Evolution of cardiovascular surgery in China: A historical perspective

The inception and development of cardiovascular surgery are inseparably linked to the development of cardiology specifically and the overall medical profession in general. From the early 20th century to the present, cardiovascular surgery has demonstrated notable achievements, evolving from a “forbidden zone” into a field in which most types of heart disease can be treated surgically. Many patients have thus regained health and a new lease of life. In this article, we reviewed the history of the development of cardiovascular surgery in China, summarizing historical experiences, commemorating the achievements of our predecessors, and recounting their spirit of exploration, endeavor, and dedication. The historic story of the development of cardiovascular surgery is of huge significance—delivering a message of hope to patients. A Brief Introduction to the Development Process of Cardiovascular Surgery in China Internationally, cardiac surgery began in the 1930s. In 1938, American Dr. Robert Gross performed the first case of arterial duct ligation, which can be considered the beginning of cardiac surgery. In 1954, the pioneer of cardiac surgery, Dr. Walton Lillehei, successfully conducted ventricular septal defect repair and total correction of Tetralogy of Fallot (TOF) under cross-circulation. Open-heart surgery was realized under cardiopulmonary bypass subsequently in the United States which promoted the rapid development of cardiovascular surgery in the world. The development of cardiovascular surgery in China, at its inception, was not far behind that of developed countries. In the 1940s, there were only a few doctors attempting a very small number of cardiac surgeries, marking the beginning of cardiac surgery in China. Between 1950 and 1965, cardiovascular surgery gradually developed into a major specialty in China. During the decade 1966 to 1976, for well-known reasons, cardiac surgery was essentially at a standstill nationwide. However, after the end of the “Cultural Revolution” in 1976, cardiovascular surgery began to recover, and international exchanges gradually increased. Developments included valve replacement surgery, coronary artery bypass grafting (CABG), open-heart surgery for infants and young children, and the successful development of domestically produced artificial valves. During the 1980s, the development of cardiovascular surgery accelerated, mirroring improvements in anesthesiology and cardiopulmonary bypass techniques, the number of cardiovascular surgeries and surgical centers increased. Especially after the government pursued a policy of reform and opening up, many doctors went abroad for study, and foreign experts came to China to give lectures, demonstrate surgeries, and engage in academic exchanges, which led China’s cardiac surgery into a phase of recovery and rapid development. More especially since 1990, cardiovascular surgery in many Chinese centers has made remarkable progress, demonstrating advanced international standards of care. Milestone Events in Cardiovascular Surgery in China Extracardiac surgery Dr. Zhang Chaomei sutured a patient with a right ventricular wall stab wound, who survived. This was the first successful cardiac surgery in 1940. Dr. Wu Yingkai was the first to successfully perform a ligation on a patent ductus arteriosus in 1944 and he also performed the first surgery for constrictive pericarditis in 1947. Dr. Shi Meixin first applied the subclavian artery to pulmonary artery shunt surgery in 1953. Dr. Fu Peibin performed the resection of the narrowed segment and end-to-end anastomosis surgery to treat aortic coarctation in 1956. Dr. Cai Yongzhi used the method of anastomosing the left subclavian artery with the excised narrow segment of the descending aorta to treat aortic coarctation in 1957. Dr. Gu Kaishi performed the first operation using the right pulmonary artery to anastomosis superior vena cava to alleviate the patient’s hypoxia symptoms in 1958.[1] Closed intracardiac surgery Dr. Liang Qichen successfully performed the first closed pulmonary valve dilation through a right ventricular incision in 1954. In the same year, Dr. Lan Sichun successfully performed a closed commissurotomy for mitral stenosis. In December 1960, Dr. Gu Kaishi collaborated with the Shanghai Surgical Instruments Factory to create a mitral valve dilator and was the first to carry out mitral stenosis dilation surgery through the left ventricular approach, improving the outcome of the surgery.[1] In 1963, Dr. Guo Jiaqiang successfully sutured and ligated patent ductus arteriosus.[2] Intracardiac direct vision surgery under hypothermic anesthesia Dr. Liang Qichen successfully performed the first direct vision incision surgery for congenital pulmonary valve stenosis under hypothermic anesthesia in January 1957. Dr. Shi Meixin and Dr. Lan Xichun closed atrial septal defect with suture directly under hypothermic anesthesia in 1958.[1] Thereafter, this type of surgery was instead by open-heart surgery for safety reasons. Open-heart surgery under extracorporeal circulation Dr. Su Hongxi first applied extracorporeal circulation in China to successfully perform a direct vision repair of ventricular septal defect in June 1958 which promoted the development of various types of direct vision intracardiac surgeries and ushered-in a new era for cardiac surgery in China. Within a few years, more than 20 institutions across the country were able to perform open-heart surgery under cardiopulmonary bypass. The types of surgeries included not only common congenital heart diseases but also complex congenital heart malformations such as TOF, as well as surgeries for mitral stenosis or insufficiency. However, it was not until the end of the “Cultural Revolution” that these senior experts resumed their work and a few young doctors began to receive training abroad. The torch was passed on, and cardiovascular surgery awoke to a new dawn.[3] The application of general anesthesia and hypothermic cardiopulmonary bypass techniques allowed for rapid development in cardiovascular surgery in China. The clinical application of cardioplegic solution made open heart surgery safer and more precise. Improvements in postoperative care significantly reduced complications after cardiac surgery, improving the success rate of operations. Achievements in the Treatment of Different Diseases in Cardiovascular Surgery in China Surgical treatment of congenital heart disease Congenital complex heart disease In the 1960s, Beijing Fuwai Hospital began to research treatment of congenital complex heart disease, a landmark from which developed further great contributions in the management of congenital complex heart disease in China. In 1962, Dr. Xue Ganxing repaired five patients with partial endocardial cushion defect under cardiopulmonary bypass. In 1978, Dr. Guo Jiaqiang started using homograft to treat patients with congenital complex heart disease.[2] From 1973, Dr. Wang Zengwei initiated surgical treatments for various complex congenital heart diseases. By October 1989, a total of 2106 surgeries were performed, including surgeries for 9 types of complex congenital heart diseases with an overall surgical mortality rate of 4%;[4] this has made an important contribution to the surgical treatment of complex congenital heart diseases. Dr. Ding Wenxiang was the first in China to carry out surgical treatment for congenital heart disease in infants and young children, using deep hypothermic circulatory arrest and limited-time extracorporeal circulation. In May 1974, he successively performed the Mustard and Senning operation for transposition of the great arteries (TGA), achieving excellent results.[2] From 1976, Dr. Guo Jiaqiang also started performing heart and major blood vessel surgeries for infants and toddlers. From 1993 to 1995, Dr. Wu Qingyu performed Rastelli operations using homograft conduits with valves to treat TGA complicated with ventricular septal defect and pulmonary stenosis, or ventricular septal defect and pulmonary atresia. From 1997 to 2001, Dr. Wu Qingyu successfully treated complete atrioventricular septal defects combined with TGA, single atrium, TOF, double outlet right ventricle, and other radical surgeries using homologous pulmonary artery valved conduits. In 2001, he performed the modified Rastelli operation for the first time in China to treat double outlet right ventricle with left anteriorly positioned aorta.[5] He also first performed the Ross procedure in China for the treatment of congenital aortic valve disease.[1] In the year 2000, Dr. Wu Qingyu reported on the clinical experience of treating single ventricle with an extracardiac conduit to connect total vena cava -pulmonary artery (TCPC) surgery. Between 2004 and 2014, Dr. Wu Qingyu performed surgeries on 110 patients with single ventricle (21 among of them were cases of revision surgery), including 5 cases undergoing single ventricle septation surgery, obtaining excellent results.[1] TOF TOF is the most common cyanotic congenital heart disease in China. Although Dr. Hou Youlin, Zhang Tianhui, and Shi Meixin performed total correction for TOF in 1959, the mortality rate was very high (mean rate 15.5%).[4] Dr. Wang Zengwei performed 150 cases of TOF radical surgery from 1965 to 1979, with a mortality rate of 6%, which represented a significant improvement. Dr. Guo Jiaqiang and others reported 1735 cases of TOF, with the surgical mortality continuously decreasing to 3.4% by the 1990s.[2] In 1992, Dr. Wu Qingyu[6] reported the results of total correction in 156 patients with TOF surgery performed from 1987 to 1992, including the successful correction of TOF with absent pulmonary valve syndrome using aortic homograft root transplantation in adult patients, reporting a mortality rate of 0.64%. In 1996, Dr. Wu Qingyu reported his personal experience of total correction operation in 228 patients with TOF. The principles of TOF treatment and surgical methods he proposed were published in the Annals of Thoracic Surgery, and were commented on by Professor Walton Lillehei, formerly the pioneer for total correction surgery in TOF. He wrote that the conclusions drawn are correct, and the surgical outcomes may be the best in the English literature.[7] Complete TGA TGA is a common cyanotic congenital heart disease. The arterial switch operation (ASO) is the best choice to cure it, but the surgical technique is complicated. Dr. Guo Jiaqiang successfully performed the first ASO in China on March 31, 1987. On March 6, 1990, Dr. Ding Wenxiang also successfully performed the operation in Shanghai. The early mortality of ASO was very high. Between 1997 and 2002, Dr. Wu Qingyu performed ASO on 30 children with TGA, in a mortality rate of 6.7%. He also has successfully performed ASO for newborns including one aged 2 h after birth, making the ASO become almost a routine procedure. Nikaidoh operation is considered to have a better effect to complete TGA complicated with pulmonary stenosis than the Rastelli operation. In August 2004, Dr. Xu Zhiwei successfully performed six Nikaidoh operations. In 2004, Dr. Hu Shengshou operated on two cases using a modified Nikaidoh method. Thereafter, Dr. Wu Qingyu successfully performed four cases of modified Nikaidoh procedure with preservation of the pulmonary valve. Corrective TGA (c-TGA) C-TGA is a kind of complex congenital heart disease. It is often associated with ventricular septal defect and pulmonary stenosis. The use of Rastelli operation may lead to left atrioventricular valve insufficiency and ventricular failure. Acknowledged as a difficult operation, Dr. Wu Qingyu successfully performed the first Double Switch operation on November 6, 2001 in China. This patient is currently studying in his third year of university. Ebstein anomaly Ebstein anomaly is a rare and complex congenital heart disease with high surgical difficulty and mortality rate. Since 1997, Dr. Wu Qingyu pioneered the anatomical correction surgery, aiming at the total reconstruction of the right ventricle and tricuspid valve.[8] Using this technique to treat 252 patients with Ebstein anomaly from 2004 to 2020, the mortality rate was found to be only 1.2%, enabling 98% of the patients to avoid valve replacement and to maximally preserve the geometric shape of the right ventricle and the function of the tricuspid valve. Surgical treatment of valvular disease Dr. Cai Yongzhi successfully performed the first mitral valve replacement surgery in 1965, pioneering the research and clinical application of mechanical heart valves in the country and promoting the development of valve surgery in China.[9] Dr. Zhu Xiaodong developed a bovine pericardium valve treated with glutaraldehyde in 1976. Dr. Luo Zhengxiang, Fang Dawei and others developed a heterologous porcine aortic valve and applied it clinically in 1977, advancing the progress of bioprosthetic valve technology in China. Dr. Cai Yongzhi collaborated with the Shanghai Medical Device Research Institute and the Lanzhou Carbon Factory to develop the tilting disc valve (abbreviated as C-L valve), which was widely used from 1974.[9] Subsequently, Dr. Zhu Xiaodong in cooperation with the Aerospace Department 703, developed the hook-hole type tilting disc (G-K) mechanical valve, which was first clinically applied in Beijing Fuwai Hospital and then promoted nationwide from 1985. In 1994, Dr. Wu Qingyu reported the successful experience of mitral valve prolapse repair surgery, demonstrating that the long-term therapeutic effect of mitral valve repair surgery is superior to artificial valve replacement. In 1997, Dr. Zhang Baoren from the Second Military Medical University reported 3656 cases of heart valve replacement surgery, with an overall surgical mortality rate of 5.68%. Dr. Zhu Xiaodong and others from Beijing Fuwai Hospital reported 4960 cases of heart valve replacement, with a total surgical mortality rate of 5.98%. The outcomes of the two groups approximated those from international advanced cardiac units. Surgical treatment of coronary heart diseases In November 1974, Dr. Guo Jiaqiang was the first in China to successfully perform CABG operation.[10] In 1975, Dr. Luo Zhengxiang and in 1980, Dr. Pan Zhi also performed CABG operation, respectively.[11] In 1984, Dr. Guo Jiaqiang was the first surgeon in China to perform CABG combined with ventricular aneurysm resection operations.[12] Over the next 10 years, only a few dozen cases of CABG were reported, scattered among a few large hospitals. Dr. Wu Xin was the first doctor to report the results of long-term follow-up after CABG in Fuwai Hospital..[13] In 1996, Dr. Wu Qingyu reported his personal experience with 110 cases of CABG; 64 surgeries used the internal mammary artery, including CABG combined with valve replacement or repair, and ventricular aneurysm resection surgery, achieving a success rate of over 99%. He proposed that a sufficiently large anastomosis, avoidance of bleeding, and full restoration of coronary artery blood supply are the key factors to successful surgery.[14] Since 1997, he performed CABG for coronary heart disease complicated with Kawasaki disease, cardiomyopathy, myxoma, and off-pump CABG, small thoracic incision CABG (minimal invasive direct coronary bypass, MID-CAB) operations with no mortality. He and others reported 1110 cases of CABG, including 60 cases of off-pump and total arterialized CABG, with a surgical mortality rate of 0.81% in 1999.[15] The results of the national key project for standardization and generalization of CABG technique, organized by Dr. Wu Qingyu showed that total mortality rate of CABG was 2.33% in 10,100 cases from 18 heart centers from 2000 to 2003. The mortality rates for elective operations and emergency operations were 1.88% and 4.77%, respectively, The mortality rate for on-pump was 2.72%, but for off-pump was 1.08%.[16] Surgical treatment of aortic diseases In 1956, Dr. Gu Kai and others collaborated with the Shanghai Textile Research Institute to develop a fibrous artificial blood vessel, which was successfully used in aortic resection and transplantation procedures. In December 1960, Dr. Li Yinghan was the first in China to successfully perform a total aortic arch resection and artificial blood vessel surgery. In 1961, Dr. Hou Youlin performed a total arch transplantation under hypothermic anesthesia, marking the pioneering stage of aortic surgery. According to reports by Dr. Shen Zonglin and others, since 1976, 191 cases of aortic aneurysm resection surgery have been performed in various locations, with a pre-1987 surgical mortality rate of 27.8%, which falling to 10.9% after 1988. Dr. Sun Yanqing and others were the first to report in China the use of the Bentall procedure in 1985 to treat 53 cases of ascending aortic aneurysm with aortic valve insufficiency, with a surgical mortality rate of 3.77%, demonstrating that the standard methods and outcomes of such surgical operations in China had reached a stable plateau. In 1999, Dr. Sun Lizhong reported 231 cases of aortic root replacement surgery, including 40 cases of root replacement and partial aortic arch replacement and 2 cases of root replacement plus total arch replacement. Due to the improvement in surgical methods, outcomes have been greatly enhanced. In 2004, Dr. Sun Lizhong performed the aortic arch replacement plus stent elephant trunk technique for the treatment of Stanford Type A aortic dissection.[17] In 2009, Dr. Wu Qingyu was the first to report the experience of treating complex aortic coarctation combined with intracardiac deformities via a bypass from the ascending aorta to the descending aorta behind the pericardium.[18] Surgical treatment of arrhythmias In May 1978, Dr. Zhang Quanfu was the first in China to carry out surgical treatment for Wolff–Parkinson–White syndrome. Dr. Wang Zengwei reported the surgical treatment results for Wolff–Parkinson–White syndrome and atrial fibrillation in 1984. In 1991, Dr. Wu Qingyu was the first in China to surgically implant an internal automatic defibrillator for a patient with recurrent ventricular fibrillation. Surgery for chronic pulmonary artery thromboembolism In 1997, Dr. Wu Qingyu was the first in China to successfully carry out the treatment for chronic thromboembolic pulmonary hypertension, significantly improving the patient’s cardiopulmonary function and restoring the heart function to Class I–II. Heart and heart-lung transplantation In 1978, Dr. Zhang Shize performed the first in situ heart transplant in China, with the patient surviving for 109 days, marking the first case of heart transplant in Asia. In March 1992, Dr. Chen Baotian at Beijing Anzhen Hospital successfully performed an orthotopic heart transplant, and the patient survived for 7 months postoperatively. In April of the same year, Dr. Xia Qiuming in Harbin adopted the warm blood cardioplegia method to protect the donor heart, performing an orthotopic heart transplant. By 1995, a total of 3 cases has been performed, all of them surviving in the long term with cardiac function recovering to Class I. Dr. Liu Xiaocheng at the Mudanjiang Cardiovascular Disease Hospital in Heilongjiang Province successfully performed two consecutive orthotopic heart transplants. In the same year, Dr. Liu Xiaocheng performed the first heart-lung transplant. In 1994, Dr. Wu Qingyu performed a heart-lung transplantation for a female patient with ventricular septal defect and Eisenmenger’s syndrome. The patient survived for 2 weeks postoperatively and died from pulmonary infection and cyclosporin overdose as a result of a nurse prescribing error.[19] After the year 2003, Dr. Chen successfully performed a heart-lung Dr. Hu performed heart-lung transplantation for a patient on 2003. far patient is the surviving patient in Asia. of left ventricular On March 2001, Dr. Wu Qingyu was the first in China to implant type of for a patient with coronary artery disease and heart by months he successfully the and performed a heart transplant on The patient died of on October This patient represented the use of the as a in China and the only patient to successfully a heart transplant with no other reports in at that invasive surgical treatment of heart disease In the early invasive cardiac surgery also made significant In 1997, Dr. and others reported performing intracardiac direct vision surgery through a small right and thoracic including cases of congenital heart disease and valve surgery, with no surgical or In 2000, Dr. reported the use of to repair atrial septal In Dr. reported four cases of cardiac surgery. invasive heart valve replacement surgery and invasive CABG are out in many in China. and 40 Dr. Guo Jiaqiang the Surgery which is to Fuwai Hospital and by the of of China. 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