Adrian Kantrowitz: the IABA and the LVAD

Philip R. Liebson, MD
Rush University, Chicago, Illinois, United States (Spring 2013)

Adrian Kantrowitz (1918-1998)

I first met Dr. Adrian Kantrowitz at my fourth-year surgery oral examination. He was one of three interviewers, and although I was sure that I failed the exam, he assured me that I had done well. I next met him almost 10 years later when I was a junior faculty member at the New York Hospital Cornell Medical Center. At this meeting, he proposed to have us use the new intra-aortic balloon counterpulsation device in our Coronary Care Unit for the treatment of cardiogenic shock. I can truly say that he not only found a way to treat cardiogenic shock in patient care, but also post-examination stress.

Kantrowitz was responsible for initial instrumentation of the intra-aortic balloon counterpulsation pump (IABP), left ventricular assist device (LVAD), heart transplant, and early version of the implantable cardiac pacemaker. He lived for 90 years (1918-1998) and continued his research into surgical technology well into his 80s.

He told his mother that he wanted to be a doctor when only three years of age and in childhood demonstrated his mechanical ingenuity by building an electrocardiograph machine from old radio parts assisted by his brother.1 He received his MD degree in 1943 from the Long Island College of Medicine, now the State University of New York, Brooklyn. Even during an internship in surgery, he published a paper on a new type of clamp to be used in craniotomy for brain surgery. Although he was interested in neurosurgery, the field was limited and he switched to cardiac surgery. After surgical residency at Mount Sinai Hospital in Manhattan, he was on the staff of Montefiore Hospital in the Bronx, and between 1955 and 1970 was on the staff of Maimonides Hospital in Brooklyn and on the faculty of SUNY Downstate, where I met him in 1959. A year before that, he had developed a heart-lung machine used for a congenital heart disease procedure on a young boy.1

In the early 1950s, Kantrowitz, working with his engineer brother, Arthur, reported on manipulating pressures and flows in the cardiac cycle in the coronary artery. They delayed augmentation of peak pressure in the arterial system from systole to diastole, augmenting diastolic flow into the coronary artery.2 This would later be the basis of the inter-aortic balloon pump.

This early experimental study resulted in further evaluation of augmentation of aortic diastolic pressure by wrapping diaphragmatic muscle around the aorta and stimulating it to contract during diastole, resulting in a significant boost to cardiac output while diminishing energy requirements of the left ventricle.2 In 1959, he reported on the use of this booster heart device using diaphragmatic muscle transposition to increase cardiac output by as much as 25%. This procedure was experimental, and Kantrowitz considered it premature to be used on humans. The dog he successfully operated on, however, was honored by the New York Academy of Sciences as the “research dog of the year.”1

From 1966 to 1970, his techniques were at the forefront of surgical intervention for failing hearts. He executed the world’s second permanent partial mechanical heart implantation in a human in 1966, although the patient died a day later because of liver disease. The device used in the procedure was a pump that responded to electrical stimulation from the heart. A second patient lived 13 days, but died of a stroke.1

At the same time, he worked on heart transplantation in a large number of dogs. When Christiaan Barnard performed the first human-to-human heart transplant on December 3, 1967, Kantrowitz performed the first heart transplant in the United States, from a brain-dead baby to a 19-day-old infant, with a severe heart defect. Unfortunately, the recipient died six hours after surgery.3

His greatest success was in the development of the IABP, initially utilized in patients with cardiogenic shock after myocardial infarction. The intra-aortic balloon pump device was triggered to the QRS complex of the electrocardiogram with a delay, so that the balloon at the tip of a catheter inserted in a retrograde manner from a femoral artery to the proximal descending aorta. The trigger caused helium to inflate the balloon, which increased diastolic pressure in the aorta, increased diastolic blood flow to the coronary arteries, increased cardiac output, and decreased the left ventricular myocardial oxygen consumption. In effect, the left ventricle was working less with increased oxygen availability.4

In a multi-institutional trial of the device used in refractory cardiogenic shock, 17% survived to leave the hospital and 9% lived for more than a year.5 Previously, this hemodynamic state would be uniformly fatal. The IABP came to be used not only for patients with cardiogenic shock, but also in patients with severe heart conditions who required surgery to decrease the work load of the left ventricle and maintain cardiac output. Over the next few decades, cardiogenic shock after myocardial infarction became less common because of earlier interventions and, when this condition developed, the use of the IABP with rapid PCI intervention or CABG improved survival.6

After 1970, his surgical team moved to Sinai Hospital in Detroit where he spent the remainder of his surgical career. In 1971, he implanted the first partial mechanical heart in a patient who could be discharged from the hospital, although the patient died three months after surgery. In 1983, he cofounded LVAD Technology, a company fostering research and development of cardiovascular devices.

In his last decade, Kantrowitz reported on his latest development—an electrically powered, pneumatically driven circulatory assist device that provided diastolic augmentation and systolic unloading of the failing heart. These were used in patients with end stage cardiomyopathy with hemodynamic and functional improvement. The results of the study were reported in Circulation in 2002, when Kantrowitz was 84 years of age!7

He died at age 90 of heart failure.

References

  1. http://en.wikipedia.org/wiki/Dr._Adrian_Kantrowitz.
  2. Kantrowitz A. Moments in history. Introduction of left ventricular assistance. ASAIO Trans 1987; 33:39-48.
  3. Kantrowitz A. America’s First Human Heart transplantation: ASAIO J 1998; 44:244-252.
  4. Kantrowitz A. Origins of intraaortic balloon pumping Ann Thoracic Surg 1990; 50:672-674.
  5. Scheidt S, Wilner G, Mueller H, et al. Intra-aortic balloon counterpulsation in cardiogenic shock. N Engl J Med 1973; 288:979-984.
  6. Kantrowitz A, Cardona PR, Freed PS. Percutaneous intra-aortic balloon counterpulsation Crit Care Clin 1992; 8:819-837.
  7. Jeevanandam V, Jayakar D, Anderson AS, et al. Circulatory assistance with a permanent implantable IABP: initial human experience. Circulation 2002;106 [Suppl I]:I-183-I-188.

 


PHILIP R. LIEBSON, MD, graduated from Columbia University and the State University of New York Downstate Medical Center. He received his cardiology training at Bellevue Hospital, New York and the New York Hospital Cornell Medical Center, where he also served as faculty for several years. A professor of medicine and preventive medicine, he has been on the faculty of Rush Medical College and Rush University Medical Center since 1972 and holds the McMullan-Eybel Chair of Excellence in Clinical Cardiology.

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