Innovation According to C. Walton Lillehei

Abstract

C. Walton Lillehei (1918–1999) represents the most distinguished American surgeon of his time and perhaps the greatest surgeon in history. As his mentor, Owen H. Wangenesteen (1898–1981), so accurately declared, Walt Lillehei was “one of the surgical immortals.” Indeed, similar words were echoed by the famous cardiac surgeon, Denton A. Cooley (b. 1920), who said, “Hardly any other cardiac surgeon has introduced a greater number of innovative techniques and concepts.”

Born in Minneapolis, Lillehei attended the University of Minnesota, where he completed his college, medical, physiology, and surgical studies. Because of his extraordinary contributions to make open heart surgery feasible and safe, he is considered the father of open heart surgery. Many other contributions followed the initial innovations, particularly the use of the bubble oxygenator, the total intracardiac repair of tetralogy malformation, the use of myocardial electrodes for treating complete heart block, and the development of three cardiac valve prostheses, among other discoveries.

The noted Minnesota surgeon was an innovator for his entire professional career. He believed in innovation and practiced innovation in any way possible. “Determination, persistence, and stubbornness” were, according to Lillehei, “the most important components of research and successful discovery.”

“Experience is a great teacher. Good judgment comes from experience, and experience comes from bad judgment.”

—C. Walton Lillehei [[10]]

C. Walton Lillehei (1918–1999) is without a doubt the greatest surgical innovator of our time, and because of his noteworthy contributions, he is considered to be the father of open heart surgery [[1], [2], [3], [4], [5], [6], [7], [8], [9]]. He intensely valued the force of innovation and discovery and forever defended the “minds of the young” as the best source of creativity. One could almost hear him saying that to stall the young's creative energy would be equal to derailing the progress of humanity [[10]]. In this writing, I concentrate and emphasize the noteworthy concepts on innovation that Lillehei put forward in the field of scientific inquiry.

Brief Biographical Remarks

Walt Lillehei, as he was frequently called by his friends and family, was a Minnesotan through and through. He was born, raised, and except for a short stint in Europe during World War II and New York for a few years, lived and worked all his life in Minneapolis and St. Paul. He epitomized the Midwest and Minnesota spirit of being open, courteous, friendly, and generous. He accepted others' ideas but challenged established dogma. The real soul of an innovator!

Lillehei was an educational and academic product of the University of Minnesota, where he received his bachelor's degree (BS, 1939), medical degree (Alpha Omega Alpha, 1942), master's in physiology (MS, 1951), and doctorate in surgery (PhD, 1951). Owen Wangensteen (1898–1981) represented the caring surgical mentor and best example for the young Lillehei. Both of them established a trusting and loyal relationship that lasted throughout their lives.

After finishing an internship in 1942, Lillehei answered the call for his services in World War II with the mobile Army Surgical Unit that he commanded with honors. He received a Bronze Star upon completion of his tour of duty. In 1946, Lillehei began his surgical residency under Chief of Surgery Wangensteen. At the University Hospital, he was able to work with the noted surgical teachers whom Dr. Wangensteen had so creatively assembled. Dennis and Varco in surgery and Visscher in physiology were frequent advisors to the upcoming surgeon. The university atmosphere was highly conducive for innovative work. Lillehei thrived in this positively charged, creative environment.

In 1951, Lillehei entered the ranks of the surgery professorial staff of the University of Minnesota, first as an instructor, then rapidly advancing to professor by June 1956. During this period, many significant developments in cardiac surgery occurred at Minnesota, and in every one Lillehei was a decisive participant, especially on the cross-circulation cases. What a time of great excitement for the Surgery Department and the entire cardiac world!

On September 2, 1952, Lillehei assisted Dr. John Lewis in the first successful surgical repair of the malformed heart under hypothermia. This incredible case stimulated the 34-year-old, fresh, and motivated young surgeon to pursue cardiac surgery during a long and fruitful career. The issues involving successful cardiac surgery were many and realistically implausible to solve in the immediate or very distant future. Lillehei applied himself with intense commitment to finding solutions for the seemingly unsolvable and difficult problems associated with performing any meaningful cardiac surgery at the time.

After a long road of challenging laboratory work at the University of Minnesota, Morley Cohen, Herbert Warden, and Walt Lillehei came out with an unexpected response [[11], [12]]. From ideas generated in Lillehei's laboratories, pertaining to the main culprit of poor blood oxygenation, the Minnesota team elegantly proceeded to study the azygos flow system, and thereafter utilized the concept of cross-circulation, where a human donor (generally a parent) would provide the oxygenation and blood pump effect to the recipient undergoing heart surgery [[9], [10], [13], [14], [15], [16]]. A tremendous feat for that time and for any time under any circumstances at any point in history! This absolutely incredible discovery offered the best to patients with congenital heart defects and the world of cardiology and cardiac surgery [[9], [11], [12], [13], [14], [15], [16]].

After the feat of cross-circulation in 1954 in a child with ventricular septal defect, many more patients received attention in operating rooms at the University of Minnesota [[13], [14], [15], [16]]. In 1955, Lillehei together with Richard DeWall introduced the bubble oxygenator as a replacement for cross-circulation [[10], [16]]. In 1957, Lillehei used a myocardial electrode as a pacemaker for the first time in a human [[16]]. By 1960, Lillehei was using portable pacemakers introduced by Earl Bakken, a notable Minnesota engineer and collaborator on this project [[16], [17]]. A great number of operations followed with incredible success for those times [[15]].

In November 1967, Lillehei left Minnesota and accepted the position of Lewis Atterbury Stimson professor and chairman of surgery at the stellar New York Hospital—Cornell Medical Center [[1], [2], [3], [4], [5], [6], [7], [8], [9]]. The scientific and innovative hopes of Lillehei did not progress as expected in New York. The move did not offer the august cardiac surgeon the opportunities he had frequently seen in Minneapolis [[1], [2], [3], [4], [5], [6], [7], [8], [9]], and did not result in the best prospects for the surgeon-scientist.

In between Minneapolis and New York, Lillehei created three prosthetic heart valves: The Lillehei-Nakib toroidal disc (1966), the Lillehei-Kaster pivoting disc (1967), and the Kalke-Lillehei rigid bileaflet prosthesis (1968) [[18]]. An incredible odyssey under any conditions and under any appreciable measure for anyone!

In 1975, the distinguished cardiac surgeon returned to Minnesota, actively joining the emerging cardiovascular technology start-up, St. Jude Medical, as the medical director of the cardiac valve division. He successfully held this position until his unfortunate death in 1999.

During Lillehei's tenure at St. Jude Medical, he participated in the development of his fourth valve, the St. Jude mechanical heart valve, perhaps the best valve produced through Lillehei's collaboration and probably one of the best cardiac valves in the world.

A constant during all of Lillehei's professional life was his resilient and courageous fight to overcome the struggles and devastating effects of cancer. In February 1950, one day after completing his surgical residency, the young surgeon recognized a tumor in his neck. Without further delay, he took this matter to the consideration and advice of his distinguished mentor, Dr. Owen Wangensteen. Recognizing the serious possibility of a malignant growth, Professor Wangensteen recommended a biopsy and subsequent radical surgery, depending on the findings. A 12-hour operation, including radical neck dissection, mediastinal exploration, and left parotidectomy, followed the diagnosis of parotid gland lymphosarcoma [[1]]. Months of recovery ensued but the Minnesota surgeon never gave up his dreams and aspirations. Regardless of the outcome, Lillehei was determined to fight for every inch of productive life. Even a subsequent course of radiation therapy did not detour the attitude of this valiant future surgical pioneer.

Table

The Seven Ages of the Evolution of an Idea with Particular Reference to the Critic
I. Idea Stage	“Won't work” “Been tried before”
II. Successful Experiments (in Animals)	“Won't work in man”
III. After One Successful Clinical Patient	“Very lucky” “Doubt if patient really needed treatment” “Too bad, a tragedy really, because now they'll continue”
IV. After Four or Five Clinical Successes	“Highly experimental” “Too risky, immoral, unethical” “I understand that they've had a number of deaths they're not reporting”
V. After Ten to Fifteen Patients	“May succeed occasionally in carefully selected cases, but most patients with this defect don't need operation anyway”
VI. After a Large Series of Successes	“So and so in Shangri-La has been unable to duplicate their results” “I hear that a number of their patients are now dying late deaths”
VII. Final Stages	“You know, this is a very fine contribution” “A straightforward solution to a difficult problem” “I predicted this” “In fact, in 1929, I had the same idea” “Of course, we didn't publish anything—nor did we have penicillin, cortisone, and fine anesthesia in those days”

Evolution of a New Idea

Lillehei's career brilliantly illustrates the most important steps in the evolution of the researcher-scientist-clinician. First, an idea needs to be born! Second, the idea needs to be nurtured. Third, the surgeon-researcher needs to be prepared to stoically defend his/her idea. Lillehei, in a brilliant way, summarized the “Seven Ages of the Evolution of an Idea” [[10], [14]] with particular reference to the critics. It would be very instructive to repeat exactly what he first published in 1982 [[14]]:

Remaining loyal to a new idea and, as we indicated before, defending the concepts and rationale associated with it represent elements of great importance for the upcoming and/or well-seasoned surgeon investigator. I could well hear the famed cardiac specialist emphasizing these two important virtues, and possibly adding that an extraordinary degree of commitment is necessary to advance the idea. In short, to have a new idea represents the first step that needs a complete continuation and follow through to make the most of an initial and seminal consideration. Other surgical greats, such as Halsted and Blalock, have also pursued Lillehei's principles in their careers [[19], [20]].

RESISTANCE TO A NEW IDEA

According to Lillehei, new ideas face resistance as part of a natural process of evolution [[10]]. I would add, new ideas are created to be resisted. New ideas stimulate opposition. New ideas constitute the origins of the adversarial battle. Master surgeon Lillehei would reflect upon these concepts in the following way [[10]]:

“Open heart surgery—now regarded as one of the most important advances of the 20th century—went through an intense barrage of criticism. It was surrounded by controversy and opposition which even threatened to delay its acceptance and application.”

The experienced heart surgeon would then add some other critical concepts regarding the acceptance or rejection of new ideas [[10]]:

“Nonetheless, the acceptance of new ideas, new concepts, new theories, has virtually always been surrounded by opposition and controversy. Many have developed this, but familiarity with history clearly and repeatedly has indicated that disapproval or opposition from established authorities in high places frequently has had a strong retarding influence upon the acceptance of new information. It seems almost a normal risk which innovators must recognize and even expect and go forward undeterred. The researcher must learn to thrive upon opposition. Also, the successful innovator needs to recognize that the intensity of the opposition may be a good measure of his success, and thereby, gain added confidence.”

It is evident, according to the advanced wisdom of Dr. Lillehei, that following the path of the innovator requires one to remain calm and ready to receive the unwarranted criticism with a positive attitude, with an added interest in the advancement of science, and in the progress of humanity. Criticism is gaining advantage, opposition is moving forward, disapproval is progress. Each one of these principles is to be repeated to the young investigator, is to be solidified in the mind of the developing surgeon-scientist, is the evidence and support to the mature and accomplished researcher.

Examples of Intolerance in the World of Science and Medicine According to Lillehei

Noted surgeon and innovator Lillehei saw surgery as the great opportunity to generate new ideas, to bring new principles to bear, and to advance the knowledge of the discipline. The unique and classical example of the development of open heart surgery through cross-circulation is just one of many monumental advances he and his colleagues accomplished. In this discovery and in others his group introduced, he admitted some intolerance as the concepts were being presented to the medical world [[10]].

The pioneer Minnesota surgeon cited selected examples of scientific and layman intolerance toward the contributions of acclaimed scientists, such as Roger Bacon (1214–1294) from the 13th century, followed by Galileo Galilei (1564–1642) four centuries later, Ignaz Semmelweiss (1818–1865) and Joseph Lister (1827–1912) from the 19th century, and Werner Forssmann (1904–1964) from the 20th century. History finally accepted the great developments made by these personalities, but Lillehei highlighted the notion of slow acceptance of their ideas and principles [[10]].

Bacon, a great philosopher, scientist, and reformer of the Middle Ages, sought scientific explanations of natural phenomena and opposed the belief that science was dangerous [[10]]. He challenged orthodoxy and was confined to prison for half of his life. Galileo, another great scientist like Bacon, remained truthful to his principles and theories when advancing the knowledge that the sun and not earth was the center of the universe. For this idea, he was punished with prison by the Inquisition and persecuted in the last years of his life [[10]]. Semmelweiss, a great medical contributor, was at the center of medical controversy when he dramatically decreased puerperal infection by washing his hands prior to pelvic examinations of parturient ladies. A number of continuous objections about hand washing contributed to him losing his job and thereafter dying in an asylum at the age of 47 [[10]]. Lillehei offered the distinct examples of Bacon, Galileo, and Semmelweiss as clear evidence of the difficulty of accepting challenging concepts at the time of their discovery [[10]].

The noted surgeon also presented two more distinguished and controversial figures at the time of their discoveries, Lister and Forssmann. The first one introduced antisepsis on August 12, 1865, at Glasgow Royal Infirmary, and the concept took more than 15 years before receiving full acceptance [[10]]. The second suffered ridicule and ostracism for refusing to back down from his idea of catheterizing the right heart. In 1929, he realized this feat, and Professor Sauerbruch fully ignored him and “orthodoxy banished Forssmann from the academic scene” [[10]]. Lillehei felt that these well-defined examples represented the intolerance that the world in general, and the world of science in particular, showed toward the introduction of new concepts and new ideas [[10]].

Life of an Innovator

Lillehei carried with pride the designation of innovator. He pursued his ideas with enthusiasm and dedication. Every task was significant for him, every idea was worthwhile, every principle was considered, every surgery became the center of new advances. His career as an innovator represented a lifelong commitment!

The accomplished thoracic surgeon felt that “determination, persistence, and stubbornness were the most important components of research” [[10]]. He also felt that persistence was “the single most important element in successful discovery” [[10]].

If one closely follows Lillehei's professional life, innovation was a way of living, innovation was the essence of his thinking, innovation centrally occupied his life and work. As radical as this commitment might appear, what I have just described encompasses the life of any innovator. Such commitment is a solitary and challenging stage, which represents full dedication to the life of the surgeon-innovator, to the work of the surgeon-researcher, to all the required elements of the scientist participating in the field of innovation. Lillehei had all these qualities, demonstrating them convincingly throughout his professional career.

Conclusions

C. Walton Lillehei was the most important and advanced surgeon-innovator of the 20th century and without a doubt in the annals of American surgery. Trained under professors Wangensteen, Varco, Dennis, and Lewis at the University of Minnesota surgical program, he quickly progressed through the professorial ranks without difficulty and advanced with intense dedication up the ladder of science and innovation.

His discoveries were many, and he is considered the father of open heart surgery because of his unique contributions to the field through the initial and essential steps of cross-circulation using the azygos flow principle. With others on his team, he introduced the DeWall-Lillehei bubble oxygenator, total intracardiac repair of tetralogy of Fallot, use of myocardial electrodes for the chronic treatment of complete heart block, and many others innovations, in addition to the cardiac valves described previously.

Walt Lillehei represented the cardiac surgeon par excellence, the innovative cardiac surgeon, and one who would be a continuous example for surgeons and students alike.