• Surgery First heart transplant in Spain with a technique that will increase the number of available organs
  • Hugo Stories, Story of a Heart

The vertiginous development of technology in the last 20 years has made it possible for us to be talking about artificial intelligence day in and day out. Advances in medical research have managed to increase survival against diseases such as cancer, even prolonging the life of patients with metastases and curing tumors that 20 years ago killed. But there are specialties in which enormous improvements have been made possible by innovations and discoveries of the middle of the last century. This is the case of cardiac surgery, whose great revolution took place 70 years ago with the invention of the extracorporeal circulation machine (ECC).

Until 1953 the heart was practically uncharted territory. Entering this organ was almost impossible because the moment the heart was opened the blood came out and the patient died. You worked on the surface, making small incisions or holes and putting your finger or a small device inside the heart to open some valve that was closed, but it was like working blindly. The American doctor John H. Gibbon had been working for years on the idea of a machine that would do the functions of the heart, which is to boost the blood, and oxygenate it properly (as the lungs do).

In 1937 he had shown that life could be maintained with such a support, but he did so in animal models (in cats and dogs) and with World War II his research was interrupted. On May 6, 1953, at Jefferson University Medical Center in Philadelphia, he used his heart-lung machine, developed with the collaboration of IBM, successfully shutting down an atrial septal defect in an 18-year-old patient. From blind surgery to open heart surgery, which caused an exponential growth to go from nothing to everything that resulted in the first heart transplant being done only 14 years later.

"This machine revolutionized cardiac surgery because until then it was anecdotal, only small operations were done, and thanks to this machine we can do everything we do today. Logically, technology has evolved and the device has changed, but the essence, the principle is the same: pump and oxygenate", explains Gregorio Rábago, head of the Cardiac Surgery Service of the Clínica Universidad de Navarra (CUN), who participates in an event organized on Tuesday 9 by the Spanish Society of Cardiovascular and Endovascular Surgery (Secce) to honor Gibbon's feat.

How the heart-lung machine works

To work inside the heart, the CEC machine, also called a heart-lung machine, is connected. The circulation of this organ, which is irrigated by the coronary arteries, has to be stopped. "We pinch the aorta and inject a substance that stops the heart. In the 50s it was acetylcholine and now we use cardioplegia, rich in potassium and nutrients. It's at 6 degrees and lowers the temperature of the heart and stops it at what we call diastole stop. That allows us to work with an empty and immobile heart. How do we reactivate it afterwards? Simply by removing the clamp from the aorta, the blood enters the coronary arteries and within a few minutes the heart spontaneously beats again. In some cases it takes a little longer and only occasionally you have to connect electrodes and stimulate it with a pacemaker, "says Rábago.

With the use, problems arose that were solved. "But you have to think that we are talking about 1953, how was the level of air transport or communications, compared to today, and the machines were rudimentary, with materials that were fundamentally metal, steel. Nor was there the knowledge of biology and physiology that there is today. Obviously the first steps were a failure and in fact Gibbon, after several patients who died, became so frustrated that he abandoned surgery and extracorporeal circulation. Other pioneers continued until they found the solution to the problems that were arising and managed to bring surgery to what it is today, but cardiac surgery has always been based on successes and failures, "says Rábago.

The specialist talks about the value shown by the professionals. "All those who started in this era had very severe failures and only the courage they had to admit failure and continue made them evolve. That's kind of the cardiac surgeon's view, that is, you have to accept failures to keep moving forward. And at that time much more."

John H. Gibbon, creator of the heart-lung machine. SECCE

But just as important as the cardiac surgeon is the work of the perfusionist, the one in charge of this heart-lung machine. "One of the great dangers of connecting the machine is that the blood when it comes into contact with a surface that is not the endothelium, it is not biological, it tends to thrombos. Heparin is used to make the blood liquid and prevent clotting. If an operation lasts 10 minutes you just need a dose of heparin, but if it lasts several hours you have to be checking the level of anticoagulation of the blood and adding the necessary doses. But not only that, we must also be sure that the oxygen supply we are making to the blood is correct, that the pH of the blood is not altered, control the amount of red blood cells there because during surgery part can be lost and they would have to be replaced ... I mean, it's a very important job. The three key pieces in heart surgery are the surgeon, the perfusionist and the anesthesiologist, and then the team that surrounds him, which are the instrumental nurses, "emphasizes Rábago.

A failure in the heart-lung machine can cause a very important failure in the patient, continues the CUN specialist. "The first perfusionists were surgeons for a matter of knowledge at that time; Then, logically, surgeons specialized more in heart repair and a generation of perfusionists who were already specifically trained took over. They are usually specialists who come from the branch of Nursing, although not necessarily, and have a super-specialized, very specific and very technical training". That is, the machine is prodigious but does not work alone. "It's like a car: without the driver it's worthless and the driver without the car isn't worth anything either."

How the machine has changed in 70 years

Rábago insists that the essence of this device remains the same in 2023, but obviously it has benefited from advances in technology and research and the machine of the 50s and now have nothing to do. "To begin with, at that time all the material was reusable (silicone tubes) and today all the material is disposable due to safety and infection standards (specific medical silicone or specific medical PVC). In the 50s there were no security or backup systems; Nowadays they are very sophisticated devices that have online pressure gauges, which are giving you at all times timely information on large monitors where you see at all times what is the oxygenation of the blood, the hematocrit, what is the hemoglobin, oxygen consumption, how that blood is oxygenated, etc. and at that time everything was done by sending a sample to the laboratory and waiting for them to return the information, " details the specialist of the CUN.

History of the CEC machine in Spain

In addition to all the knowledge of his specialty, caste comes to the greyhound and Rábago can tell almost firsthand much on the subject since he is the son of Dr. Gregorio Rábago Pardo, who performed the first heart operation with extracorporeal circulation in Spain, in December 1958, in which there was also a cousin of his father, Dr. Pedro Rábago. "Aunt of the two was Conchita Rábago, wife of Dr. Jiménez Díaz, who prohibited my father a little when he was orphaned in the year 39 and that's why he studied Medicine. At the end of the war, my grandfather, who was a lawyer, had a car accident and died of cardiac tamponade: from the blow there was a pericardial effusion, something that today would be silly, but at that time nobody dared to open the heart and pericardium. "

A patient with one of the first heart-lung machines. SECCE

After training at the University of Madrid, in 1952 Rábago Pardo went to General Surgery at the Provincial Hospital of Madrid with Dr. González Bueno. In January 1956 he received a scholarship from the Fundación del Amo and went to the USA where he came into contact with cardiac surgery at the hands of important specialists in Los Angeles, Philadelphia (with Bailey, another of the 'fathers' of cardiac surgery) and Harvard until October 1957, when he returned to Spain, to the Cardiac Surgery service of the Jiménez Díaz Foundation (at that time it was called Clínica de la Concepción). which had been inaugurated in the year 55. With the head of Service, Dr. Castro Fariñas, they began to experiment with dogs and in June 1958 the Fundación del Amo donated to the hospital the first extracorporeal circulation pump used in Spain, a Kay Cross.

That same year, Rábago Pardo took charge of the Cardiac Surgery Service and on December 10 performed the first open heart operation in our country. "Of that team that made it, there are two people alive, with more than 90 years. One is the head of Cardiology at that time, Pedro Rábago, my father's cousin, and the other is the surgeon Miguel Urquía, who was the perfusionist in that intervention, "says Rábago Jr.

The surgery - a pulmonary stenosis - went well, but after eight days the patient, 21, died of an adrenal hemorrhage. He was a patient with a history of tuberculosis and had a lung abscess. "A few days after his death, a session was set up at the medical-surgical association of Madrid, where there was a very bitter discussion between different professionals and it was criticized if it had been done correctly. Those who performed the intervention were all very young professionals, under 30, wanting to do things in a society that was still medically very conservative, but in the end it was concluded that what had to be done had been done and that was the starting gun, the first cardiac surgery services were created already with well-established extracorporeal circulation and the race has been unstoppable. to this day," says Rábago.

Although the comparisons are odious, Rábago says he has never been worried. "You always have a little more pressure, but my father had his career and I had mine. For me it has always been a pride to be my father's son and unfortunately I could not work long with him. I went abroad to complete my training, I was between the US and France, where my father died at the age of 62. It was the year 92 and he went to Paris to receive an experimental chemotherapy treatment, but he did not tolerate it well and ended up dying. However, the demand, the work and that the patient comes first I learned from him, "recalls the cardiac surgeon of the CUN.

Rábago ends up insisting on the courage to fail. "When you have a misfortune in the operating room, the next day you have to operate, you can not stop because if not, we do not advance. You lose one but you save 100, so the balance is positive." From the first surgeries to correct congenital alterations, or the next step that were valvular heart disease, through coronary surgery, to aortic aneurysms, heart transplants or artificial hearts, in all this rapid progress the heart-lung machine has been key, without which today we could not do transplants or all those open-heart interventions.

  • Cardiology
  • Transplants

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