Within the western medical tradition, Lancisi (1654–1720) laid the foundation for contemporary understandings of the pathology of heart disease. In particular he described the ‘aneurysm of the heart,’ which would now be termed dilatation, and recognised the swelling of neck veins as pathognomonic of right heart dilatation.

Albertini (1672–1733) of Bologna, a pupil of the great physician Malphigi, was the first physician to realise the importance of dyspnea as a symptom of heart disease. Morgagni (1682–1771), a professor of anatomy at Padua, recognised and anatomically distinguished between the two chief forms of cardiac enlargement: dilatation and hypertrophy. He also deduced that dyspnea and asthma could have cardiac causes, connecting these symptoms to right heart failure in particular. Senac (1693–1770), a French physician, was the first to write about the importance of inflammation as a cause of heart disease. He described thrills that were associated with valvular insufficiency. Laennec (1781–1826) invented the stethoscope in 1819 and regarded dilatation and hypertrophy to be the most important cardiac lesions. William Stokes (1804–1878) recognised the importance of the myocardium and analysed its relationship to valvular disease [2].

In 1895 Otto Frank, a famous German physician, showed the importance of cardiac filling and size in governing its contractility. In 1915 E H Starling demonstrated conclusively the relationship of pre-load and cardiac filling to cardiac contraction and performance in an experimental heart-lung preparation. This was called ‘Starling’s law of the heart’ and was the basis of the Frank-Starling curve or relationship. The Frank-Starling curve is a plot of cardiac size and contractility [3]. This curve or law is the very basis of defining the limits of ventricular dilatation and the decompensation that occurs when the heart enlarges beyond a certain size.

The present emphasis on the medical management of modern heart failure is not that much different. The last few decades has seen great strides in the development of devices and surgical procedures in treatment of heart failure. However, very little of this is known to the wider medical community, let alone the cardiac surgical fraternity. Heart failure has often been called the final surgical frontier. However, this is not quite true as the history of cardiac surgery will attest….

Cardiac surgery is a relatively young surgical specialty that is now in a stage of flux. The heart was always held in great reverence. The great Viennese surgeon Theodor Billroth asserted in the 1880s that it might be dangerous to contemplate surgery on the heart.

In the European tradition, the first surgical treatment of heart failure was drainage of a pericardial effusion that was unresponsive to diuretics, performed by Francisco Romero in Aragon around 1814. Dominique Larrey, surgeon to Napoleon’s Imperial Guard drained a traumatic pericardial effusion presenting as tamponade in 1814.

Dr. Daniel Hale Williams, an African American surgeon who set up the Provident Hospital not far from the campus of the University of Chicago, performed the first repair of a cardiac wound in a patient called James Cornish, in 1893. Dr. Daniel Hale Williams called for six of his fellow black physicians to help him get the dying man into an operating room. This was done based on careful clinical evaluation of the patient. Carefully making an incision along the fifth rib, Williams exposed the man’s still-beating heart and his near fatal wound. Williams and his surgeons evaluated sewed up a small but ragged gash located on the surface of the heart between two coronary arteries and closed the pericardium. A few days later, when the patient’s condition deteriorated, he was taken back to the operating room and the pericardium opened up through a separate incision in the chest. Fluid collected within was drained and the pericardium sewn up again. This patient lived for over 38 years thereafter, ultimately succumbing to the effects of another barroom brawl [4]. This is very pertinent to this book, which was conceived and produced at the University of Chicago, when the first major cardiac procedure was performed in an affiliate hospital. This fact is even more poignant, because one of the authors of this chapter has been on the faculty of this university.

There were two similar instances in Europe around the same time. In 1894, Ansel Cappelen sutured a 2 cm laceration on the surface of the ventricle, at the University of Oslo, Norway. His patient remained gravely ill succumbing 4 days later.

Ludwig Rehn at the University of Frankfurt am Main, in 1896 is credited with having the first successful repair of a large cardiac wound with a surviving patient.

The early decades of the twentieth century set the tone for cardiac surgery, especially in patients with heart failure as a consequence of rheumatic stenosis of the mitral valve.

Lauder Brunton wrote a remarkably prescient but restrained paper in 1902, entitled “Preliminary Note on The Possibility of Treating Mitral Stenosis by Surgical Methods”. Sir Brunton, working at St Bartholomew’s hospital in London, studied a variety of instruments that could be introduced through the ventricle or the auricle. He also proposed that the commissures be divided rather than the leaflets. Despite his great vision, extensive cadaver work, supporting his work, the paper set off a flurry of critical letters. The prevailing view of the cardiologists was skeptical and claimed that the prognosis of the condition depended on the state of the heart muscle rather size of the mitral orifice. Things have not changed that much more than a hundred years later! Unfortunately, Brunton’s predictions took almost 50 years to prove.

Elliot Cutler, across the Atlantic at the Peter Bent Brigham Hospital, Boston worked with many types of cutting instruments. On May 20, 1923, he operated on a bedridden patient who survived for four and a half years, but could not be sure how much relief of mitral stenosis there was. The subsequent experience with the various cutting procedures of the mitral valve failed because the focus was on cutting the leaflets rather than the commissures.

It was 23 years after Brunon’s paper, that Henry Souttar introduced a finger through the atrial appendage to ostensibly free up a stenosed mitral valve, on May 6, 1925; to his surprise he found a regurgitant valve, but established the principle of finger fracture.

In 1910, Alexis Carrel reported on experiments performed at the University of Chicago, and at the Rockefeller Institute, New York, at the American Surgical Association. He described a relatively safe period of vena caval occlusion or of cross-clamping of the heart, making it “feasible to cut a mitral or triscuspdian valve, or to perform the curettage of endocardiac vegetations”.

Billroth was not alone, for most of history, the human heart has been regarded as an organ forbidden to surgeons. World War II changed a lot of surgical attitudes. Pioneering advances in antibiotics, anesthesia and blood transfusions were made by military doctors, who faced injury and suffering on a massive scale.

Dr. Dwight Harken, as a young U.S. Army surgeon was one of the first surgeons to use these improved techniques to gain access to the heart. Many of Harken’s patients were young soldiers evacuated from the European front with shell fragments and bullets lodged inside their hearts. Leaving shrapnel wounds could be very dangerous while removing them could be fatal. Using animal experimentation, he tried to develop a technique that would allow him to cut into the wall of a still beating heart, insert a finger, locate the shrapnel and remove it. All of his first 14 animal subjects died. Of the second group of 14, half died. Of the third group of 14, only 2 died. Harken used these techniques in his patients with no deaths, proving that the human heart could be operated upon.

It wasn’t long before surgeons began wondering if Harken’s technique might be applied to defective heart valves. In 1947, Harken performed a repeat of the Cutler procedure, which resulted in death of the patient. In 1948, within days of each other, Harken and Dr. Charles Bailey, of Philadelphia independently reported on successful closed mitral commisurotomy using valvulotomes and carefully designed knives. Across the Atlantic, Russell Brock at the Brompton Hospital, London utilized Souttar’s approach of finger fracture through the left atrial appendage with very good results. Dubost in Paris devised a reliable mechanical dilator, which was subsequently modified by Oswald Tubbs in South Africa in 1955. This was the early evolution of valvular reparative surgery for heart failure – a truly international effort, which provided dramatic relief to a desperately ill group of patients with mitral stenosis [5].

In the ensuing years, dramatic strides were made in anesthesia, cardiopulmonary support, valve replacement, myocardial protection, etc to facilitate modern cardiac surgery.

In terms of the development of cardiovascular surgery, Alexis Carrel, a very innovative researcher, pioneered many of the concepts that helped make contemporary heart surgery possible, including cardiac and other solid organ transplantation [6].

Following on from Carrel’s pioneering work many groups and stalwarts developed various aspects of heart surgery. In Stanford, California Shumway and co-workers worked tirelessly to help make cardiac transplantation a reality [7]. Eventually, the introduction of Cyclosporin A helped make transplantation viable [8].

In relation to the development of other surgical options for treating CHF Chachques [9] and co-workers, working in Paris in the mid-1980s, used an interesting discovery in skeletal muscle transformation to try to improve the function of the failing heart. The left latissimus dorsi muscle was harvested with its intact neurovascular pedicle, wrapped around the heart and transformed over a period of 10 weeks to a fatigue resistant state. This technique, known as dynamic cardiomyoplasty, provided some relief to patients with heart failure, but was bedevilled by major morbidity. In addition, the muscle transformation took too long and could impact on the condition of a patient with severe cardiac failure. The mechanism by which this technique worked was probably through containment of the dilating ventricle.