The Development of Surgery of Heart and Great Vessels in Japan;a History
Akira Furuse, Honorary President
The Japanese Society for Cardiovascular Surgery
probably no other area of medicine has shown such rapid development as has cardioaortic surgery. We are now at a stage when this type of surgery is being carried out safely on a daily basis on patients of almost all ages, including the very young and the elderly. This has been achieved as a result of the dedicated efforts and determination of medical staff, starting with surgeons specializing in the heart and great vessels, as well as the tears and fears of patients and their families who have chosen to undergo hazardous surgery. The modernization of Japan's cardiovascular surgery took a late start because of the Second World War, but the gap was later closed in a short time, and now Japanese results are on a par with those of the rest of the world. In this paper, we will examine the history of our nation's cardiovascular surgery, and enumerate the achievements that have contributed in high degree to this progress.
1. The early days of heart surgery
Before World War II, even on a world scale, cardiac and great vessel surgery was still in its infancy, and was limited to surgeries for pericarditis and cardiac trauma. In Japan, Seo of Chiba University performed pericardiectomies in three cases of constrictive pericarditis in 1928.
The first surgical operation for cardiac trauma in Japan was performed by Tohru Sakakibara of Okayama City Sakakibara Hospital. In 1936, he performed pericardiotomy on a construction worker, relieving that patient's cardiac tamponade, which had resulted from a stabbing in a fight, and he staunched the hemorrhage from the heart by pressure using gauze. In the following year, Ozawa et al. from Osaka University sutured a wound inflicted by an iron fragment in the right ventricle of a patient, which resulted in an impassioned discussion at a National Conference of the Japan Surgical Society between Sakakibara and Ozawa regarding the techniques used for hemostasis
Incidentally, in other countries, pericardiectomy has been performed since Weil's first operation in 1885, and suturing of the heart, since Rehn's 1896 operation, indicating that cardiac surgery in Japan had a much later start than that in the West.
2. Closed heart surgery
In Western countries, the full-scale development of cardiac surgery began around the time of the Second World War with closed heart surgeries by, for example, Gross's ligation of the ductus arteriosus in 1938, Blalock's anastomosis in 1944, Brock's pulmonary valvotomy in 1948, and Harken's mitral commissurotomy, also in 1948.
Thus, during the war, Japan lagged far behind Western countries in the field of cardiac surgery, but, in response to the resulting delays in development, there arose a strong cooperative spirit among Japanese surgeons to make up for lost time.
In Japan, the first case of surgical ligation of a patent ductus arteriosus was carried out on May 5, 1951, by Tohru Sakakibara; and Kimoto, of the University of Tokyo, also performed ductus arteriosus ligation on June 21 of the same year. Brock's procedure was first employed in Japan on the 10th of the next month in a case of pulmonic stenosis.
The Blalock anastomosis was performed by Kimoto on November 22, 1951, on a 6-year-old boy with tetralogy of Fallot. Kimoto proceeded to perform 10 more such operations within the next few months, and played a major role in the dissemination of surgical approaches to congenital heart disease in Japan
Mitral commissurotomy was performed by Tohru Sakakibara on July 18, 1952.
3. Normothermic open heart surgery
In 1951, Swan carried out normothermic removal of a shell fragment from a ventricle while both venae cavae were occluded, and in the same year, Varco used the same technique to treat pulmonic stenosis. The first attempt at normothermic open heart surgery was by Ozawa at Osaka University, who performed infundibulectomy in a case of tetralogy of Fallot in November 1954. This technique was applied in three cases, but its use was discontinued in 1955 because of time limitation.
In 1954, Lillehei devised the cross circulation approach using the heart and lungs of a parent of the patient, and successfully performed a number of open surgeries in cases of congenital heart disease, but this method did not come into wide use in Japan.
4. Hypothermic open heart surgery
The duration of circulatory occlusion is rigorously restricted to about three minutes, and the number of cases that can be treated with open heart surgery during this short period is limited. In 1950, Bigelow developed a general hypothermia technique that allowed for extension of this period of occlusion, and in 1953, Lewis et al. used this technique successfully in the surgical treatment of atrial septal defect. In this way, the advantages of hypothermic open heart surgery became accessible.
Shigeru Sakakibara et al. of Tokyo Women's Medical College performed open heart pulmonary valvotomy under general external hypothermia in a case of pulmonic stenosis on July 10, 1954; and on January 11, 1955, they used the same procedure in a patient with atrial septal defect.
Then, in a clinical case, Kimoto of the University of Tokyo performed selective cerebral perfusion hypothermia developed in experimental studies by Asano et al., and successfully carried out corrective surgery on January 17, 1955, on an atrial septal defect; on May 30, on a ventricular septal defect; and then, on November 16, on a tetralogy of Fallot.
In this way, the general external hypothermia technique of Shigeru Sakakibara et al. and the selective cerebral perfusion hypothermia method of Kimoto et al. became pivotal procedures that marked the dawn of open-heart surgery in Japan. The fact that these two were once fellow residents, but proceeded to compete in different institutions, and achieved so much, deserves special mention.
This method of hypothermia was further advanced by the experimental research of Watanabe, Okamura et al. at Tohoku University. They developed a method of profound hypothermia by immersion using deep anesthesia with ether, and announced at the Japanese Association for Thoracic Surgery meeting in December 1956 that circulatory arrest for an hour or two at a rectal temperature of 15° to 17°C was possible. This advance was also reported in a German Surgical Society meeting in 1958, and contributed to the development in 1959 of Drew's method of profound hypothermia by perfusion using an extracorporeal circulation. Thus, the advances made in Japanese cardiac surgery began to travel around the globe, and became a prominent influence in this field.
This technique of profound hypothermia by perfusion was then repeatedly used in a clinical setting by Okamura, Niizu et al., at Iwate Medical College, and was employed in 1961 for infant open-heart surgery by Horiuchi et al. at Tohoku University. Through being passed on to Dillard by Mohri, this method became known in the United States. In 1965, a combination of external hypothermia and rewarming by perfusion with a heart-lung machine was successfully utilized in infants by Higasa and Shirotani at Kyoto University. Then, during a period of study in New Zealand, Atsushi Mori gave the details of this method to Barratt-Boyes, through whom this procedure became known to the general world of surgery. In this way, Japan played an important role in the history of hypothermic open-heart surgery.
5. Open-heart surgery using heart-lung machine
The dissemination of the heart-lung machine in surgical practice relied on the development of several technologies and would not have been possible with the efforts of surgeons alone. In 1953, Gibbon succeeded in repairing an atrial septal defect using a screen-type artificial lung, and, with the added successes of Lillehei and Kirklin et al., the era of the heart-lung machine was born.
Since 1952, experimental research has been carried out in Japan, at Nagoya University, Keio University, the University of Tokyo, and Tokyo Women's Medical College, but clinical successes were slow to appear. The first success in open-heart surgery using a heart-lung machine was achieved only in 1956. On April 18 of the same year, Manabe of Osaka University carried out corrective surgery for tetralogy of Fallot. The successful operations with a heart-lung machine were carried out by Shigeru Sakakibara in a case of mitral insufficiency on April 24, Inoue of Keio University on an atrial septal defect on June 11, and by Kimoto to correct tetralogy of Fallot on September 15, and Japan became an active participant in the era of the heart-lung machine.
Artificial hearts initially had Sigma motors, but the considerable hemolysis, noise, and risk of a power cut were major problems in their use. In 1961, the roller pump appeared and remarkable progress was seen. Then, in 1984, the centrifugal pump came into use.
For artificial blood oxygenation, DeWall-Lillehei's bubble type oxygenators had limited capacity in both oxygenation and debubbling, and problems of hemolysis and the priming volume of blood were also present. From about 1961, rotating disc-type oxygenators came into use, and a significant improvement was seen. However, these were very large devices, and the priming volume was still substantial. What is more, prolonged preparation was needed, and a more user-friendly device was sought. The emergence of disposable bubble-type oxygenators met such needs. In 1966, a Japanese-made sheet-type bubble oxygenator was developed and distributed at an affordable price, and many institutions adopted it quickly. In 1970, a disposable, hard-shell foam oxygenator appeared, and was much easier to use, because it had a built-in heat exchanger, and the debubbling function lasted longer, so that the device could be used for longer periods. The new oxygenator model developed in 1972 was of limited usefulness at this initial stage because of the numerous design faults in both the original laminated type and the coil type. However, under the direction of Suma at Tokyo Women's Medical College, a hollow-fiber oxygenator came into use in 1981, and this type is still widely used.
With the development of artificial heart-lung machines, procedures for protecting the myocardium were also advanced significantly, and this contributed greatly to the success rate of open heart surgery. Initial-stage open-heart surgery was mostly performed with intermittent occlusion of the aorta at slightly reduced temperatures. This had the advantages of being quick but there were considerable problems due to myocardial ischemia, and although there were benefits in the results of reparative surgery of simple malformations such as atrial septal defect, more complicated procedures such as those used to treat tetralogy of Fallot failed to show improvement in success rates. For postoperative problems such as low cardiac output syndrome, considerable efforts were made to save the life of even one such patient.
However, in the late 1970's, the emergence of the method of cold cardioplegia offered a revolutionary step forward in maintaining the integrity of the myocardium, and the outcome of open-heart surgery improved greatly in many institutions. Owing to developments in extracorporeal circulation, myocardial protection, and pre- and post-operative management, the results in all branches of cardiac surgery showed improvement, and consequently, open-heart surgery became available for seniors and for infants with complicated congenital heart disorders, in both of whom it had not been feasible before.
In the area of ischemic heart disease, Sezai of Nippon University in February 1970 succeeded in carrying out a bypass from the aorta to the right coronary artery with a beating heart using an arterial autograft, and in June of the same year, Hayashi of Tokyo Women's Medical College performed anastomosis of the left internal thoracic artery with the left anterior descending branch using an extracorporeal circulation; and Asada from Kobe University performed a bypass from the aorta to the right coronary artery with the use of the great saphenous vein. The progress of methods of myocardial protection improved the safety of bypass surgery and coronary artery surgery came into wide usage in general hospitals. Furthermore, in the late 1990's, bypass surgery with a beating heart without the use of a heart-lung machine was introduced, and has come into frequent use because complications are less common. It is not an overstatement to say that Japan leads the world in the practice of this technique.
In recent years, with the constant high-speed international exchange of information, there is no longer anything that can be termed a purely Japanese type of cardiovascular surgery, for the field has become a globally interactive clinical colloquium. However, against this backdrop, the surgical techniques that were developed in Japan and are still in use include univentricular heart repair, intraventricular repair of the Taussig-Bing malformation, anterior enlargement of a small aortic annulus, and coronary artery bypass using the right gastroepiploic artery.
The first heart transplant in Japan was performed on August 8, 1969 by Wada at Sapporo Medical College. Owing to the inadequate communication of information to the general public by the medical societies of the time, there was considerable public mistrust of operations involving brain-dead donors, and for many years, heart transplants were not performed, so that, in terms of transplant surgery, Japan became a barren land. However, in view of the sustained efforts of Japanese surgeons, the Organ Transplantation Bill was passed in June of 1997, and heart transplants were resumed on February 28, 1999, by Matsuda of Osaka University.
6. Surgery of the great vessels
The world's first resection of an abdominal aortic aneurysm was performed in 1951 by Dubost, who replaced the aorta with a cadaver allograft. Japan's first abdominal aortic aneurysmectomy was carried out on July 25, 1952. Kimoto of the University of Tokyo in this case used an alcohol-preserved allograft as a replacement, and on February 18, 1953, in another case, transplanted a section of similarly preserved sheep's aorta. The former patient died seven years later of an aortoduodenal fistula, while the latter survived for 11 years before succumbing to a subarachnoid hemorrhage. Although, in the autopsies, the sheep's aorta showed some atherosclerosis, it had become indistinguishable from the patient's own aorta. In the first case in which an artificial graft for the abdominal aorta was used, Ohhara, at Tohoku University, used a nylon prosthesis, but in 1959, under the direction of Tatsuo Wada, the manufacture of crimped Dacron prostheses was initiated, and abdominal aortic aneurysm surgery began to spread.
Ascending aortic resection with lateral suturing was first performed by Kimoto. The surgery took place in November 1952, before any such operation had been attempted in the West, but the patient died 34 days later after the aneurysm recurred and then ruptured in its peripheral sutured portion. The first long-surviving Japanese case of ascending aortic resection with lateral suturing was that performed by Juro Wada in 1959. Ascending aortic replacement was performed with an extracorporeal circulation by Niitani et al. in 1967, and in the same year, Funaki et al carried out another such operation during circulatory arrest with the use of perfusion hypothermia. Both were successful.
Descending aortic aneurysmectomy was first done in July 1956 by Kimoto using a nylon vascular prosthesis. Kiyoshi Miyamoto of the University of Tokyo reported spinal fluid drainage during occlusion of the descending aorta to make possible protection of the spinal cord, a procedure that was an innovative step in Japanese vascular surgery and that is still in clinical use around the world.
The first replacement of the descending aorta in Japan in a case of dissecting aortic aneurysm was reported by Kisaku Kamiya of Nagoya University in 1962. This aneurysm was resected from just below the take-off of the left subclavian artery to just above the diaphragm using hypothermic anesthesia, and after eliminating the false lumen on the distal end, a Tetron graft was anastomosed to the true lumen. The patient recovered fully and lived a long life.
Successful removal of an aortic arch aneurysm using a temporary bypass method was achieved by Kimoto in 1960, and again by Juro Wada in the same year. Replacement of the aortic arch while employing a heart-lung machine was first reported by Takashi Miyamoto of Osaka University in 1964.
The most important aspect of aortic arch replacement is protection of the brain. However, after the experimental profound hypothermia method reported by Watanabe et al. in 1957 at Tohoku University, there was very little development, and cerebral hypothermia by perfusion was more frequently employed. Asano experimentally introduced selective cerebral hypothermia by perfusion for heart surgery, but also applied this method for aortic arch surgery, and in 1970 named this configuration a “separate extracorporeal circulation,” which he proceeded to publicize. After this, the selective cerebral perfusion technique developed fast in Japan, and yielded surgical results in aortic arch surgery that were of worldwide importance. Also in 1988, Ueda et al of Tenri Hospital introduced the retrograde brain perfusion method, which helped to spread the practice of aortic arch surgery in hospitals as a result of the ease of its application in emergency surgery, such as in aortic dissection.
Excision of thoracoabdominal aortic aneurysms was begun in 1966 by Shigeru Sakakibara. General external hypothermia was employed, and reconstruction of the abdominal aorta along with the celiac and superior mesenteric arteries was carried out using DeBakey's method. Full recovery was achieved.
One of the reasons for the improvement of surgical accomplishments in recent years has been the progress in artificial blood vessel development. The transplantation of synthetic grafts in areas of the body that require systemic heparin administration calls for low-porosity materials, but the woven Dacron grafts of former years became very hard to suture as a result of pretreatment. The material of the new woven Dacron graft, however, makes for much easier suturing.
7. National and international leadership by the Japanese
Society for Cardiovascular Surgery
The Japanese Association for Thoracic Surgery, which was established in 1948, was originally focused on general thoracic surgery, but reports on cardiac surgery became increasingly frequent. On the other hand, in 1972, the Japanese Council for Cardiovascular Surgery was formed in order to function as a new chapter of the International Society of Cardiovascular Surgery, and in 1975 became the Japanese Society for Cardiovascular Surgery. The names of the Presidents and Congress Chairmen are listed in the following chart. The Japanese Society for Cardiovascular Surgery, in conjunction with the relevant Societies, has taken on the responsibility of certifying cardiovascular surgeons, of managing the database, and has worked actively in areas such as medical ethics and safety management.
The international members of the Japanese Society for Cardiovascular Surgery are simultaneously members of the Asian Society for Cardiovascular and Thoracic Surgery. Seventy percent of the members of the Asian Society are members of the Japanese Society. The Asian Society for Cardiovascular and Thoracic Surgery has been actively involved as the third limb of the international cardiothoracic surgery network, together with the American and European Associations and Societies, and is active in ameliorating the relations among international societies. Members of the Japanese Society for Cardiovascular Surgery are making significant international contributions as nuclear members of the Asian Society for Cardiovascular and Thoracic Surgery.
Table 1. Presidents and Congress Chairmen of the Japanese
Society for Cardiovascular Surgery
|1972||Seiji Kimoto||Masahiro Saigusa||Tokyo|
|1992||Akira Furuse||Hitoshi Mohri||Sendai|