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Lillehei, Lewis, and Wangensteen: The Right Mix for Giant Achievements in Cardiac Surgery

2005; Elsevier BV; Volume: 79; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2005.02.078

1552-6259

Vincent L. Gott,

Coronary Artery Anomalies

The dawn of open-heart surgery occurred at the University of Minnesota on September 2, 1952, when Dr John Lewis and his surgical team closed an atrial septal defect using total-body hypothermia and inflow stasis. Eighteen months later on March 26, 1954, Dr C. Walton Lillehei and his surgical team used a parent as a biologic oxygenator to repair a ventricular septal defect in a 1-year-old boy. This technique of cross circulation was then used in a total of 45 children during the next 16 months to successfully repair tetralogy of Fallot, atrioventricular canal, and ventricular septal defect. Remarkably, two thirds of these children were discharged from the hospital. Thirty years later, Dr Lillehei reported that 17 of his 27 patients with repair of a ventricular septal defect had survived and were all New York Heart Association class I.These landmark operations in the open heart could not have been achieved by Drs Lewis and Lillehei without the remarkable support that they received from their surgical chief, Dr Owen Wangensteen. Doctor Wangensteen would later state in his book, The Rise of Surgery, that: "The outstanding contribution to the advancement of surgery in the 20th century has been the development of open-heart surgery." The dawn of open-heart surgery occurred at the University of Minnesota on September 2, 1952, when Dr John Lewis and his surgical team closed an atrial septal defect using total-body hypothermia and inflow stasis. Eighteen months later on March 26, 1954, Dr C. Walton Lillehei and his surgical team used a parent as a biologic oxygenator to repair a ventricular septal defect in a 1-year-old boy. This technique of cross circulation was then used in a total of 45 children during the next 16 months to successfully repair tetralogy of Fallot, atrioventricular canal, and ventricular septal defect. Remarkably, two thirds of these children were discharged from the hospital. Thirty years later, Dr Lillehei reported that 17 of his 27 patients with repair of a ventricular septal defect had survived and were all New York Heart Association class I. These landmark operations in the open heart could not have been achieved by Drs Lewis and Lillehei without the remarkable support that they received from their surgical chief, Dr Owen Wangensteen. Doctor Wangensteen would later state in his book, The Rise of Surgery, that: "The outstanding contribution to the advancement of surgery in the 20th century has been the development of open-heart surgery." I am deeply appreciative of the fact that Dr Bolman and his program committee have asked me to talk about the dawn of open-heart surgery at the University of Minnesota. Obviously, the seminal events that occurred at this medical center 50 years ago cannot be summarized in 20 minutes or 4,500 words, but I will try and give you a brief overview of those exciting days in the early 1950s, at least as I remember them.The dawn of open-heart surgery did occur right here at the University of Minnesota on September 2, 1952, when John Lewis closed an atrial septal defect in a 5-year-old girl using total-body hypothermia with inflow stasis (Fig 1). Doctor Lewis is seen on the near side of the table; the child was cooled to 82°F with a cooling blanket and rewarmed in a tank of warm water. This first patient made a successful recovery, and during the next 3 years, Dr Lewis successfully corrected atrial septal defects in more than 50 children. The surgeon standing on a stool behind Dr Lewis was a young faculty person by the name of Walt Lillehei, and he was heard to say as he left the operating room, "Boy, there's got to be a better way to do open-heart surgery than with total body hypothermia."Before moving on to Dr Lillehei's seminal achievement with cross circulation, it is important to note that modern closed-heart surgery commenced in 1938 with the ligation of a patent ductus arteriosus by Robert Gross at the Boston Children's Hospital. The next major step in closed-heart surgery occurred at the Johns Hopkins Hospital on November 29, 1944, when Alfred Blalock provided palliative treatment for the problem of tetralogy of Fallot with his operation that anastomosed the subclavian artery to the pulmonary artery. By 1950 Dr Blalock and his team had performed more than 1,000 of these Blalock-Taussig operations. In 1948 Clarence Crafoord in Stockholm corrected the coarctation defect, and in June of that same year, Drs Charles Bailey and Dwight Harken carried out successful closed mitral commissurotomies.Eight months after Dr Lewis's successful closure of an atrial septal defect, Dr John Gibbon successfully corrected the same lesion in an 18-year-old girl at Jefferson Medical College in Philadelphia using a new screen oxygenator that he had developed. This procedure, performed on May 15, 1953, was a monumental achievement. Unfortunately, Dr Gibbon's next 4 patients, all with a preoperative diagnosis of atrial septal defect, did not survive, and Dr Gibbon was so discouraged that he never again did open-heart surgery. There was a general feeling that these patients suffered from a "sick-heart syndrome" and needed to be supported on a heart-lung machine for a week after surgery. And so, at the end of 1953 and early 1954, there was a deep feeling of pessimism that open-heart surgery might never be successful.This general discouragement about open-heart surgery changed drastically on March 26, 1954, when Dr Lillehei closed a ventricular septal defect (VSD) in a 1-year-old boy (Fig 2). In this photograph we see Dr Lillehei (wearing a headlight) on the patient's right; his first assistant is Richard Varco. Behind Dr Lillehei are two residents, Drs Morley Cohen and Herbert Warden, who worked on the cross-circulation technique in Dr Lillehei's laboratory. The operative field of the father, who served as a biologic oxygenator for his son, may be seen behind Drs Cohen and Warden. This is a day I will never forget as an intern on Dr Lillehei's service; I am standing behind Dr Varco. The individual on my right was a third-year resident by the name of Norman Shumway.Fig 2Doctor C. Walton Lillehei's first cross-circulation case performed on March 26, 1954, for repair of a ventricular septal defect (see text for details).View Large Image Figure ViewerDownload (PPT)Unfortunately, Dr Lillehei's first patient died of pneumonia 11 days postoperatively; however, the next 2 children had successful repairs of a VSD. During the next year, Dr Lillehei and his team operated on 45 children using cross circulation. Time does not permit description of the remarkable success of this technique, but using cross circulation, Dr Lillehei along with his team was the first surgeon to successfully correct VSD, tetralogy of Fallot, and atrioventricular canal. Remarkably, two thirds of these children were discharged from the hospital. Among those children who died, heart block was a major cause of mortality as the use of the pacemaker and a myocardial wire was not introduced until January 1957 by Dr Lillehei and his team.Ten of Dr Lillehei's cross-circulation patients had a tetralogy of Fallot or a pulmonary atresia defect. On April 27, 1955, Dr Lillehei presented the results of these 10 children at the American Surgical Association meeting in Philadelphia [1Lillehei CW, Cohen M, Warden HE, et al. Direct vision intracardiac surgical correction of the tetralogy of Fallot, pentology of Fallot and pulmonary atresia defects. Ann Surg 155;142:418–45.Google Scholar]. The surgical outcome for these 10 tetralogy patients is presented in Table 1. Four of these children did die in the early postoperative period, but 6 were discharged from the hospital. It is important to note that Dr Lillehei was operating on a beating heart; he had no cardiotomy sucker, and the VSDs in the first 7 patients were closed without a patch; it was only the final 3 patients in this series who had the benefit of a patch. For me, the remarkable thing about this series of tetralogy patients is the duration of bypass time; it may be noted that for a number of these children, cardiac bypass time was 6, 9.5, and 20 minutes; the longest bypass time was 21.5 minutes in patient 10. In preparing this paper I was able to look over most of the more than 600 papers that Dr Lillehei published, covering everything from the first successful mitral valve repair in 1956 to the first clinical use of a pacemaker and myocardial wire in January 1957 to the implantation of the many newly designed prosthetic valves from his laboratory. The results we see in this table, that is, the first report of successful repair of the tetralogy defect with only 6 to 20 minutes of bypass time, represent for me, at least, Dr Lillehei's most remarkable achievement. Figure 3 depicts the operative repair of the 22-month-old child with pulmonary atresia; the VSD has been closed without a patch, and the right ventricular outflow track is being opened through the infundibular muscle with a modified Hartmann tonsil punch (Figs 3A, 3B). The ventriculotomy was closed without an infundibular patch (Fig 3C). This child made a successful recovery.Table 1Clinical Data on 10 Patients Undergoing Correction of Tetralogy of Fallot Using Cross CirculationCase No.AgeWeight (kg)Total Bypass Time (min)Results111 years26.411.5Excellent214 years38.69.0Died, 1 hour318 months7.76.0Died, 12 hours419 months8.59.5Excellent52.5 years9.310.0Died, 2 hours6aThis patient had pulmonary atresia.22 months10.020.0Excellent73.5 years13.012.0Died, 11 hours818 months9.516.0Excellent97 years16.816.5Excellent1010.5 years26.021.5Excellenta This patient had pulmonary atresia. Open table in a new tab Fig 3Successful repair of tetralogy of Fallot with pulmonary atresia using cross circulation (see Table 1 and text for details).View Large Image Figure ViewerDownload (PPT)When Dr Lillehei presented this series of 10 tetralogy patients at the 1955 American Surgical Association meeting, Dr Gibbon was the president of the association and moderator of this particular session. Doctor Gibbon invited Dr Blalock to be the initial discusser, and I quote the first paragraph of Dr Blalock's discussion: "I suspect it's a mistake for an old conservative surgeon to discuss this paper. I must say that I never thought I would see the day when this type of operative procedure could be performed. I want to commend Dr Lillehei and Dr Varco and their associates for their imagination, their courage and their industry."During the 13 months that Dr Lillehei was using cross circulation to correct a variety of ventricular defects, no other surgeon attempted this type of repair. The next surgeon in this country to correct a ventricular septal defect was Dr John Kirklin using the Gibbon oxygenator at the Mayo Clinic on March 22, 1955. And so for the next year, the only two active open heart centers in this country were 90 miles apart in Minneapolis and Rochester. We would later learn that in July 1954, Dr Clarence Crafoord in Stockholm, using a disc-oxygenator developed by Dr Ake Senning, successfully resected a left atrial myxoma, and Dr Forest Dodrill successfully repaired a VSD in a 3-year-old girl on December 1, 1955, at Harper University Hospital in Detroit. Doctor Dodrill used a bubble-oxygenator that he developed with General Motors for this operation [2Stephenson L.W. Arbulu A. Bassett J.S. et al.Forest Dewey Dodrill: heart surgery pioneer: Michigan Heart, Part II.J Card Surg. 2002; 17: 247-257Crossref PubMed Scopus (8) Google Scholar]. The fourth surgeon in this country to move ahead with total correction of VSDs was Dr Denton Cooley who did his first VSD repair on April 5, 1956, using a DeWall bubble-oxygenator.In looking back at Dr Lillehei's other memorable papers, certainly the 30-year follow-up of his cross-circulation patients presented at the 1985 Annual Meeting of The Society of Thoracic Surgeons has to be included. In this paper [3Lillehei C.W. Varco R.L. Cohen M. et al.The first open-heart repairs of ventricular septal defect, atrioventricular communis and tetralogy of Fallot using extracorporeal circulation by cross-circulation a 30 year follow-up.Ann Thorac Surg. 1986; 41: 4-21Abstract Full Text PDF PubMed Scopus (96) Google Scholar] Dr Lillehei summarized the long-term results in 45 patients undergoing cross circulation (Table 2). Remarkably, 17 of his 27 patients with VSD were 30-year survivors, and all were New York Heart Association class I at the time the paper was presented in 1985. Six of the 10 tetralogy patients operated on were discharged from the hospital. Atrioventricular canal was a very difficult defect to repair in 1955 and 1956, primarily because of the limited open heart time and the prevalence of postoperative heart block in these patients. Two of the three hospital deaths among the 5 patients undergoing atrioventricular canal repair resulted from heart block.Table 2Thirty-Year Follow-up on 45 Patients Undergoing Cross-Circulation Operations March 26, 1954–July 19, 1955Cardiac DefectNumber of PatientsMortalityHospitalLateVSD2782Tetralogy of Fallot1044AV canal531Isolated infundibular pulmonic stenosis1Pulmonic stenosis, ASD and APVR11PDA with severe pulmonary hypertension1Total4516 (36%)7 (16%)APVR = anomalous pulmonary venous return; ASD = atrial septal defect; AV = atrioventricular; PDA = patent ductus arterious; VSD = ventricular septal defect. Open table in a new tab Doctor John Kirklin was the primary discusser of this paper at The Society of Thoracic Surgeons meeting, and I quote four sentences of his discussion. "We have just heard an exciting presentation by one of the most talented cardiac surgeons ever to work in this field. The remarkable results presented today and particularly the perfectly magnificent early papers presented by Dr Lillehei, which you all should read, make him forever an inspiring, brilliant and memorable cardiac surgeon. To me, in addition, he was then and is now a friend, always willing to discuss his knowledge of cardiac surgery with anyone willing to learn. We were all fortunate to have heard this magnificent presentation today." Doctor Denton Cooley also discussed this paper and opened his discussion by saying, "I have two reasons for having an almost emotional response to Dr Lillehei's paper. First, as the 'J. Maxwell Chamberlain Memorial Paper,' it honors Dr Chamberlain, a gifted surgeon and close friend, and second, it recognizes C. Walton Lillehei, a talented investigator and pioneer surgeon who provided the can-opener for the largest picnic thoracic surgeons will ever know."This paper is entitled "Lillehei, Lewis, and Wangensteen: the right mix for giant achievements in cardiac surgery" (Fig 4). Certainly, John Lewis's closure of an atrial septal defect and Walt Lillehei's achievement in cross circulation that followed 2 years later could not have taken place if it had not been for the remarkable opportunities that were provided at the University of Minnesota in the early 1950s by the chief of surgery, Dr Owen Wangensteen. Doctor Lillehei stated in an unpublished manuscript entitled "The first: open heart surgery, pump-oxygenator, pacemaker and other new technologies," that: "The successful development of intracardiac surgery at the University of Minnesota was an important result of Dr Wangensteen's unique training program which placed a heavy emphasis upon the relevance of basic science and research in the teaching of young surgeons. These men with minds prepared by research had a competence and readiness to cast aside long-standing beliefs, customs and traditions in approaching unsolved problems." Doctor Norman Shumway stated in his paper, "C. Walton and F. John," which he presented at Dr Lillehei's 80th birthday festschrift: "Probably Wangensteen's greatest attribute was his total lack of envy. When his colleagues became world leaders in cardiac surgery, he fully supported their celebrity and took great pride in their accomplishments" [4Shumway N.E. Walton C. John F. et al.Ann Thorac Surg. 1999; 68: S34-S36Abstract Full Text Full Text PDF PubMed Google Scholar].Fig 4Doctors C. Walton Lillehei, F. John Lewis, and Owen H. Wangensteen.View Large Image Figure ViewerDownload (PPT)Doctor Lillehei is generally considered as the father of open-heart surgery because of his pioneering work in the repair of VSD, tetralogy of Fallot, and atrioventricular canal. However, during the next three decades many other pioneering achievements would emerge from his research laboratory. Most notably, these include the development of the Lillehei-DeWall bubble-oxygenator, the first use of a myocardial wire and pacemaker to treat heart block after ventricular defect repair, the first repair of a mitral valve, and the development of many different prosthetic valves, including the Lillehei-Kaster tilting-disc valve and the St. Jude bileaflet valve.Doctor Lillehei was the recipient of more than 80 significant awards and honors; probably his finest award was the Lasker award, which he shared with Drs Richard Varco, Herbert Warden, and Morley Cohen in 1955. This award is generally known as the American Nobel Prize; Dr Lillehei was nominated for the Stockholm Nobel Prize on a number of occasions—I am aware of 7 different years that Dr Lillehei was nominated for the Nobel Prize [5Documented nominations for the Nobel Prize in Physiology or Medicine were submitted for Dr Lillehei in 1986, 1988, 1990, 1992, 1994, 1995, and 1998. The nomination in 1995 was for Dr Lillehei and Dr John Kirklin.Google Scholar]. Other important honors include a festschrift issue of the Journal of Thoracic and Cardiovascular Surgery in November 1989 to commemorate Dr Lillehei's 70th birthday. Doctor John Kirklin was the editor of the journal at that time; it was only the second time that the journal had honored a surgeon by devoting a complete issue and cover to that surgeon. The other occasion was in November 1984 when the journal commemorated the 100th birthday of its founding editor, Evarts Graham.Although Dr Lillehei was, appropriately, very pleased with his many important scientific contributions to the field of cardiac surgery, he was probably most proud of his training of 154 cardiothoracic surgeons at the University of Minnesota and Cornell Medical Center between 1951 and 1979. As we indicated in a paper presented at the 70th Lillehei Festschrift in 1988 [6Gott V.L.C. Walton Lillehei and his trainees One man's legacy to cardiothoracic surgery.J Thorac Cardiovasc Surg. 1989; 98: 846-851PubMed Google Scholar], 23 of his 154 trainees became directors of cardiothoracic programs around the world; they, in turn, trained 477 additional surgeons. Twenty-one of these second-generation trainees became program directors and they in turn trained 164 surgeons. Two of these third-generation trainees became program directors and trained 25 additional surgeons. And so, a total of at least 820 cardiothoracic surgeons residing in 36 countries could trace their preceptor lineage back to Dr Lillehei. Very likely, during the last 16 years, the number of surgeons who can trace their training lineage to Dr Lillehei has at least doubled to approximately 2,000 trainees.How fast these past 50 years have gone: the cover of the March 2004 issue of the Journal of Thoracic and Cardiovascular Surgery commemorates Dr Lillehei's first cross-circulation case 50 years earlier. How fortunate for those of us trainees who happened to be in Wangensteen's department in the mid 1950s. I was also very fortunate to be invited into Dr Lillehei's laboratory a little more than a year after his first cross-circulation case. I cannot imagine another surgical mentor in the world who established such a close rapport and bond with his trainees. When we were in Dr Lillehei's laboratory, he would send down almost daily new ideas and suggestions that we could try in the open canine heart with Dick DeWall's new bubble-oxygenator. Doctor Lillehei was quick to give us credit for the things we did in the laboratory, publicly and in the authorship of our papers. We all have our memories of Dr Lillehei as a person; we all recognized his brilliance, his courage, and his fortitude; for me, though, one of his greatest attributes was his total approachability—he was always there ready to listen—he was always there as a friend and strong supporter.Doctor Wangensteen would later state in his book, The Rise of Surgery, that: "The outstanding contribution to the advancement of surgery in the 20th century has been the development of open heart surgery" [7Wangensteen O.H. Wangensteen S.D. The rise of surgery. University of Minnesota Press, Minneapolis, MN1978Google Scholar]. I am sure that most cardiac surgeons would agree that the man whom we primarily honor at this commemorative event, Dr C. Walton Lillehei, was the principal early contributor to the development of open-heart surgery. I am deeply appreciative of the fact that Dr Bolman and his program committee have asked me to talk about the dawn of open-heart surgery at the University of Minnesota. Obviously, the seminal events that occurred at this medical center 50 years ago cannot be summarized in 20 minutes or 4,500 words, but I will try and give you a brief overview of those exciting days in the early 1950s, at least as I remember them. The dawn of open-heart surgery did occur right here at the University of Minnesota on September 2, 1952, when John Lewis closed an atrial septal defect in a 5-year-old girl using total-body hypothermia with inflow stasis (Fig 1). Doctor Lewis is seen on the near side of the table; the child was cooled to 82°F with a cooling blanket and rewarmed in a tank of warm water. This first patient made a successful recovery, and during the next 3 years, Dr Lewis successfully corrected atrial septal defects in more than 50 children. The surgeon standing on a stool behind Dr Lewis was a young faculty person by the name of Walt Lillehei, and he was heard to say as he left the operating room, "Boy, there's got to be a better way to do open-heart surgery than with total body hypothermia." Before moving on to Dr Lillehei's seminal achievement with cross circulation, it is important to note that modern closed-heart surgery commenced in 1938 with the ligation of a patent ductus arteriosus by Robert Gross at the Boston Children's Hospital. The next major step in closed-heart surgery occurred at the Johns Hopkins Hospital on November 29, 1944, when Alfred Blalock provided palliative treatment for the problem of tetralogy of Fallot with his operation that anastomosed the subclavian artery to the pulmonary artery. By 1950 Dr Blalock and his team had performed more than 1,000 of these Blalock-Taussig operations. In 1948 Clarence Crafoord in Stockholm corrected the coarctation defect, and in June of that same year, Drs Charles Bailey and Dwight Harken carried out successful closed mitral commissurotomies. Eight months after Dr Lewis's successful closure of an atrial septal defect, Dr John Gibbon successfully corrected the same lesion in an 18-year-old girl at Jefferson Medical College in Philadelphia using a new screen oxygenator that he had developed. This procedure, performed on May 15, 1953, was a monumental achievement. Unfortunately, Dr Gibbon's next 4 patients, all with a preoperative diagnosis of atrial septal defect, did not survive, and Dr Gibbon was so discouraged that he never again did open-heart surgery. There was a general feeling that these patients suffered from a "sick-heart syndrome" and needed to be supported on a heart-lung machine for a week after surgery. And so, at the end of 1953 and early 1954, there was a deep feeling of pessimism that open-heart surgery might never be successful. This general discouragement about open-heart surgery changed drastically on March 26, 1954, when Dr Lillehei closed a ventricular septal defect (VSD) in a 1-year-old boy (Fig 2). In this photograph we see Dr Lillehei (wearing a headlight) on the patient's right; his first assistant is Richard Varco. Behind Dr Lillehei are two residents, Drs Morley Cohen and Herbert Warden, who worked on the cross-circulation technique in Dr Lillehei's laboratory. The operative field of the father, who served as a biologic oxygenator for his son, may be seen behind Drs Cohen and Warden. This is a day I will never forget as an intern on Dr Lillehei's service; I am standing behind Dr Varco. The individual on my right was a third-year resident by the name of Norman Shumway. Unfortunately, Dr Lillehei's first patient died of pneumonia 11 days postoperatively; however, the next 2 children had successful repairs of a VSD. During the next year, Dr Lillehei and his team operated on 45 children using cross circulation. Time does not permit description of the remarkable success of this technique, but using cross circulation, Dr Lillehei along with his team was the first surgeon to successfully correct VSD, tetralogy of Fallot, and atrioventricular canal. Remarkably, two thirds of these children were discharged from the hospital. Among those children who died, heart block was a major cause of mortality as the use of the pacemaker and a myocardial wire was not introduced until January 1957 by Dr Lillehei and his team. Ten of Dr Lillehei's cross-circulation patients had a tetralogy of Fallot or a pulmonary atresia defect. On April 27, 1955, Dr Lillehei presented the results of these 10 children at the American Surgical Association meeting in Philadelphia [1Lillehei CW, Cohen M, Warden HE, et al. Direct vision intracardiac surgical correction of the tetralogy of Fallot, pentology of Fallot and pulmonary atresia defects. Ann Surg 155;142:418–45.Google Scholar]. The surgical outcome for these 10 tetralogy patients is presented in Table 1. Four of these children did die in the early postoperative period, but 6 were discharged from the hospital. It is important to note that Dr Lillehei was operating on a beating heart; he had no cardiotomy sucker, and the VSDs in the first 7 patients were closed without a patch; it was only the final 3 patients in this series who had the benefit of a patch. For me, the remarkable thing about this series of tetralogy patients is the duration of bypass time; it may be noted that for a number of these children, cardiac bypass time was 6, 9.5, and 20 minutes; the longest bypass time was 21.5 minutes in patient 10. In preparing this paper I was able to look over most of the more than 600 papers that Dr Lillehei published, covering everything from the first successful mitral valve repair in 1956 to the first clinical use of a pacemaker and myocardial wire in January 1957 to the implantation of the many newly designed prosthetic valves from his laboratory. The results we see in this table, that is, the first report of successful repair of the tetralogy defect with only 6 to 20 minutes of bypass time, represent for me, at least, Dr Lillehei's most remarkable achievement. Figure 3 depicts the operative repair of the 22-month-old child with pulmonary atresia; the VSD has been closed without a patch, and the right ventricular outflow track is being opened through the infundibular muscle with a modified Hartmann tonsil punch (Figs 3A, 3B). The ventriculotomy was closed without an infundibular patch (Fig 3C). This child made a successful recovery. When Dr Lillehei presented this series of 10 tetralogy patients at the 1955 American Surgical Association meeting, Dr Gibbon was the president of the association and moderator of this particular session. Doctor Gibbon invited Dr Blalock to be the initial discusser, and I quote the first paragraph of Dr Blalock's discussion: "I suspect it's a mistake for an old conservative surgeon to discuss this paper. I must say that I never thought I would see the day when this type of operative procedure could be performed. I want to commend Dr Lillehei and Dr Varco and their associates for their imagination, their courage and their industry." During the 13 months that Dr Lillehei was using cross circulation to correct a variety of ventricular defects, no other surgeon attempted this type of repair. The next surgeon in this country to correct a ventricular septal defect was Dr John Kirklin using the Gibbon oxygenator at the Mayo Clinic on March 22, 1955. And so for the next year, the only two active open heart centers in this country were 90 miles apart in Minneapolis and Rochester. We would later learn that in July 1954, Dr Clarence Crafoord in Stockholm, using a disc-oxygenator developed by Dr Ake Senning, successfully resected a left atrial myxoma, and Dr Forest Dodrill successfully repaired a VSD in a 3-year-old girl on December 1, 1955, at Harper University Hospital in Detroit. Doctor Dodrill used a bubble-oxygenator that he developed with General Motors for this operation [2Stephenson L.W. Arbulu A. Bassett J.S. et al.Forest Dewey Dodrill: heart surgery pioneer: Michigan Heart, Part II.J Card Surg. 2002; 17: 247-257Crossref PubMed Scopus (8) Google Scholar]. The fourth surgeon in this country to move ahead with total correction of VSDs was Dr Denton Cooley who did his first VSD repair on April 5, 1956, using a DeWall bubble-oxygenator. In looking back at Dr Lillehei's other memorable papers, certainly the 30-year follow-up of his cross-circulation patients presented at the 1985 Annual Meeting of The Society of Thoracic Surgeons has to be included. In this paper [3Lillehei C.W. Varco R.L. Cohen M. et al.The first open-heart repairs of ventricular septal defect, atrioventricular communis and tetralogy of Fallot using extracorporeal circulation by cross-circulation a 30 year follow-up.Ann Thorac Surg. 1986; 41: 4-21Abstract Full Text PDF PubMed Scopus (96) Google Scholar] Dr Lillehei summarized the long-term results in 45 patients undergoing cross circulation (Table 2). Remarkably, 17 of his 27 patients with VSD were 30-year survivors, and all were New York Heart Association class I at the time the paper was presented in 1985. Six of the 10 tetralogy patients operated on were discharged from the hospital. Atrioventricular canal was a very difficult defect to repair in 1955 and 1956, primarily because of the limited open heart time and the prevalence of postoperative heart block in these patients. Two of the three hospital deaths among the 5 patients undergoing atrioventricular canal repair resulted from heart block. APVR = anomalous pulmonary venous return; ASD = atrial septal defect; AV = atrioventricular; PDA = patent ductus arterious; VSD = ventricular septal defect. Doctor John Kirklin was the primary discusser of this paper at The Society of Thoracic Surgeons meeting, and I quote four sentences of his discussion. "We have just heard an exciting presentation by one of the most talented cardiac surgeons ever to work in this field. The remarkable results presented today and particularly the perfectly magnificent early papers presented by Dr Lillehei, which you all should read, make him forever an inspiring, brilliant and memorable cardiac surgeon. To me, in addition, he was then and is now a friend, always willing to discuss his knowledge of cardiac surgery with anyone willing to learn. We were all fortunate to have heard this magnificent presentation today." Doctor Denton Cooley also discussed this paper and opened his discussion by saying, "I have two reasons for having an almost emotional response to Dr Lillehei's paper. First, as the 'J. Maxwell Chamberlain Memorial Paper,' it honors Dr Chamberlain, a gifted surgeon and close friend, and second, it recognizes C. Walton Lillehei, a talented investigator and pioneer surgeon who provided the can-opener for the largest picnic thoracic surgeons will ever know." This paper is entitled "Lillehei, Lewis, and Wangensteen: the right mix for giant achievements in cardiac surgery" (Fig 4). Certainly, John Lewis's closure of an atrial septal defect and Walt Lillehei's achievement in cross circulation that followed 2 years later could not have taken place if it had not been for the remarkable opportunities that were provided at the University of Minnesota in the early 1950s by the chief of surgery, Dr Owen Wangensteen. Doctor Lillehei stated in an unpublished manuscript entitled "The first: open heart surgery, pump-oxygenator, pacemaker and other new technologies," that: "The successful development of intracardiac surgery at the University of Minnesota was an important result of Dr Wangensteen's unique training program which placed a heavy emphasis upon the relevance of basic science and research in the teaching of young surgeons. These men with minds prepared by research had a competence and readiness to cast aside long-standing beliefs, customs and traditions in approaching unsolved problems." Doctor Norman Shumway stated in his paper, "C. Walton and F. John," which he presented at Dr Lillehei's 80th birthday festschrift: "Probably Wangensteen's greatest attribute was his total lack of envy. When his colleagues became world leaders in cardiac surgery, he fully supported their celebrity and took great pride in their accomplishments" [4Shumway N.E. Walton C. John F. et al.Ann Thorac Surg. 1999; 68: S34-S36Abstract Full Text Full Text PDF PubMed Google Scholar]. Doctor Lillehei is generally considered as the father of open-heart surgery because of his pioneering work in the repair of VSD, tetralogy of Fallot, and atrioventricular canal. However, during the next three decades many other pioneering achievements would emerge from his research laboratory. Most notably, these include the development of the Lillehei-DeWall bubble-oxygenator, the first use of a myocardial wire and pacemaker to treat heart block after ventricular defect repair, the first repair of a mitral valve, and the development of many different prosthetic valves, including the Lillehei-Kaster tilting-disc valve and the St. Jude bileaflet valve. Doctor Lillehei was the recipient of more than 80 significant awards and honors; probably his finest award was the Lasker award, which he shared with Drs Richard Varco, Herbert Warden, and Morley Cohen in 1955. This award is generally known as the American Nobel Prize; Dr Lillehei was nominated for the Stockholm Nobel Prize on a number of occasions—I am aware of 7 different years that Dr Lillehei was nominated for the Nobel Prize [5Documented nominations for the Nobel Prize in Physiology or Medicine were submitted for Dr Lillehei in 1986, 1988, 1990, 1992, 1994, 1995, and 1998. The nomination in 1995 was for Dr Lillehei and Dr John Kirklin.Google Scholar]. Other important honors include a festschrift issue of the Journal of Thoracic and Cardiovascular Surgery in November 1989 to commemorate Dr Lillehei's 70th birthday. Doctor John Kirklin was the editor of the journal at that time; it was only the second time that the journal had honored a surgeon by devoting a complete issue and cover to that surgeon. The other occasion was in November 1984 when the journal commemorated the 100th birthday of its founding editor, Evarts Graham. Although Dr Lillehei was, appropriately, very pleased with his many important scientific contributions to the field of cardiac surgery, he was probably most proud of his training of 154 cardiothoracic surgeons at the University of Minnesota and Cornell Medical Center between 1951 and 1979. As we indicated in a paper presented at the 70th Lillehei Festschrift in 1988 [6Gott V.L.C. Walton Lillehei and his trainees One man's legacy to cardiothoracic surgery.J Thorac Cardiovasc Surg. 1989; 98: 846-851PubMed Google Scholar], 23 of his 154 trainees became directors of cardiothoracic programs around the world; they, in turn, trained 477 additional surgeons. Twenty-one of these second-generation trainees became program directors and they in turn trained 164 surgeons. Two of these third-generation trainees became program directors and trained 25 additional surgeons. And so, a total of at least 820 cardiothoracic surgeons residing in 36 countries could trace their preceptor lineage back to Dr Lillehei. Very likely, during the last 16 years, the number of surgeons who can trace their training lineage to Dr Lillehei has at least doubled to approximately 2,000 trainees. How fast these past 50 years have gone: the cover of the March 2004 issue of the Journal of Thoracic and Cardiovascular Surgery commemorates Dr Lillehei's first cross-circulation case 50 years earlier. How fortunate for those of us trainees who happened to be in Wangensteen's department in the mid 1950s. I was also very fortunate to be invited into Dr Lillehei's laboratory a little more than a year after his first cross-circulation case. I cannot imagine another surgical mentor in the world who established such a close rapport and bond with his trainees. When we were in Dr Lillehei's laboratory, he would send down almost daily new ideas and suggestions that we could try in the open canine heart with Dick DeWall's new bubble-oxygenator. Doctor Lillehei was quick to give us credit for the things we did in the laboratory, publicly and in the authorship of our papers. We all have our memories of Dr Lillehei as a person; we all recognized his brilliance, his courage, and his fortitude; for me, though, one of his greatest attributes was his total approachability—he was always there ready to listen—he was always there as a friend and strong supporter. Doctor Wangensteen would later state in his book, The Rise of Surgery, that: "The outstanding contribution to the advancement of surgery in the 20th century has been the development of open heart surgery" [7Wangensteen O.H. Wangensteen S.D. The rise of surgery. University of Minnesota Press, Minneapolis, MN1978Google Scholar]. I am sure that most cardiac surgeons would agree that the man whom we primarily honor at this commemorative event, Dr C. Walton Lillehei, was the principal early contributor to the development of open-heart surgery. This study was supported in part by the Mildred and Carmont Blitz Cardiac Research Fund. The author wishes to thank Eileen Wright and Barbara Dobbs for their assistance in preparing this manuscript.