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WGR: This is November 14, 1979. This is Gerald Rainer and I have the distinct privilege of being in the office of Dr. Åke Senning in Zurich, Switzerland. It is an early fall day and a little cool – pleasant environment and a marvelous time for Dr. Senning to share some of his experiences in the early days of open heart surgery with us. I have asked Dr. Senning to speak informally and spontaneously about his times in the pioneering development of open heart surgery. Dr. Senning.
SENNING: First of all, I must say I never intended to become a doctor. I wished to be an engineer, become an engineer, but I did forget to send in my application in time to the technical school, so I started to study medicine as my mother wished me to do. Then, I thought I would never wish to become an academic surgeon and started my training in a small hospital south of Stockholm and have been in different clinics. Then, I saw all of these accidents and thought the best specialty would be traumatology. So I went to orthopedic surgery, what we called extremity surgery. I did general surgery, neurosurgery and, finally, I intended to finish my training with Crafoord in thoracic surgery. But Crafoord, I don’t know if it was because he wished to have some calm in the operating theater, sent me down to the experimental lab to make a heart-lung machine. In this lab, Urich had been doing the experiments with brain perfusion with the machine that Crafoord and Anderson had done.
Dr. Ake Senning
- Worked with Dr Clarence Crafoord at Karolinska Institute, Stockholm.
- Developed pump oxygenator and used it for removal of atrial myxoma 1953 (patient still alive today).
- Implanted one of first encapsulated pacemakers (1958).
- Devised atrial correction approach for transposition of great vessels (1958).
- Honorary member of Society of Thoracic Surgeons.
- Chairman, Department of Surgery, University of Zurich, 1961 until retirement.
This was in February, 1948. I must say I did not know that it was so difficult to do such a machine but it was so very interesting. So sometime I was down in the lab and most of the time was in the operating theater. I had parallel with the experimental work most of the time – 30 patients. I have every second day the surgical policlinic with up to 200 patients and during the night, often as well during the day, we made experiments. The machine we did – we saw that I needed too much blood in this oxygenator that we had before, so that was the reason why we changed to a rotating screen machine. With this machine we only needed 450 cc of blood in the trough. You know when you work in an experimental lab you don’t have the service you have in the operation theater.
Therefore, it was necessary to do an automatic pump because else we pump the trough empty often and the experiment was finished with the air embolus. So we made an automatic pump that was very simple. I used a valve that was used for the milking machines and turned that around so that it worked as a pressure valve and had to an extent the working on two tubings and on the outside of these tubings I had taken tires from (you say it right) racing bicycles and cut out pieces. When the blood in our trough increased then the pressure in the tires increased so the pump did pump more. That was the first machine we made.
About 1953, in the autumn, we had a series of dogs with 10 in each series where either all dogs survived when on our open heart or one, maximum two, dogs died. So we thought we were ready to do even clinical cases.
WGR: This was what year?
SENNING: 1953, in the autumn. Then in February 1954, I had the chance to go to the United States and first visit Gibbon and saw his machine and he was very nice to us and showed us everything we wished to see then and he told us everything he knew about extracorporeal circulation. But he told me to go to Minneapolis. So I went to Minneapolis and saw Wangensteen first. It was a very funny episode. I came in the corridor and there was sitting a girl with her back to me, so I asked her if I could meet Dr. Wangensteen. She said, “What’s your name?” I said, “Senning.” “What did you say?” “Senning”, I said. She asked, “Are you from China?” She turned around and she was Chinese. In any case, Wangensteen sent me down to Walt Lillehei. And Walt Lillehei was doing this controlled cross-circulation experiment. But, these few days I was there they did not have any dogs, so I could not see any experiment but Walt showed me how they made it. I didn’t believe much in it because I thought it was too dangerous for the donors – you know they use the parents as donors. In any case, Varco and Lillehei thought different and they started as far as I remember in April, 1954, their clinical experiment, and did, I believe, about 45 or something like this and they really pioneered with the VSD’s and Fallot’s and similar cases.
We had one case which Crafoord thought was the ideal case and that was a woman, 42 years old, who had had cerebral embolus and recovered from this and was found to have a large pseudomyxoma on the left auricle. So Crafoord decided to do this patient. Now, I did forget to say one thing and that was our experiments started to be really successful, really successful first in the connection with hypothermia. I had met Bigelow in Paris, 1951 and he had had his fantastic series at that time of 12 monkeys. He had the heart open, I think, for 20 minutes with the temperature around 200 centigrade and all of them survived. That impressed me much so I intended to combine the extracorporeal circulation with hypothermia. And then, ____??____ came from Canada. He is a young French fellow and we started with a combination of hypothermia and extracorporeal circulation. Then there was another factor, too, and that was when we operated on the mitral valve, we often got air emboli. So, we had to find out a method to make a cardiac standstill and I thought many of these dogs who had ventricular fibrillation – we could defibrillate them. So I induced ventricular fibrillation to the cardiac standstill.
And when we then now got to these patients – first of all we placed the patient on a plastic sheet on the operation table and then we had planks around her so we got a trough, and filled this with ice water so we cooled her by surface cooling to 260 centigrade. And then we just took away the planks and the water was gone. And we connected the heart-lung machine and we induced ventricular fibrillation and we opened the heart from the left side. You understand how easy it was to get to this pseudomyxoma out. It was very difficult to get around the corner but it went fine and, after the operation, we rewarmed her the same way we cooled her. And then we left her on the operation table till the next day. And I was lying on the stretcher and looked at her most of the night and she survived and she is still surviving
WGR: Is that right?
SENNING: She has 2 children and is grandma right now. I have not seen her myself. Crafoord met her a couple of years ago as far as I know.
WGR: Incredible!
SENNING: Now, I don’t know what to tell more.
WGR: Tell us if you would, Dr. Senning, also about the first totally corrected anomalous pulmonary venous drainage and the transposition case that you mentioned to me.
SENNING: I happen to have the record here We made him in November, 1956. We had made an anastomosis between this common stem between the anomalous pulmonary veins and the left auricle. And after that, we ligated the superior left cava of the superior left cardinal vein.
WGR: How did you approach this? All through the right side?
SENNING: We did that through the right side – yes, and I think that is the standard method most people do. And he, also, had an uncomplicated course and was surviving two years ago.
WGR: And how did you manage technically the first transposition?
SENNING: Ja, the first – although why I did start to do it. It was the mother of the children’s best friends. One day they phoned me and asked me if we couldn’t do anything through a transposition because she had had a child and this child died on the 8th day of transposition of the great arteries. So, I sat down at this table and looked at the possibilities to make correction on the arterial side, on the venous side, and in the ventricular – no, in the intraventricular, and to me it seemed the easiest to do it on the auricular side – to switch the auricles. So we had one patient who was 8 years old in Poland who had been with us with a diagnosis of tetralogy of Fallot but it was found out that it was transposition and we could do nothing with this patient. So we called him back. I had shown Crafoord the method of doing it on dogs and on cadaver, and he was sure we could do it. This patient came from Poland and we did this operation. He had a very high pressure in the pulmonary artery, but, apparently, this pressure was lowered after the operation. Now, this man has been living a normal life. He has been playing football, working, etc, but now a year ago he got endocarditis of the tricuspid valve, got valvular insufficiency, and died of a right heart decompensation – of systemic ventricular decompensation.
WGR: And what year was he operated?
SENNING: 1958, in October.
WGR: So he lived for 20 years? I always thought that was one of the best operations for transposition. It only took me a week of careful study to figure out how to do it, but it is still a good approach, isn’t it?
SENNING: I think they are going back to it when they see that they get all this stenosis with the Mustard operation. The Mustard is simple – there is no doubt – but from our series of 200 transpositions to date with a patient who had not been operated before and where we had done a standard operation, we have had no stenosis up to now. Where we had to put in a patch – I have 2 patients who have had stenosis of the veins. This first patient was operated about 2 weeks before we made this first pacemaker. It is on the picture up there. This was also a rather dramatic thing.
WGR: How did you get in on that perchance?
SENNING: Ja. You know when we started with ventricular septal defect in the end of ’54, we got the blocks – AV blocks – as all people did and then we tried with different percutaneous electrodes but they all got infected. We did also spontaneous block in elderly patients and they also got infected and they died from the sepsis. And at that time, I could not find out a way to get the transcutaneous lead without an infection. We make channels – they were more than 12 cm, then it lasted a little longer but still they got infection. And I talked with a friend of mine if he couldn’t help me do the electronics for it. And I have the idea that you could charge an accumulator transcutaneously with a high frequency current. And, Imquist, whom I asked, he immediately said it was easy to do. So we did it and tried it in dogs and it functioned very well in dogs. But there was one difference when I made the first patient and that was I had a cautery and in the experimental lab I did not have any diathermic apparatus at all. So, when I put in the pacemaker it functioned very well. I made – what you say – stop the bleeding with a cautery and destroyed one of the – what you call them?
WGR: The batteries?
SENNING: No, not the batteries but the diode in it. Perhaps one of the transistors. It was one of the transistors that was destroyed by the current. So, it make off 8 hours the accumulator was empty. Then we had to put in another. We had made two and these pacemakers – the housing was made by epoxy resin and it was molded in shoe polish wax can. We did two of them and the second one did function. The patient is still living.
WGR: Is that right?
SENNING: Yes.
WGR: Incredible!
SENNING: He built up a big firm for electronics for ships and he sold it, I think, two years ago.
WGR: That’s incredible! That is lasting longer than some of our present pacemakers.
SENNING: No, no but he has. I know.
WGR: That is right but he has still done very well.
SENNING: He refused to have Lithium battery pacemaker in the beginning because he said, “remember how many troubles we have had, with the leads, with the batteries and everything. No we stick with this pacemaker. We know it will last for about 2-1/2 to 3 years. But the Lithium we do not know yet.” But now he has lived with this pacemaker.
WGR: Well, Professor, thank you very much for your time. I appreciate it very much.