University Times

Collectively, they walked a fine line between courage and recklessness in a field more closely entwined with life-and-death decisions than any other type of surgery. “Open Heart: The Radical Surgeons Who Revolutionized Medicine,” by surgery professor David K.C. Cooper, profiles the surgeons who, over the course of some seven decades, advanced the field of heart surgery from the repair of congenital defects through the development of heart-lung machines, artificial valves and hearts, coronary artery bypasses, open-heart procedures and transplantation techniques.

Cooper, who has led a research team at the Starzl Transplantation Institute since 2004, had the privilege of entering the field of heart surgery during the most exciting time in the specialty’s development. As a medical student at Guy’s Hospital in London, Cooper was influenced by two of its pioneers, Russell Brock and Donald Ross. “I’d read about them even before I was a medical student, so I was very enthused that this was the cutting age of surgery.”

Cooper was present when Ross performed the first heart transplant in the United Kingdom in 1968 and later worked with famed transplant surgeon Christiaan Barnard in South Africa before following him to the Oklahoma Transplantation Institute in Oklahoma City in 1987.

It was there that surgeon Nazih Zuhdi shared his observation that no one had documented the development of heart surgery from the surgeons’ perspective and, knowing that Cooper enjoyed writing, encouraged him to pursue their stories firsthand. “I’ve always been interested in medical history,” Cooper said.

Although a few of the major figures had died, Cooper was able to talk with many others, along with their rivals, colleagues and research staff. He recorded interviews over the course of 15 years then compiled the stories on weekends and in airports while maintaining his own career. “It was very much a part-time hobby.”

In his book, Cooper documents the backgrounds, achievements and motivations of the key players in the field, adding his own observations to the words of the doctors themselves and the recollections of their colleagues.

He delves into a world of sometimes-flawed personalities: a mixture of mavericks, nerds, partiers and workaholics whose competitive, sometimes contentious professional relationships and egos helped fuel the field’s progress.

Some professional rivalries caused long-term rifts, including one between Baylor colleagues Denton Cooley and Michael DeBakey. The decades-long feud began when Cooley, without permission, surreptitiously performed the first artificial heart implantation while DeBakey, his superior, was out of town. DeBakey opposed using the artificial heart in humans at the time because long-term survival in animals hadn’t been achieved. “He basically pinched DeBakey’s artificial heart and did a patient,” Cooper said. “They fell out over that and basically didn’t speak to each other for about 40 years.”

While some of the surgeons achieved rock-star fame, others worked in relative obscurity. Their recollections paint a picture of a heady time in the field where advances often came with a high price, both in the life-and-death nature of the work and its emotional impact on the doctors and their families.

Persistence — and the belief that lives that inevitably were lost were not wasted — marked many of the surgeons. Some, who apparently could not deal with the emotional impact of patients’ deaths, fell away. “A lot of people dropped out because they couldn’t take it. I can understand that. It’s so terribly stressful,” Cooper said.

One such surgeon was John Gibbon, who spent two decades developing a heart-lung machine, only to walk away from heart surgery forever after using it in surgeries on four patients. Three of the four died, “and he didn’t do it again,” Cooper said. Another, F. John Lewis, whom Cooper credits as being “the first surgeon in the world to operate inside the living human heart with an unimpeded view,” performed the historic operation in Minneapolis using hypothermia, which reduces the body’s need for oxygen. He later retired early from medicine to pursue personal interests in art, music and writing, aspiring unsuccessfully to play and sing in a piano bar. “He became to me a very sad figure, always searching for something to fill this void,” Cooper said, adding that Lewis received little recognition for his contributions.

Cooper characterized the group as the medical equivalent of the first astronauts, whose work in developing open-heart surgery “has had far more relevance to the average citizen’s everyday life than has the landing of men on the moon,” he wrote.

“A lot of them I liked very much,” said Cooper, “but probably overriding everything is admiration for Walt Lillehei, even though he had a lot of failings. I really feel he had the courage to do something that probably nobody else would.”

Lillehei, active in Minnesota during the 1950s and 1960s, frequently is recognized as the father of open-heart surgery. In conjunction with engineers, Lillehei pioneered the development of a portable heart pacemaker. He was known for performing surgery using cross-circulation, during which a parent’s circulatory system would be connected to a child’s to allow doctors to stop the child’s heart long enough to repair it while the parent’s heart pumped for them both.

However, Lillehei’s penchant for the partying lifestyle tarnished his reputation. His “riotous living” and a conviction for tax evasion cost him his job, although the judge opted to fine him and sentence him to community service rather than jail in recognition of the humanitarian value of his medical talent.

In reading Lillehei’s work as a junior doctor, “I thought, this was the real pioneer in the field. He took risks that you probably couldn’t do today,” Cooper said.

Cooper cited Barnard’s observations of working under Lillehei. “He said to me, ‘We’d go into the operating room on Monday, do one operation every day and at the end of the week have five dead patients. Next Monday we’d come back and do it again.’ It was that persistence. He knew eventually he was going to get it right.”

Cooper recalled his own experiences with Barnard, recounting the doctor’s response after Cooper’s team proved, using baboons, that a machine designed to preserve donor hearts so they could be transported, worked. “He said, ‘That’s fantastic. Next time we get a patient, we’ll do it in a patient. Next time we get a donor heart we’ll store it in the machine.’ I remember saying to him, ‘Wait a minute, we’ve only done six.’ And he said, ‘Does it work or doesn’t it work?’ I said, ‘Yes, it works.’ He said, ‘Well, do it in a patient. You can’t stay in the laboratory forever.’”

Cooper said, “I thought that was really good advice because in a lot of medical research, people work in research for their whole lives and nothing of it goes into the clinic. They’ve worked on mice or something or other. They’ve done all this work, and a lot of this medical research is not going to make an impact in the care of patients.

“To me, that’s why you’re in medical research — because you want to improve the care of sick people.”

Decades ago, advances could be tested immediately in a way that would not be possible today. “In those days, you didn’t have to go to the FDA or anybody; you just did it,” Cooper said. “There was no committee for animal research. If you thought it was ethical, you did it. You didn’t have to go to the committee to ask their permission. And there were no committees for human research.”

Some practices would be unthinkable today. Cooper’s book includes a reprint of the consent form obtained by transplant surgeon James Hardy in 1964, three years before Barnard’s groundbreaking human heart transplant.

“They used a chimpanzee heart. I call attention to this in the book because the consent form the patient’s family signed — the patient couldn’t sign because he was already comatose — was one paragraph. It says they’d never done a heart transplant. It doesn’t mention anything about using a chimpanzee. If you did that today, just think about the medical-legal things — there’d be all sorts of trouble. You’d be sued like mad,” he said.

“But that was normal at the time. That’s just the way they did things.”

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Cooper said he has been pleased with the response to his book, adding that he was especially encouraged by praise from Cooley. “He said to me, ‘I knew all these guys; you got them all right. Their contributions and their personalities, just right.’”

A colleague of Cooley’s, an expert in artificial hearts and assist devices, told Cooper the book is valuable for today’s young surgeons who don’t know how heart surgery came to be commonplace. “They think it’s always been easy like this. They don’t realize all these difficulties we had.”

Like many of the interviewees in his book, Cooper believes that the real progress in the field is over now that heart surgery has become routine.

“To some extent that’s why I moved out into other areas of research,” Cooper said. “There was very little excitement anymore in trying to do something new and trying to overcome problems.” Cooper said that in Cape Town in 1980, only half the transplant recipients surpassed the 1-year survival milestone. “When I gave up clinical work in 1996, our one-year survival was 96 percent,” he said.

As early as the 1980s, Cooper realized that the biggest problem with transplantation was a lack of donors. “That’s why I started looking at animals as a potential source of organs.”

While stem cells and regenerative medicine techniques are garnering attention, “I think it’s going to take a long, long time” before growing human organs will become a reality, he said. Cooper finds more potential in pursuing xenotransplantation, which he foresees as “the next great medical revolution.” His main focus now is “outwitting evolution,” as he puts it — through research into genetically modifying pigs to produce cells and organs for transplantation.

Genetically modified pigs are seen as a potential source for human-compatible organs, tissues and cells including corneas, kidneys, hearts, livers and lungs as well as islet cells and human immunoglobulin.

“Gradually we’re getting better at genetically manipulating the pig so the pig is more and more immune to the human rejection response,” he said. “The more you do to the pig, the less you have to do to the patient” to prevent rejection.

He sees potential with islet cells that could be transplanted into humans to cure diabetes — such pig cells already have successfully been implanted in monkeys.

Certain pigs also could be used to produce immunoglobulin that traditionally would be pooled from human donors. Sensitizing a modified pig to anthrax, for example, would produce antibodies that could protect military troops either as a precaution or after they’ve been exposed. “You can do this with any infectious agent you know about,” making such research useful in fighting bioterrorism in addition to its value in transplantation.

“Xenotransplantation would be the next big jump,” Cooper contends.

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Cooper’s current writing projects are a reference book on brain death that he is co-editing and, for more general audiences, a book written in collaboration with colleagues in the American Osler Society medical history organization.

That publication will profile physicians better known for something other than practicing medicine. Those “doctors of another calling” include St. Luke, Dante, Copernicus and modern figures such as runner Roger Bannister, revolutionary Che Guevara, actor Graham Chapman and novelist Khaled Hosseini.

—Kimberly K. Barlow