Dr. Robert E. Gross and first operations in cardiovascular surgery

Robert E. Gross (1905-1988)

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

There is a myth that Dr. Robert E. Gross (1905-1988), a Harvard surgeon, performed the first cardiovascular surgery. There is no question that he performed the first successful major operation on the great vessels near the heart in which the patient survived, the ligation of a patent ductus arteriosus on August 26, 1938. He also performed the first successful correction of coarctation of the aorta in 1945. He made many contributions to the development and practice of cardiovascular surgery in his long career.

Let us not overlook, however, the first successful repair of a heart wound, by Daniel Hale Williams, an African-American surgeon, in 1893 at the Provident Hospital in Chicago. Going even further back, in 1801, Francisco Romero, a Spanish surgeon, operated on the pericardium. On the heart itself, we can look back to 1895 at the Rikshospitalet in Kristiania (Oslo after 1905), when Axel Cappelen ligated a bleeding coronary artery from a stab wound. In fact, even before Dr. Gross’ successful operation on the patent ductus, another surgeon at the Massachusetts General Hospital the previous year, successfully ligated the patent ductus but the patient became septic and died shortly. Even most interestingly, Charles A. Lindbergh assisted Alexis Carrel in developing an extracorporeal system to support organs during surgery, in experiments at the Rockefeller Institute in the mid-1930s.

Robert Edward Gross, however, provided a consistently outstanding practice in pediatric cardiovascular surgery over a period of 40 years, and from 1947 to 1966, was the surgeon-in-chief of the Children’s Hospital in Boston and William E. Ladd Professor of Surgery at Harvard Medical School. Although he was born and raised in Baltimore, Gross spent summers as a youth working on a Minnesota farm since he enjoyed the outdoors. Therefore it is not surprising that he received his college education at Carleton College in Northfield, Minnesota. Reading Harvey Cushing’s biography of Sir William Osler led to a desire to study medicine at Harvard Medical School, where Cushing was teaching at the time. He just did not walk into Harvard; he had the credentials of Phi Beta Kappa at a highly respected liberal arts college. He became a top student at the medical school and earned the honor of membership in Alpha Omega Alpha, the honorary academic society.

After medical school, he underwent two years of training in pathology at the various hospitals attached to Harvard under the mentorship of SB Wolbach, the Professor of Pathology. During this period, he enjoyed interruptions for horseback riding on weekends at Wolbach’s stables in Framingham. There must be something in the air of Framingham that makes it a cradle for the development of medical advances. During this period, Gross studied much autopsy material of anomalies of the heart and great vessels.

Gross then spent several years as a resident in surgery under Elliot Cutler at the Peter Bent Brigham Hospital. Cutler, who had performed several operations on mitral stenosis as far back as 1924, had predicted that the first operation on the great vessels would be a ligation of a patent ductus. After surgical training at the Brigham, Gross spent almost a year as a traveling surgical fellow in Britain and the continent. It was 1938 and Gross, now 33 year of age, was chief surgical fellow at Boston Children’s Hospital. Working with a young pediatrician, they followed up on Cutler’s prediction by perfecting a technique to ligate the patent ductus.

 

Cross-section of the heart depicting the patent ductus arteriosus

Let us step back a little and discuss the pathophysiology of this condition. The ductus, which is a short channel between the top of the descending aorta and the pulmonary artery, is normally open during gestation, providing blood to the aorta from the pulmonary artery since the heart cannot pump blood adequately from the left side of the heart during gestation. The ductus usually closes at the time of birth. If it remains open, the left ventricle has to work harder since it is delivering blood both to the systemic circulation and to the lower pressure pulmonary circulation, in effect creating a high output from the left side of the heart. This eventually leads to failure of the left ventricle as well as an increased pressure in the pulmonary arterioles. In some ways the pathophysiology is similar to that of a ventricular septal defect, both involving a left to right shunt with increasing work of the left ventricle. With ligation of a patent ductus, however, the heart is not involved in the surgical procedure, and at the time a closure of a ventricular septal defect could not have been accomplished because cardiopulmonary bypass had not yet been developed.

Gross performed his first ligation on a 7-year-old girl, having gotten permission from the acting chief of surgery at the hospital while Cutler was away. This was a resident performing as chief surgeon using a new technique on a condition that had never been treated surgically! Some situations that you could get away with in 1938 could never happen now, including annexation of one European country by another. The operation was successful; the girl was out of bed the next day and was discharged 10 days later.

Following this procedure, 10 other children were operated successfully by ligation of the ductus. However, an eleventh child died suddenly two weeks after the procedure and on autopsy was found to have a massive hemorrhage from separation of the ligature. Following this, further procedures were no longer accomplished by ligature but by clamping both sides of the ductus, cutting the connection, and suturing the clamped sides. He eventually performed a total of 1,610 ductus operations up through 1972.

In the 1980s, when Gross had retired to Vermont, his first patient, now 58, called on him. During their the visit he remarked, “If you hadn’t made it, I might have ended up here in Vermont as a farmer.”

 

Cross-section of the heart illustrating the coarctation

of the aorta

Following his successes with patent ductus, Gross studied techniques to open coarctations of the aorta. A coarctation is a narrowing in the descending aorta around the location of a previous ductus. Because of this, the back pressure builds up in the proximal aorta and the left ventricle, producing hypertension and possibly leading to left ventricular failure. Complications can also include a decrease in blood flow to the periphery, especially if an associated patent ductus is present. Gross’s initially animal studies to repair a coarctation were marked by failure. The coarctation could be alleviated by removing the narrowed area and creating a channel from the proximal to the distal part of the aorta but there was frequent hind leg paralysis in the animals. At that time Dr. Charles Hufnagel, eventually a pioneer in heart valve surgery, was an assistant resident. He worked with Gross and used hypothermia on the dogs immediately after the operation, which prevented the paralysis. Hypothermia was accomplished by laying the dogs in a bed of ice after the procedure. In 1945, Gross performed the first successful coarctation correction operation on a patient. In many of the patients, an arterial graft was necessary to connect the proximal and distal ends of the aorta around the dissection. Until retirement, Gross had performed over 800 of these operations successfully.

Other congenital procedures that he pioneered included repair of a double aortic arch and total anomalous pulmonary venous drainage, that is, the veins draining into the right atrium or venae cavae instead of the left atrium. In this condition, there would be no blood going into the systemic circulation unless there was a residual patent ductus and/or atrial septal defect, frequently present in this condition. The treatment was to clamp and cut the pulmonary veins, frequently in fact a common pulmonary vein, and anastomose the vein into the left atrium. In order to do so successfully, Gross and his colleagues devised a pump oxygenator, necessary for operation of this and other congenital anomalies involving cardiac procedures.

Gross had extensive publications in the field of pediatric cardiovascular surgery but one of his most classic authorships was “Abdominal Surgery in Infancy and Childhood,” coauthored in 1941 with Dr. William E. Ladd, then chief surgeon at Children’s Hospital. A second, and quite expanded, edition published in 1953 became a medical text in many languages.

He was the recipient of many honors, but perhaps the most endearing was having a surgical chair at Harvard named after him. He died in 1988 at age 83 being incapacitated after many years because of back problems.

References

  1. Moore FD, Folkman J. Robert Edward Gross July 2, 1905 – October 11, 1988. National Academies Press.
  2. Gross RE, Hubbard JH. Surgical ligation of patent ductus arteriosus; report of first successful case. JAMA 1939;112: 719-731.
  3. Gross RE. Coarctation of the aorta. Surgical treatment of one hundred cases. Circulation 1950;1:41-55.

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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