Clarence Crafoord: a giant in cardiothoracic surgery, the first to repair aortic coarctation.

On October 19, 1944, Clarence Crafoord performed the first successful repair of aortic coarctation. The operation was done a year before Robert Gross did his first case (he is often claimed to have been the first). In fact, Gross had read Crafoord's report before he performed his own first operation. Crafoord's achievement was not an isolated event. In the late 1920s he had performed two successful pulmonary embolectomies, in the 1930s he introduced heparin as thrombosis prophylaxis, and in the 1940s he pioneered mechanical positive-pressure ventilation during thoracic operations and worked out a safe and precise technique for pneumonectomy. During the 1950s a string of innovative surgical procedures were done at his unit in Stockholm. These included the second successful case of cardiopulmonary bypass in the world, the first case of atrial repair of transposition of the great arteries, endarterectomy of the left coronary artery, and the first implantation of a pacemaker into a human. In this article we will pay tribute to Clarence Crafoord and describe some of the contributions that he and his collaborators made to the field of cardiothoracic surgery.

The aortic coarctation and the Etruscan man: morphohistologic diagnosis of an ancient cardiovascular disease.

Reports of cardiovascular diseases in ancient time are very rare since the material mainly consists of skeletal remains; therefore, these diagnoses can only be carried out indirectly, through the marks left on bones. Here we show a case of coarctation of the aorta diagnosed on bones. Aortic coarctation is a congenital disorder in which a portion of the aorta is narrowed to various extent. A collateral circulation system is enrolled to allow adequate compensation of the blood flow. Collateral vessels may become enlarged, producing a distinctive notching on the pleural surface of the ribs and on adjacent bones. Excavation of a sixth to fifth century B.C. Etruscan tomb revealed three funerary chambers (celle) housing 14 skeletal remains of adults. The ribs of one of the male skeleton showed "nail stroke" indentations. Detailed macroscopic examination enabled us to identify them as notching and led to the diagnosis of postductal aortic coarctation. Histological analysis of bone tissue from the notching areas excluded inflammatory and pathological erosive events, supporting the macroscopic diagnosis. The present paper is the first description of aortic coarctation in paleopathology.

The early history of cardiac surgery in Stockholm.

Cardiac surgery in Stockholm grew on a sound foundation of well-developed general thoracic surgery. The portal figure is Clarence Crafoord (1899-1983) who already in 1927 had succeeded with the Trendelenburg pulmonary embolectomy operation. He went on to develop lung surgery in general. With foresight he stimulated the chemists of Karolinska Institute to purify heparin, first for prophylaxis against venous thromboembolism and later for use with the heart-lung machine. In 1944 he became the first surgeon to successfully operate on patients with coarctation of the aorta. With Viking Olov Bjork and Ake Senning the heart-lung machine was improved, finally allowing its clinical use in a patient operated in 1954 for a myxoma of the left atrium, with long-term survival. This was the first successful use of the heart-lung machine in Sweden and the second in the world. He and his coworkers, first at the Sabbatsberg hospital and from 1957 at the Karolinska hospital made major contributions to cardiology and radiology, apart from the progresses in cardiac surgery. Contributions such as pressure recording from the left atrium by needle puncture in 1950, the Senning operation for transposition of the great arteries and the first use of a totally implantable cardiac pacemaker in 1958 are indeed medical history.

Aortic coarctation reconstructed by resection and homograft replacement in the 1950s: long-term outcome 40 years after operation.

Since the first successful repair of aortic coarctation by Dr Clarence Crafoord in 1945, there are few data regarding late follow-up of homografts in this position. Between 1957 and 1959, 7 patients underwent surgical correction of aortic coarctation by Professor József Kudász at the Department of Cardiovascular Surgery, Semmelweis University, using freeze-dried aortic homograft. We were able to locate 4 of these patients and found no significant complications due to the operation. We report on this 40-year follow-up of implanted aortic homograft.

The ductus and the coarctation.

After Robert E. Gross' historic ligation of a persistent ductus arteriosus in August 1938, it took 6 years before the first coarctation was operated on. Gross initiated experimental procedures directed at repair of coarctation even before the ductal operation had been performed. He had the desire, the drive, and the determination. Why the delay that allowed Clarence Crafoord to perform the first coarctation repair in October 1944?

Classics in thoracic surgery. Correction of aortic coarctation.

Experiments performed in the 1930s demonstrated the results of cross-clamping the aorta in animals. Findings from these experiments permitted cross-clamping of the aorta both above and below the origin of the ductus, in a series of ductus Botalli cases. This experience in turn led to the decision to perform a radical operation for coarctation of the aorta by placing clamps above and below the coarctation, removing the clamps, and sewing the aorta end-to-end. The first coarctation resection was performed on October 19, 1944. A total of 216 operations for aortic coarctation were performed from 1944 to January, 1958. In the last 180 patients, use of a continuous, everting end-to-end suture practically excluded complications from the suture. With this technique there were few complications and a primary mortality not exceeding 6%.

Coarctation of the abdominal aorta: pathophysiologic and therapeutic considerations.

Coarctation of the aorta is the most frequent cause of hypertension in infants and children. Ninety-eight per cent of coarctations occur in the descending aorta near the ligamentum arteriosus. Five patients are presented with the relatively rare problem of coarctation of the abdominal aorta. The anatomic,pathophysiologic and clinical aspects in these patients cover a range of variants. Clinical and laboratory studies of the genesis of hypertension in coarctation are reviewed in chronologic outline. An experimental model of abdominal coarctation with hypertensive and renin-angiotensin II correlations suggests but does not prove a renal mechanism for the hypertension. The same conclusion must be drawn from study of the clinical cases.