Portal de Periódicos da CAPES

Yesterday, Today, and Tomorrow

2003; Lippincott Williams & Wilkins; Volume: 49; Issue: 6 Linguagem: Inglês

10.1097/01.mat.0000096567.67742.cc

1538-943X

Steven J. Phillips,

Good morning. It is my pleasure to welcome you all to the 49th meeting of the American Society for Artificial Internal Organs. I am especially pleased as your President to welcome the International Society of Artificial Organs to Washington, DC, for the first joint meeting of our two societies. I have two passions in life—one is my family, as depicted here during a recent family gathering (Figure 1), and the other is medicine. The first ASAIO meeting I attended was in 1967 in Atlantic City. I was a first year surgical resident and was overwhelmed and awed to be in the company of the pioneers of this society. Little did I know that nearly 30 years later I would be standing here as your president. I am truly honored and humbled by this experience. Figure 1: Family picture during a recent vacation cruise.Yesterday, my early years were spent in surgical training with Dr. Adrian Kantrowitz, who is shown in Figure 2 with Dr. Joseph Krakauer, with one of the early intra-aortic balloon pump patients. 1 These were very exciting times for me as a young physician. These were the days of the initial implants of the mechanical auxiliary ventricle, the intra-aortic balloon pump (IABP), and the first cardiac transplants done in the United States. I want to tell you the story of the first patient to receive an IABP. Dr. Kantrowitz involved his clinical house staff in many of his research projects. Figure 2: Dr. Joseph Krakauer and Dr. Adrian Kantrowitz, at the bedside of one of the initial balloon pump patients.My assignment was the IABP. One afternoon Dr. Kantrowitz called me and said, “Steve, we’re ready for a clinical patient. Find me one.” As a first year surgery resident, I was responsible for covering the emergency room at night. In the break room next to the emergency room was a 24/7 poker game. The room was filled with cigarette smoke, empty pizza boxes, and people sitting in for a few hands of poker. That evening on my way home I stopped to check the ER and sat in for a few hands of 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 IABP.” 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. 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 the Chief of Cardiology. Drs. Tjonneland, Butner, and I inserted the first IABP. It functioned quite well and allowed the patient to survive. At 7 A.M. we called our respective chiefs who came running to the patient’s bedside with great trepidation. The reason was that in those days the department of medicine and the department of surgery were not on the most collegiate terms. In retrospect, I am sure that the IABP would never have been inserted if it were left up to the chiefs to decide. Shortly after Christian Barnard performed his historic heart transplant in Cape Town, South Africa, Dr. Kantrowitz performed a second transplant in the United States. It was done on a 3 week old baby utilizing deep hypothermia and circulatory arrest. The transplant was carried out in the middle of the night. The bathinette that we used for the transplant belonged to my first son, because the only bathinettes available were unacceptable for clinical use, as they were from the animal lab. As all the stores were closed and I had a newborn son, I ran to the house staff quarters and literally took my son’s bathinette out from under him (Figure 3). Figure 3: Preparing a 3 week old infant for the first US cardiac transplant using my oldest son’s bathinette. The procedure was performed utilizing deep hypothermia and circulatory arrest.This next picture (Figure 4) is of a young Dr. Phillips explaining the IABP to Dr. Christian Barnard and Dr. Walton Lillihei, Dr. Christian Barnard did not stay very long as he confided in me that there was a limousine waiting outside with Dean Martin and their dates. Dr. Barnard and I became fast friends. Figure 4: Explaining the function of the IABP. Left to right: Drs Krakauer, Phillips, Mamaleos, Kleinman, Lillehai, Barnard, Kantrowitz, and Tjoeland.The Vietnam War interrupted my surgical training. I spent 1968–1969 in Vietnam as a company surgeon with the 101st Airborne Division. Figure 5 shows my aid station on the left and getting ready for a chopper mission on the right. In Figure 6 I am shown on a beach, near Hue city, with a surfboard. War was hell, but someone had to surf. I did such a good job in Vietnam that they sent me back for a second tour prior to my discharge in 1970. Figure 5: A: Aid station. B: Preparing for a chopper mission.Figure 6: Surfing off the coast of Vietnam, circa 1968.I completed my surgical training with Dr. Kantrowitz in 1970. I did my fellowship in cardiopulmonary surgery at the University of Oregon with Dr. Albert Starr. In 1974 my family and I moved to Des Moines, Iowa, to establish a cardiac surgical program. I was busy from the day I arrived. In 1975 I embarked on our program of emergency coronary artery bypass surgery for patients with evolving acute myocardial infarction (AMI). We demonstrated that acute and timely intervention during evolving AMI salvaged myocardium and significantly reduced morbidity and mortality. 2 Though initially quite controversial, acute intervention for AMI is the established standard of care. I continued to work in the area of artificial organs. I developed a permanent balloon pump, which was implanted in two patients in 1975. The insertion was performed retroperitoneally with the pneumatic line exited through the iliac crest. The bone stabilized the driveline, and its vascularity resisted ascending infection. Both patients were discharged home and returned intermittently to the hospital for IABP, as you would treat a dialysis patient. In 1976, I patented and implanted a parallel aortic pump (PAP) in two patients. 3 The 100 cc PAP was pneumatically operated, exited through the iliac crest, and was pulsed during diastole utilizing a modified IABP console (Figure 7). Figure 7: A: Schematic of the parallel aortic pump. Note the pneumatic driveline exits through the iliac crest. B: Close-up view of the pumping chamber.In 1983, we described the technology for percutaneous femoral cardiopulmonary bypass. 4 This technology became widely accepted and is still in use (Figure 8). Figure 8: Percutaneous bypass via the femoral vessels, as shown above, was used in more than 50 patients.In addition to our own devices, we participated in clinical trials of commercially available left ventricular assist device (LVADs) and the total artificial heart (Jarvik). 5–7 A pump that caught my attention was the Wompler hemopump 8,9; this axial flow pump was the precursor to our modern day rotary LVADs such as the DeBakey and Jarvik systems. In the mid-1980s, I developed a disposable heart/lung machine. Figure 9 depicts utilizing a standard oxygenator fitted with axial flow pumps. The concept was to be able to pull the system from a package and connect a patient to bypass. The system used three pumps. There was a larger arterial return pump and two smaller pumps—one for cardioplegia and the other for suction. The system worked quite well in the animal laboratory, but I was never able to find an industry sponsor to bring the system to clinical application. Figure 9: Prototype disposable heart lung.The book and the movie, The Hunt For Red October, involved a top-secret submarine with a silent propulsion system based on magneto hydrodynamics (MHD). MHD propels fluids with magnetic pulses. This next picture (Figure 10) shows a small pump that we developed in our laboratory based on magneto hydrodynamics. The pump had no moving parts and functioned very well in a mock circulation loop of a cardiogenic shock model. We published these data describing our shoe box sized magneto hydrodynamic pump that was able to flow at 4 L/min. 10,11 Approximately 1 month after publication, we were visited by representatives of the Department of Defense who wanted to know how we were able to successful apply magneto hydrodynamics to the circulatory system when they, after millions of dollars and 20 years of research, could barely get it to work. We spent some time collaborating with the government scientists working at the secret Department of Defense Argon laboratory outside of Chicago. I was never made aware of the outcome of the government research and we discontinued our project due to lack of funds. Figure 10: Prototype magneto hydrodynamic pump. This pump contained no moving parts. It was able to propel blood in a mock circulation shock loop at 4 L/min.In 1985 we were approved to perform cardiac transplants. Figure 11 is a picture of two boys who were born to one of my young transplant patients. I believe this is the first time a female cardiac transplant recipient had a child. Figure 12 shows me with Dr. James Hardy. Dr. Hardy performed the first lung transplant in the world in 1962 and in 1963 implanted a gorilla’s heart into a man. This operation was performed at the University of Mississippi. The fact that a gorilla’s heart was implanted into a white man was not well accepted by the Ku Klux Klan. Figure 13 is a picture from my research in xenotransplantation. This work was done at the cardiovascular research laboratory at the veterinary college at Iowa State University. My experiment involved implanting a piglet heart into the neck of calves. The piglet heart was removed and preserved. Following total body washout of the piglet with saline, the calves’ blood was cross-circulated through the piglet. The piglets’ carcass was used as a biological filter to remove the calf’s preformed xenoreactive antibodies. The calf also received anti-complement cobra venom, azthroprine, cyclosporine A, and steroids. Our controls had zero survival, whereas our treated animals survived up to 10 hours. 12 We had to terminate these experiments due to lack of funding as well.Figure 11: Two sons born to a young female cardiac transplant patient. Against my advice, she became pregnant twice.Figure 12: Dr. James Hardy performed a human lung transplant in 1962 and a xenocardiac transplant in 1963.Figure 13: Calf on the operating room table awaiting a piglet heart.My today includes a series of interviews by the White House search committee for the position of Commissioner of the Food and Drug Administration. In 1998, as the representative for ASAIO, I testified before the entire Committee on Commerce as a witness on the implementation of the Food and Drug Administration Modernization Act of 1997. 13 In 1997, I retired from active practice following my third spine surgery in 5 years. In 1999 I took the position as Director of Research and Education at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The NIH is the largest and most prestigious biomedical research organization in the world. Some of my responsibilities at the NIH included support and oversight of the data collection for the human genome project; the visible human project; programs related to food safety, toxicology, and environmental health; disaster management; and biological and chemical terrorists agents. I developed projects with third world medical groups and universities that would allow them to connect to the Internet to access medical information. I retired again in 2002 but remain a consultant to the NLM Board of Regents. Tomorrow has arrived. The 21st century is emerging as the molecular century. The use of nanotechnology, robotics, genetics, hybrid tissue scaffolding, and artificial intelligence will transform our world. Cloning will become part of our everyday science. We will grow organs using genetic cloning and stem cell technology. The bionic human will become a reality. We will be able to grow eyes, livers, hearts, and kidneys—a true six million dollar man. Cell lines will be created to regenerate replacement parts. Much of this work will be led by ASAIO in partnership with industry, government, academic health centers, and research institutes. ASAIO and its members will continue to improve the quality of life through medical and biomedical science ASAIO has 1,400 members from 40 different countries with 30 different professional degrees. We are the home of next generation medicine and cutting edge research. The first meeting of ASAIO occurred in the Carlyle hotel in Atlantic City on June 4, 1955. We will be 50 years old in 2004. Thank you very much for the privilege of addressing you as your 49th President. Acknowledgment I want to thank Rachel Phillips for her technical assistance in preparing this manuscript.