Chapter category: Heart
Development of Blood Cardioplegia and Retrograde Techniques, The Experimenter/Observer Complex
Coronary Sinus Intervention in Cardiac Surgery, Second Edition
Edited by: Werner MohlISBN: 1-58706-006-X
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Chapter authors:
Gerald D. Buckberg
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A surgical colleague, Dr. Mohl, asked me to describe the course of develop-ments in myocardial protection coming from our studies during the past 28 years, as all seems to flow logically. Such logic may be perceived since events do not normally progress in a coordinated way. It is uncommon that inadequate technical repair is the cause of perioperative low output syndrome after repair of adult and congenital defects. The usual cause is inadequate myocardial protection. This Foreword relates how studies in the UCLA cardiothoracic laboratory addressed this problem during the past 28 years and some clinical changes that developed from these studies. My interest started during my residency training. I quickly realized that one could do a perfect anatomic procedure in adult and pediatric cardiac disease, and wait anxiously to determine how the corrected heart will perform when cardiopulmonary bypass is discontinued. Failure to function normally made me realize that, at that moment, we had hurt the heart with our methods of myocardial protection more than we improved it anatomically. I decided that I must try to understand how this happened and try to define ways we can do better.
At that time, important observations by Najafi and Taber on subendocardial necrosis after ventricular fibrillation with valve disease made it clear that continuous perfusion via the coronary arteries was not the answer. We needed to understand the concept of supply (i.e., flow and its oxygen distribution) and demand (how much energy is required) during extracorporeal circulation. This would allow surgeons to develop a knowledge of physiologic balance of protective methods they could bring to the Operating Room, to allow them to make logical decisions. I participated in microspheres studies at the University of California at San Francisco, before returning to UCLA in 1971. This regional flow method led us to determine in 1973, with Christof Hottenrott from Heidelberg, Germany, that subendocardial blood supply was inadequate during ventricular fibrillation in hypertrophied ventricles. This information led us to abandon ventricular fibrillation during valve surgery. It seemed clear, at that time and now, that two elements are very important. These are technical perfection surgically and avoidance of cardiac damage during the mechanical process of correcting the cardiac lesion.
In 1865, Claude Bernard, a famous French physiologist, wrote a book entitled, An Introduction to the Study of Experimental Medicine. In that volume, he described the individual as either an experimenter or an observer. The observer, like an astronomer, watches the natural course of phenomena and reports themhe does not change them. Conversely, the experimenter perturbs the natural order of things (i.e., cardiopulmonary bypass or clamping the aorta), and Mother Nature provides a response. This response may be very different from the logic that led to the experiment and the expected outcome, but it is there. To use this new information, the experimenter must immediately become an observer and appreciate what has been revealed. One simply cannot persist in looking only for the expected, for such efforts will lead nowhere, as only Mother Nature speaks the truth and we must listen! Science and life are not different.
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