 Thank you, you know, it's It's interesting to me being in the Texas Medical Center now since 1963. It's up for a couple years in Vietnam that I've had an opportunity to personally witness the development of all the Elvads of consequence and they're in use and it's interesting that it should occur in Houston Because Houston had no particular Importance in medicine certainly before the 50s and Specifically I want to end up with the a brief survey of how the continuous Flow of blood pumps came about because they they all of course that are being used now Came from my lab or around my desk now One of the things people actually one of my cardiologists told me about this that I've been planted and More heart transplants and more pumps and I have but not because I wanted to I did I did it because none of my associates wanted to They were all basically in private practice and I was the only one that had an academic salary So and you didn't get paid for these pumps much at least comparatively speaking and And then and you were up all night, etc. So I ended up doing nearly all of them And why Houston as I Said there's a lot of it had to do with this man. Dr. Devaki and Dr. Devaki as Dr. Cooley said in this Picture of him he looks a bit like Groucho Marx if some of you remember him in fact He looks a lot like Groucho Marx, but he wasn't very funny. He was he was very tough and very Difficult taskmaster, but he built up a bailer from my Medical school that was on probation when he came here to By the time I went in the early 60s. It was considered the best of medical school in the South certainly the This is the way it looked when he came here is Houston was known as the turn of the century for the timber and cotton and And you can see why it had timber because it was at the edge of the east Texas forest and you can see that little building in the midst of all that forest there's a This little building and that is Baylor College of Medicine, which is the first one Built in the Texas Medical Center and Dr. Devaki told me when he came here to interview He actually heard gunshots and and the gunshots were actually coming from people hunting out in that woods anyway, he Dr. Cooley was also from Houston and he trained with Blalock. This is a very important little things in history to determine all sorts of eventual Destinations and and Cooley since he worked with Blalock Blalock was the first one to do Any sort of corrective cardiac surgery of merit and he did shots. He never did open-heart surgery in his life But he did do the shots of Dr. Cooley who was very adept surgically from the start helped and and Actually did some of these procedures between them is Albert star who developed the first Valve that worked This is the Medical Center again a little later, but It's only importance is you see Methodist Hospital right in the middle and are in front of that is Texas I'm sorry is the St. Luke's Hospital and the Texas Children's and the importance of that is that since Dr. Cooley had worked with Blalock He had privileges at Texas Children's which at that time was Attached to St. Luke's so the other Baylor surgeons all worked at Methodist, but Dr. Cooley using this pathway Also had privileges at St. Luke's Now the early days of cardiac surgery we know about Gibbons doing the first case in 1953 that succeeded and a woman who the last time I checked was still alive it was about my age and But the next three cases he did all died and he quit doing heart surgery all together and This was something that Lila high research that there was only it was the only survivor of the first 20 cases Now Lila high was a very important person in the history of Heart surgery because he was the first person to actually do open heart surgery Successfully and did it by cross-circulation He did the one of his fellows pregnant wife gave him the idea that perhaps the adult Could support the child because it was mainly Continental heart surgery in those days long enough to allow for into a open heart surgery and Allow it to be performed successfully. This is sort of the way it was hooked up and it it was Undoubtedly the first really successful heart surgery They also Cooley went up there in the fall of 55 and he met DuWall and DuWall was working on the first Bubble oxygenator now the bubble oxygenators were very traumatic to the blood and no one that had it had survived and They really were trying to use Sort of a copy of the Gibbon up there Cooley came back and he and his brother-in-law made this machine He got it as a coffee maker and he got it from a restaurant supply house somehow his brother-in-law had some connections there and they used a steel wool in the top to filter out the air and he bubbled oxygen through the deoxygenated blood and Out to the patient Cooley lily Was the most important surgeon? To nearly to everyone's feeling at this Of the in the early days of heart surgery because it was the first one to show it could actually be done successfully But lily who I got to know very well And in my life and he really thought Cooley was the most important because Cooley was the first one to do it with a heart-lung machine and this is the first case he did it was a post-infarct VSD a hard case to do even today and He operated on this man and corrected his VSD in April of 1956 and he reported it here For that year of 1956 he reported doing 95 cases and This was in the Texas heart I'm sorry the state of Texas Medical Journal a very inconsequential medical journal was the first open heart surgery that was Successful it's interesting for this crowd to know that they started out Just giving half the dose of heparin that we know Normally give and he also used two pumps. He used a pump on the venus return side Then it went into the oxygenator and then a pump on the exit the arterial side and He cannulated both the superior and trivia vena cava just through the right atrial appendage and This is another schematic of what he was doing bubbling this blood to Auctionated and this is the reason Cooley got away with it because He was so fast and that was important in those days because of the destruction of the blood. You see this very short operative time to correct this simple atrial septal defect, but it was very important and He reported 95 cases with nine acute deaths more late deaths, but this was Incredible at the time and the Mayo Clinic and the University of Minnesota at that time a little high told me had done 48 cases with 22 deaths so 50% mortality and that's why people came to Houston They didn't come here for the weather or the beach they came here because if you needed heart surgery, it was the best hope for you now This is once dr. Cooley got started. We did more heart surgery here than any place in the world In fact until 1984 we did more heart surgery at St. Luke's Hospital than all of Western Europe This is the It wasn't a typical day This was our largest amount of cases. We did 52 cases in one day and 10 operative rooms Cooley himself did 14 of them and you can see these were all Tough cases. They weren't simple cases that you could just lie to die through these mitral valve Tetrology or a stally and Etc. Etc. But I remember he left the hospital at 6 30 because he was taking his daughter to the baseball game and the artificial heart of course is what we started with in the early 60s and Dr. DeBakey was very instrumental in this he got the National Advisory Heart Council to develop Funding or to give funding to develop a total heart and Baylor got the most of the money There's a lot of money five hundred thousand dollars in 1963 was a lot more than of course There is now and one of the reasons of course dr. Bakey was in with everybody, but particularly this was when LBJ had Due to the tragic death of John Kennedy had become president and LBJ was very actually forward-thinking He he really did a lot of civic or Very a lot of good to the to the country that surprised everyone you certainly me and This was the first and it's important to remember this Just if you want to know the history is that this was the first time that the NIH supported a clinical Go it's the first time they gave money for a clinical Frugation for it because prior to that they just gave a pure basic science grants And obviously this was the time we were going to the moon so making an artificial heart that didn't seem like too big a challenge and Man made you go now as far as this is From the early 60s from this era and it was certainly dr. Bakey's main research goal at the time Dr. Bakey became very famous in that era. He was On the cover of time he was on the cover of look and he was on all the the media which And his sisters he was also the first Doctors for it. I know that had press agents because his sisters acted as press agents and they would always have it in the paper in the media whenever he gave a talk and But he also as I said that's the first meaningful support of mechanical cardiac assist With this he hired Domingo Liotta who had worked on an artificial heart? with Cough and a kutsu at the Cleveland Clinic. He was from Argentina He'd done some basic work while he was in Argentina He presented at one of the asylum meetings. Dr. Bakey was impressed by it and and enticed him to come to Houston Now Dr. Bakey as I told you was He was very accomplished, but but he he wasn't really a very warm fuzzy sort of guy he Dr. Bakey was a strict discipline area in fact in his operating room You couldn't speak unless he spoke to you and you couldn't Unless he asked a question for you to answer which you better have the answer There was no sound in the operating room Back in the 1960s Michael Dubakey was one of a handful of leading heart surgeons He was known as the Texas tornado And I know what you know what I want to do you see well Dr. Bakey was quite a taskmaster. He was it was like Working under a marine drill sort. It's the patient's life that you're concerned about and I think Dr. Bakey always Emphasize that and in a matter that was very forceful His exacting standards brought to Texas a host of luminaries Marlene Dietrich the Shah of Iran and the Duke of Windsor Everything had to be in perfect order there was even an order that people had to be in in this line That you when you went on rounds Now these are things you heard from him throughout the operation he was always attacking the resident and of course we heard this a lot and He actually I went in one day to talk to one of them see geologists and He had all his assistants men in their late 30s early 40s standing in the corner Well, he would do a bowel aneurysm with his nerves, which he could actually do anyway. It's a different world this is something of course we heard a lot from him and it was very very Very much to the case he Had this diagram This wasn't actually his diagram. I'm sorry. This is just Gives you an idea what we were really working for in those days the left Ventricular recovery and device removal was the immediate goal of the L VADs the idea of long-term support and of course when transplant started in the 60s became another Secondary goal of the technology one of the things that was noted by Dr. Vackey and others that sometimes when you couldn't get a patient off bypass simply by leaving them on bypass Sometimes the heart would recover enough To allow you to wean them. This is actually in the first report of the use of an inter Caporial L VAD long-term L VAD and and in it he Demonstrated how this gave him the idea of using the L VAD as a bridge to recovery by a prolonged support and in 1966 Actually, I was on the service then and I remember this woman very well It's a 37 year old woman that actually had to buy an aortic and mitral valve replaced with a with a ball valves and most of those Patients died and she Dr. To make he anticipated this and he supported for ten days She's a very brave woman here. She is that you see the pump is on the outside of the body But it was flowing about two liters and it kept her alive the pump was removed. This is a later when she came back for a visit she did very well and and Tragically died in a car accident eight years after this and this was the first goal of the use of the L VAD's Dr. Maki points out it Was Designed to allow her to recover now the transplantation sort of came out of the blue some way was working on this and Dick Lauer but Crispin hard actually did the first successful heart transplant And I got to know Chris Bernard. He's a very entertaining very cordial guy, you know all the Nurses loved him and the people that worked with him. He's very very congenial and I Asked him one time why he thought the first heart transplant occurred in South Africa and he pointed out that the problem in or reminded me I knew this that in America was defining brain death because You were dead when you lost your pulse. That was a legal definition of Death and and so you had to have a pulse if you were gonna have a heart that would be of inequality for transplant and Dr. Bernard reminded me that In South Africa, you were actually dead when your doctor said you were dead So he had a little more leeway with the brain death definition But he really helped because once he did this which was in December of 67 Then it became much easier in the US to To pursue this dr. Canowitz Tried two cases in the US and dr. Chomay tried a case and they both died in the first Successful case. Here's dr. Cooley with Chris Bernard was done by dr. Cooley and This Era was a Time when there was a lot of attention paid to these Heart transplants and when dr But hard Successfully performed the first one in the sense. He got the patient off the heart-lung machine the patient woke up and was able to be interviewed and And he looked like he was doing very well and And as dr. Bernard admits here he died because he over-immune suppressed him which was a common problem in that era But he obviously recovered from the operation as I said dr. Cooley did the first patient to live after a heart transplant in Houston here's that crowd with Chris Bernard a little high at Stinson and dr. Canowitz and the first Implantation of an artificial heart was done by dr. Cooley in Houston and as you can It was done as dr. Liotta became became obvious to him that dr. Devaki was never gonna implant a total heart and One of the reason dr. Devaki actually didn't start doing heart surgery Until 1960 not to crew. He'd already done several hundred cases So he was much more depth than anyone in the world Technically and and I think he felt that this would be a good way to abridge a patient to transplantation it's clearly a patient that was dying and he Liotta brought the heart over and dr. Cooley implanted he sewed it in and in less than an hour and And of course here's the first report and You'll notice the absence of dr. Devaki's name in the report, but it it was a very important because it shows that again the feasibility of it Not the practicality of it. It was not practical. He died of overwhelming Substance he was way over him in suppressed, but it did show that it could be done Here he is awake immediately after the He was brought back to the to the recovery room We just seldom do that today with our total heart patients but As I said, he died of overwhelming transplant Rejection laboratory work You know it resulted in dr. Devaki not speaking to Dr. Cooley for another 30 years anyway this The failure of heart transplant led us to pursue the Mechanical support with the new renewed vigor. This is one of the the early Grants that were this was what they call a request for proposals and this was 77 actually the first one out in 74 and One of the goals was to have at least two years of Tether free in other words out you could be an outpatient and And actually leave the hospital The first pump to actually be implanted though was a temporary pump To allow for ventricular recovery again after heart transplant Jack Norman was working on this when I came back from Vietnam and started working over here with Oscar Cooley and Jack Norman and this went in the retrocolic gutter It was quite an operation that lost a lot of blood. It really impaired the the use of the As the the coagulation I'm sorry the coagulation systems these patients just bled Constantly and and all of them died none of the left the hospital We had one patient that lived six months, but he lost his arm and both his legs From that we began working on this totally implant all Pump for long-term use that not as a bridge to recovery at the same time in the mid 70s This was a very ingenious pump designed largely by Vic Poirier and Curt Dossy working for the Accompany in in Boston and That it is very simplistic It pump filled to empty There was not much enthusiasm for it because the transplants the group Began very popular once sectors foreign was introduced and I did all the implants from 1986 they were done until 1990 and then the group at Columbia became involved Eric Rose and Munoz and Valjeva Nundum and others and The the beautiful for about this pump. It's the only implantable mechanical device Surgical device that didn't require any coagulation. I didn't use any any coagulation the the group at Columbia sometimes gave aspirin But the reason is that within 24 hours in plant the pump was coated with the cells The it did require a console and the patients had to push this console around It was approved by the FDA and the first one to be approved by the FDA Because it actually had a control group of patients that Although they met all the criteria for the implantation They weren't implanted because the company couldn't make enough pumps and as you can see the the control group was a legitimate control group and and The nearly all of the control group died very early and the LVAD was very Successful on the other hand the electrical powered pump which was of course the initial RFP was implanted in this patient and implanted in 1991 and this was the first patient to actually leave the hospital and again, this is the The pump and operation This just demonstrates all the paperwork that we had to do and the companies Had to support in order to get these approved now the The complications of course were high but but this pump was also approved by the FDA in 1998 the and I spent more than five hundred million dollars and On the research and the company spent the same amount so over a billion dollars were spent on research of the postal pumps and They spent nothing on the development of the continuous flow pumps Rob Jarvik's wife the Nimbus company that went bankrupt and I paid for the research in these pumps I made this statement in 2005. In fact, they quit making postal pumps by 2012 now the continuous flow pumps were Largely stimulated by the the problem of the durability of the of the postal pumps they only lasted two years at best and So the they really were just Another bridge to transplant and dr. Shumway, I knew very well also would harass me about this because we had to have a longer Durability of a pump and that's why I started working on continuous flow pumps now. Nobody else was interested anybody tells you that oh, there was a lot of Interest in this at that time. They're they're lying and I was I was there. They were just mistaken let us say but it comes nobody believed in it and I had a debate in a PSIO in 1985 with Glenn Pennington a very knowledgeable Follow in this field and he showed us he kept pointing out to me he won the debate Because of the problem that he foresaw with the bare receptors causing central hypertension and by loss of post utility and The other hypertension would be the renal hypertension and both these would result in a high instance of stroke and We also leave the positional reflexes etc etc and the the other problem was the high RPMs to give a Meaningful blood flow and it was felt that if you went about 2,500 it would destroy the blood and the other Barrier that was finite was You couldn't you had to have bearings for those pumps and you couldn't lubricate a bearing in in the bloodstream, so all these were felt to be total Obvious reasons that continuous flow pump was Impossible rich Whamper showed me his idea and in April of 1985 and this was based on an axial flow pump that They used in Since again over 2,000 years ago we developed this first small pump and Implanted it in a patient in 1988. It was successfully implanted and salvaged a patient from sure death from Transplant rejection this man lived several more years after We were able to reverse his actual The problem with rejection this young boy's heart actually stopped completely and He was small, but I implanted the pump through a retro peritoneal Exposure of the abdominal aorta and You can see his heart isn't beating at all at this point and the only flow he has to his body is going through the pump and and this was an important patient to me because clinically it showed you didn't need Any pulse at all with These continuous flow pumps this young boy Did very well and in target function would normalize with just a non-pulse to a flow It was very interesting and we had a lot of publicity at the time but as I said, we didn't have the Fairware with all to continue the research in the in the pump and But it was as I said many times at the it was what started the whole interest in continuous flow pumps Rob Jarvik also was working on blood washed bearings and we did over Six years of work with dr. Jarvik and we were able to implant the Pump successfully in the experimental animal by the early 90s so the Hema pump showed that we can have high RPMs and Pump blood successfully and Jarvik showed the feasibility of the Non-postal, I'm sorry of blood wash bearings the they're the those things those two advances or the basis of all the Research and in all the pumps that are in use today I'm gonna not this is a Illustrates the bearings the little red bearings that This is a dollar Jarvik, but it was a very Good demonstration of where the bearings are on the blood string and And we went on to develop what you know, and I was a heart mate to the heart where and the heart made three Then we don't have good data on all the durability of these pumps. Thorntech kept good records and they did the best job of that and we were able to show that the meaningful long-term Survival and and we now have patients that have had these pumps in over 15 years So they've not been pumped to failure The first centrifugal force pump that we began working on was a hardware in 1994 Is the beautiful pump we could implant on the diaphragmatic surface? And it can also be used as a right or left-sided pump. It's the first implantable right-sided pump big poor year and and courtesy who I've been working with since the 70s to develop the first hardware and the development of these two pumps Showed us that we could use a bearing lesser pump in the bloodstream, so we didn't have to deal with that and also we could put the pump into a pair of cartilages, so there's no pump pocket and Place it on the diaphragmatic surface of the of the heart the The last research that I want to Touch upon has to deal with a totally implantable continuous flow pump and At at the end of last year, they've been over 60,000 of these continuous flow pumps and planted worldwide and And in the US it's more than twice the number of transplants and There's no reason to think these pumps won't last 15 to 20 years, so we've certainly Solved some ways nightmare and in addition these patients can return to useful meaningful long-term life expectancy this young man was able to Recover his heart function, which I think is going to be another goal that will work for in the future and His pump was removed over six years ago, and he's he's still doing well this is one of the patients that's had his pumping over 15 years and The other thing that I didn't anticipate this young man is nine years old now He had this pumping planted when he was four and he's still doing quite well the last thing is the I want to touch on is the Totally pulse it's hard as I said my experience with the continuous flow pump led me to believe that you could have a Pump without a pulse at all This is one of our experimental animals. You see there's no pulse at all in this patient and that's we actually Billy Cohn and I implanted this in a patient and he recovered nicely, but unfortunately had amyloid that had Involved the kidney and the Long and the liver and we finally had to discontinue that's his support You make these pumps very small. There's just one moving part This is a magnetically suspended pump and it pumps to both the the right and left side and it's has Influent potential for durability also and We hope that we'll be implanting this pump within clinically within the next two years And it'll fit as I said much easier and can be totally Powered internally in addition you can create a pulse with this pump simply by altering the RPMs so I think we've come a long way with these continuous flow pumps and I think Dr. Dabaki Told me when I was a medical student in the 60s by 1980 we'll have a hundred thousand Americans with an artificial heart I think we'll have that in the future, but he was a little off on the time frame This I'm convinced it can be done too and I think one of the things that I've learned and one of my advantages is I've never looked back and you can't make an advance By looking back. I had a long conversation with his Irish singer He never took music lessons, you know, and he thought that was one of the things that helped him the most in his in his career as a musician and and you always have to remember that Creativity is impossible looking back