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History of Cardiac Surgery in Catalonia

On the past century the foundations were layed for the on come of modern surgery, by finding the solution to problems such as pain, hemorrhage and sepsis-infection).

The establishment of modern surgery in our country during the second half of the 19th century is due to Salvador Cardenal, who, from Catalonia, introduced the Lister antiseptic method to the rest of Spain(1).

In acknowledgement of his merits he was named Honorary member of the British Royal School of Surgeons. The culmination of his triumph came with the acclaim he received from all the surgeons present at the International Congress of Medical Sciences held in Amsterdam in 1879(2), in acknowledgement for his contributions.

With the appearance of antibiotics and the improvement of anesthesia, surgery had the necessary support to continue its development.

The last organs to resist surgical treatment were the heart and lungs. The opening of the thorax has been considered high risk surgery since it usually entails innumerable problems and complications.

The development of cardiac surgery is fairly recent. Apart from the attempts of a few surgeons who were too far ahead of their time to he understood and followed by others, we should consider that cardiac surgery appeared after the II World War. At this time, cardiac surgery experienced a rapid advance, as did the constant changes in techniques which allowed to rapidly overcome the limitations of heart surgery in favor of the advantages of open-heart surgery, first with time limitations with the use of hypothermia, and finally to present day techniques of surgery with extra corporeal circulation(3).

The beginnings of cardiac surgery in Catalonia as we know it today date back to the fifties decade. Its development took place outside the university. This is remarkable and can be explained by the fact that mid century surgery professors were more worried about avoiding the loss of their social position than about promoting the members of a team in the study surgical techniques.

In Barcelona, the development of cardiac surgery has been parallel to that of the rest of the world. A.Caralps Masó and J.Paravisini Parra introduced cardiac surgery in Catalonia using closed-heart techniques. Later, M.Castro Llorens used profound hypothermia and finally J.Reventós began the path that led to surgery with extra corporeal circulation.

Many secrets of the heart and circulation have been discovered thanks to cardiac catheterization and angiocardiography, techniques that have provided accuracy to clinical diagnosis and constituted an essential aid for the cardiac surgeon in his search for and localization of the lesion. The triumphs in the diagnosis of heart disease and postoperative intensive care have overcome many of the limitations of the surgical treatment of cardiac disease.

Until the advent of present day extra corporeal surgery hypothermia was used, crossed circulation with a human volunteer or the connection of the patient to a cardiac lung machine of limited use which only allowed a few minutes of cardiac arrest in order to repair a small defect. In spite of their limitations, the implantation of valvular prosthesis and by-pass operations have become widespread, allowing an incapacitated cardiac patient to attain a life with a reasonable quality level.

With the possibility of a heart transplant, a reality since December 3rd, 1967 when Christian Barnard tried it for the first time in the world, and the appearance of cyclosporine in the eighties decade, the horizons of cardiac surgery are even wider.

In Catalonia cardiac surgery experienced a similar development to that in other countries. We can distinguish several phases in its development:

Isolated facts in cardiac surgery.
Surgery specialization.
Appearance of specialized cardiac surgery centers.

* From History of Catalan Cardiology (1872-1992). Manuel de Fuentes Sagaz

1. Isolated facts in cardiac surgery:

At the beginning of the 19^th century, an important fact took place in relation to the advance of heart surgery. For the first time in the world, three pericardiotomies are practiced as a treatment for pericarditis with effusion.

In 1819, Francese Romero(4), born in Concabella (L’Aranyó, in the Segarra region of Catalonia), practiced the first pericardiotomy in the world, in Almeria, later publishing his results in the “Dictionnaire de la Société de Médecine”(Paris, 1818-19). He did it at least in three cases of patients in extremely serious condition with an important pericardial effusion. In two of these three cases he achieved clinical recovery.

At the end of the 19^th century, the opinion about the possible surgical operation of the heart was that Medicine could not be expected to do the impossible(5).

When Ludwig Rehn did the first cardiac suture in 1897, he did away with the erroneous belief based on Falopio's aphorism

that: «Vulnerato corde homo vivere non potest.»

Analogous to the 1897 results were those obtained by Ribas Ribas, who, in 1906 at the Hospital de Ia Santa Creu, sutured a cardiac lesion also produced by a knife(6). Due to the extreme severity of the patient's conditions there was no time to take her to the operating theater and she was attended in the emergency ward. It was the first cardiac suture done in Catalonia and possibly the first in Spain.

Three days later the patient died as a consequence of an empyema. The autopsy revealed that the suture had been effective. In his conclusions Ribas Ribas recommended heart surgery in all cases of cardiac wound.

2. Specialization in surgery:

When surgery was limited to a specific number of techniques, a single person could be acquainted with them and carry them out correctly. When the number of surgical techniques and their sophistication began to increase, the surgeons specialization became more necessary.

According to Moisès Broggi, A.Trias Pujol was the great creator of surgery specialization in Catalonia. At the end of the thirties, Trias established several sections in his General Surgery Chair, with people especially prepared and with expertise in the different specialized fields, under the hegemonious control of the general surgeon. These surgeons would later become the first specialists(7).

With the advent of cardiac surgery a certain conflict raised between the classical general surgeons and the pioneer cardiac surgeons. General surgeons would dare to operate anything; however, surgical incision on the heart required not only the application of anesthesia and asepsis, but also a better knowledge of cardiac pathology.

Cardiac surgery specialization in Catalonia was done via two paths: on the one hand, by thoracic or vascular surgeons who later specialized in cardiac surgery and learned cardiology, and on the other, surgeons who directly specialized in cardiac surgery.

The development of cardiac surgery has been parallel to the perfection and development of modern anesthesia methods. Cardiac surgery in Catalonia has closely wed world progress in this field, overcoming the difficulties of financially insufficient and non-technified hospital medicine.

The first catalan surgeons who acted on the heart were general surgeons, especially those with experience in thoracic surgery. Spurred-on by the first results obtained in cardiac surgery and its spectacularity, some surgeons carried it out spontaneously. Others like Caralps Masó, practiced it more frequently, attaining great professional success.

In the process of coming evermore closer to the heart, the first cardiac operations were done on the pericardium. The first pericardiectomy done in Barcelona was carried out by Caralps Masó in June 1936 on a patient of Codina Altés with constrictive pericarditis(8). This operation continued to be successfully practiced during the following years(9,10).

Operations on the heart began to take place in Catalonia in the fifties. The surgeon who did the first mitral commissurotomy in Catalonia was Valls Serra, who practiced it on October 25^th,1952 in Barcelona(11,12).

Another catalan surgical landmark was the first closure of a persistent ductus arteriosus by Soler Roig on July 23^rd,1947(13) applying the technique he had learned in London.

Arandes(14) and Piulachs(15-17), professors at the Medical School of Barcelona, also tried doing cardiac surgery but the results obtained made them desist. At this time, Caralps Masó stood out for his work as a cardiac surgeon. He was the first among us to practice the Blalock operation on Fallot's Tetralogy. This consisted of an anastomosis of the subclavian artery with the pulmonary artery, with the aim of alleviating the stenosis of the pulmonary artery(18).

He also successfully did mitral commissurotomy(19) one of the most widespread operations in these early years of cardiac surgery.

Of all surgeons, only Caralps specialized in cardiac surgery. He continued to practice it during all his professional life, also doing experimental cardiac surgery in a continuous way with his son Josep M.

Also outstanding is that J.Paravisini did the correcting surgery of an aortic coarctation for the first time in Spain on March 17^th, 1955(20).

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