Defying orders to make heart surgery history

When the first fetal cardiac surgery was performed at Children’s Hospital Boston in 2001 – entering Jack Miller’s heart through his mother’s abdomen and opening blood flow – the world was stunned. But more than 60 years earlier, another operation was equally game-changing.

It was 1938, a time before heart-lung bypass, when ether and chloroform were only starting to be supplanted by more controllable anesthetics, when tinkering with the heart or even opening the chest were seen as dangerous and taboo.

Tinkering was what Robert E. Gross, chief surgical resident at The Children’s Hospital, liked to do. He was interested in a congenital heart condition known as patent ductus arteriosus, a passageway between the pulmonary artery and the aorta that’s supposed to close after birth — but doesn’t.

During gestation, the fetus gets oxygen from its mother via the umbilical cord, not its lungs, so the role of the ductus is to shunt blood from the pulmonary artery, away from the lungs, and into the aorta. When a newborn takes its first breath, its circulatory system instantly changes: Muscles clamp the ductus shut, allowing blood to circulate to the lungs.

When this doesn’t happen, the baby is left with an abnormal circulation that strains the heart. Oxygen-rich blood that should go to the body re-circulates through the lungs, leading to lung congestion and shortness of breath. In Gross’s time, patients lived, on average, into their 20s; some only to age 7 or 8.

The arrow at top shows a patent ductus arteriosus connecting the aorta and pulmonary artery and. (Ao=aorta, LA=left atrium, LV=left ventricle, PA=pulmonary artery, RA=right atrium, RV=right ventricle)

Gross had started his medical training in pathology, and had done autopsies on infants with congenital anomalies, especially those of the heart and great vessels. He was convinced that a patent ductus arteriosus could be closed surgically, and performed successful test operations in dogs.

But William Ladd, Chief of Surgery at Children’s, forbade him to try it in humans: It was simply too risky. Arteries contain blood under great pressure, so even a small mistake could be quickly lethal. Moreover, as recounted by surgeon and cancer pioneer Judah Folkman, who trained under Ladd, the chief feared that opening a child’s chest would cause the lungs to collapse, perhaps fatally.

The 33-year-old Gross, undeterred, waited until Ladd went on vacation, and, in direct defiance of his order, tried his operation on the first suitable patient he encountered: a 7-year-old Boston girl named Lorraine Sweeney.

Lorraine several months post-surgery (Boston Children’s Hospital Archives)

Sweeney was weak and “delicate.” She tired easily and her mother could hear a buzzing noise in Lorraine’s chest from several feet away. Gross’s operative notes described it like this:  “Palpating finger placed on the heart disclosed an astounding coarse and very strong thrill which was felt over the entire cardiac musculature…. When the stethoscope was placed on the pulmonic artery there was an almost deafening continuous sound like rushing steam…”

On August 26, 1938, as described in JAMA, Gross made an incision along the third rib space and allowed the left lung to collapse, exposing the heart and its vessels.

“I was scared to death, scared to death,” recalled anesthesia nurse Betty Lank, interviewed in 1999 at the age of 95. Another hospital had already tried the repair, and the patient had died.

Gross closed off Lorraine’s ductus with a temporary clamp. The strange sounds stopped, and over the next three minutes, Lorraine’s diastolic blood pressure rose to normal levels. “Believing that the ductus had not stayed open as a compensatory mechanism for some other cardiac defect, it was decided to ligate it permanently,” Gross wrote. He tied it off with surgical thread.

Robert Gross MD Lorraine Sweeney
Sweeney in 1963, on the 25th anniversary of her historic heart operation.

The postoperative note in Lorraine’s medical chart read: “Condition good. Patient awake immediately, quite restless. Morphine.”

“Then she ran a temperature,” recalled Lank. “We were all worried sick. And then she got over it and I think she was in the hospital nine days.”

“By today’s standards, Dr. Gross performed a relatively simple type of surgery,” said Alexander Nadas, then Children’s cardiologist-in-chief, in an interview in 1988 marking the 50th anniversary of Lorraine’s operation. “He didn’t have to go inside the chambers of the heart to do the job; he just tied off a little tube – simple. Yet, this was the clear-cut beginning of modern heart surgery.”

Ladd, returning from vacation, was furious. Some accounts say Gross was fired, others say he went on strike. He spent several months at his farm in rural Framingham, during which no cardiac surgery was done at Children’s; there simply wasn’t anyone on staff who could treat many of the cases, according to Folkman’s account.

Sweeney and Gross pose in the surgery room, 1963

Gross used to say that “a surgeon in an academic department must pull a new rabbit out of the hat every few years.” He went on to other cardiac firsts, successfully treating a vascular ring (in which the windpipe and esophagus are completely encircled and compressed by a “ring” formed by the aorta and/or surrounding blood vessels) and congenital narrowing (coarctation) of the aorta (in parallel with a similar first in Sweden). He was the first surgeon to graft artery tissue from one person into another and to treat a rare defect called aortopulmonary window.

Amazingly, Gross performed these surgical feats with only one working eye. As a child, his father had trained him to develop depth perception by giving him clocks to take apart and reassemble.

Sweeney at age 80

By his own account, Gross performed his last ductus operation, number 1,610, in March 1972. Today, Lorraine is a great-grandmother in her 80s. Other of Gross’s patients weren’t so lucky. But it was a time when, in Gross’s view, there wasn’t much to lose: Congenital heart defects almost always proved lethal.

Learn about Boston Children’s Heart Center today.