 1966, Dr. Kantrowitz performed the first implantation of a partial mechanical heart on a human. On December 6, 1967, he performed the first heart transplant on an infant and the first in the United States. The initial clinical use of the IABP for the treatment of cardiogenic shock was the culmination of years of research by Dr. Kantrowitz and his team. As I remember, one afternoon in 1967, Dr. Kantrowitz called me and said, “Steve, we’re ready to implant the balloon pump in a patient”. As a first year surgery resident, I was responsible for covering the emergency room at night. The break room next to the ER hosted a 24/7-poker game. That evening I stopped to check the ER and sat in for a few hands of poker. The room was filled with cigarette smoke, empty pizza boxes, and people playing poker. Sitting next to me was Dr. Menachem Shapiro, the Chief Medical Resident. I explained the function of the IABP to him and said, “Menachem, if you have a patient with cardiogenic shock, give me a call, and we will implant the IAPB”. At 4 a.m. my phone rang and it was Menachem. He said. “Steve, we have a 48 year old woman who is dying in cardiogenic shock. We have run out of medical treatment options. Come on over with your pump”. I mobilized the team and we met at the patient’s bedside. As it was 5 a.m., I did not want to awaken Dr. Kantrowitz, nor did Dr. Shapiro want to awaken his Chief. Drs. Tjonneland, Butner, and I inserted the first IAPB. It functioned quite well, especially after Dr. Jordan Haller inserted a transvenous pacemaker to relieve the patient’s heart block. This first patient survived. At 7 a.m. we called our respective chiefs who hurried to the patient’s bedside. From its initial clinical use, over 37 years ago, to its current extensive use of over 100,000 times annually in the US alone, the balloon pump, developed and pioneered by Dr. Adrian Kantrowitz, remains the first choice intervention for mechanical circulatory assistance. A permanent balloon pump, (the experimental patch booster), was commercialized as the CardioVad System and successfully implanted in a number of patients. The initial clinical implantations of the IABP, and its more permanent CardioVad spin-off demonstrated that LVAD’s can be successfully used for cardiac support. – Steven J. Phillips, M.D.

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