 So I'm talking to the cardiology group, I'm trying to touch on a few things that impact cardiology and I think some of our neuro devices particularly will. Let's see how you advance this. Here we are. Of course we have to go a little bit to the history. And it is important to recognize, as I've gotten older, to recognize Dr. DeBakey's contribution. He looked, we used to think he looked a little bit like the comedian Groucho Marx. And he does actually. But he wasn't funny, let me tell you. He's the toughest guy I've ever been around. But as I've gotten older, I've understood he had to build a lot of things and he didn't want to waste time doing it. This was the medical center when he came here. Dr. DeBakey told me all these were restaurants and things like that. And you had this sort of back road in here. And Dr. DeBakey told me he heard gunshot when gunshots going off and when he first came here, this was 1948. And they were actually hunting deer out there in the medicals and all these woods. Anyway. Ma'am, age ago now as far as my research work is concerned is to perfect the artificial heart. When I started, this was one of his big deals. He was going to make an artificial heart. And he had to get funding for it. You know, the government doesn't do anything. The government sends out RFPs, requests for proposals. For example, you know what the B-17 was a bomber that destroyed Europe and got about 60,000 American boys killed also? You know what the B stood for? Anybody know? Bomber, it sounded like it was going to be a bomber, but it didn't. The B stood for Boeing. Because Boeing won the contract to build over McDonald Douglas. The thing that helped a lot in the field, and basically the whole field came from here, Houston, except for the words, if the guys did in Utah, but that sort of reached a dead end. And the, and the Becky was behind this. They had a meeting up there in 63 to push the development of the total heart. We were already planning on going to the moon, and this seemed sort of a sideshow to that. What are you doing? This is, I got to tie this. Well anyway, if you had the next slide, I would show Dr. DeBakey with his hands in LBJ's pocket getting the money to start the whole research field. And that was important because as I said, you had to have the funding to do this research and it certainly wasn't a field that the private companies could be involved in. It's important to also remember that transplantation was just out of anybody's brain at that time. That was just too far-fetched to even consider a possibility. Shumway was the only one that was really working on heart transplants. And he was sort of by himself in Minneapolis and California. Domingo Leodo was an Argentinian engineer, a doctor who started working on the artificial heart in Argentina. He presented his work in Osayo in 1961. Dr. DeBakey happened to be there and he recruited him to come to Houston to work on these things. There was LBJ, the patron saint of Texas, and Dr. DeBakey. We always thought Dr. DeBakey was sort of a mutant of some sort because most people's forehead starts here, like, oh, you've been at LBJ? It goes straight up. But now Dr. DeBakey goes at a 45-degree angle here. When I was a medical student, we said he was a product of an alien visitation to Lake Charles, Louisiana in 1908. But let me tell you, he was a smart guy. He was very brainy. He was fortunate he had two sisters that looked exactly like him. Exactly like him. And they were just as smart as he was. Lois DeBakey, I think, was smarter in some way. And they wrote all his papers. Dr. DeBakey one time told me he said, never trust a surgeon that's writing a lot of papers. Well, he had like 700 papers, but he didn't write them. His sisters wrote them. And I just don't know what his whole career would have been without him. And I'm sure he appreciated that himself. But Lois DeBakey founded the American Medical Writers Association and she was his first president. And she was smart. And she was mean to him. He didn't want to cross her. Anyway, this was a lot of money in 1965. And this was a 1965 time. Here's DeBakey again. He's on the front page of time. He was very controversial because he was the first doctor to sort of get into the public eye and also to get money from the government. And he was very smart in doing that. And this was in that journal. Somebody, I have a journal, but somebody popped it. But this is a slide from that time magazine. These are the new hearts that they were working on with Domingo Leodius. This is something out of your high school science project. You know, you made it in your garage. But they nearly were made in the garage because Domingo Leodius was just making these things up in the lab. And none of them worked very well. This was the medical center when I started. And we had to... I can't make this thing work. Anyway, what's wrong with this thing? Joe, this worked before you got a hold of it. Anyway, here's where we parked. This is the medical student parking. Had to walk all the way over here. Of course, this is all the University of Texas now. I think the medical students parking Fort Bend County somewhere now. I don't know. Anyway, if he could hear Dr. Bakey, I would say the heart was just a pump. And it seemed simple enough to make a pump. And it was. It was simple to make a pump. But it wasn't simple to make one that would last year in and year out, beating 100,000 times over 24 hours. If you do nothing. And it's quite a remarkable organ. Now, Dr. Cooley came here shortly after Dr. Bakey. Dr. Bakey came in January of 1949. Dr. Cooley came in 1951. He'd been with Blalock. And that was very important because Texas Children's and St. Luke's were one hospital at that time. You couldn't fund a children's hospital. So they had the idea that the Biscopayans always were long on cash. Could fund the children's hospital. And that actually worked for a number of years. But the main thing for us and for me and for you actually was it resulted in Dr. Cooley having privileges at St. Luke's. All the other surgeons were at Methodist and under more or less Dr. Bakey's thumb. And Cooley was over here where he had a lot of freedom. And the Cooley was a magnificent technical surgeon. He could do what he would ever be able to do. Duplicated. And even looking back on it today I was here and I can't believe he did the things that he could do technically. But he went to visit Little High. And Little High did cross circulation which was the first successful open heart surgery was cross circulation. Congenital heart surgery where the parent served as the oxygenator because they couldn't make good oxygenators for those things. The first 26 patients after Gibbon who did the first successful open heart surgery first 26 died, all died. And so it was a thought and Gibbon never did another one after his first one that it was just something wrong with the heart. And you couldn't correct it by heart surgery. And Cooley went up there and saw them doing this and came back and made his own heart lung machine which you can see up in the museum. It was a coffee maker and it was made drip coffee. His brother all got it in a restaurant supply house and he put steel wool up here and bubbled oxygen through the blood through a pump and had it come down here in the air. And that's what he started doing heart surgery with and he had the best results in the world mainly because he was so fast. Here it is in action. He did the first, his first case was a post infarct VSD bad case to do today and he plugged it with Ivalon sponge. I asked him one time what Ivalon sponge was and he forgot. But it worked and the patient lived and this was April of 1956 and by the end of the year he'd done 95 cases and his lived and the reason he lived is because of this he was so much faster than anybody else. He had all his cases and this time we're timed with a stopwatch. That's these y'all just kept a stopwatch so none of them ever went. The longest one I ever saw was 18 minutes and that was a tetralogy. And so he actually had people to live and he reported this in 57 and the Mayo Clinic and the University of Minnesota at the same time had done 58 cases with 35 deaths. So if you needed a heart surgery guess what you've tried to get to Houston if you could because nobody came to Houston for the weather or the beach. They came here because Cooley was the best technical heart surgeon in the world and Dr. Devagy didn't do a heart surgery until 1960. So Cooley had already been doing it for four years and he did it, he moved everything to St. Luke's after the first year or so. So that was as I said mainly the reason we're here. When I was a medical student we were all required to do a project and I I had no interest in surgery but I was a history English major and one of my co fraternity brothers at Texas was a medical student with him here as well, Frank Polk and he wanted to be a heart surgeon everybody wanted to be a heart surgeon then because after the bay he was famous and I didn't pay much attention to it so we had to do a research project and he signed me up we had to have our title in November the first when we were first year medical students so we had a couple of months but he stopped me on October the 30th and asked me what I was going to do for my research and I told him I said I don't know I haven't given any thought yet, you know, had another day and he signed me up for to work with Domingo Leota on the artificial heart so that's how it got involved and he had a trimmer and he quit doing surgery the next year and surgery research and I stayed with Leota and I've been working on it ever since then he I remember Dr. Devaki telling me this and it looked like he was probably right it looked pretty simple and it was simple to make a poem just not one that would last and perform the way the natural heart does and so he was a little off on those heart transplantation interposed itself here and this first episode of heart transplant started in December of 67 with Chris Bernard and Dr. Cooley they they did, Dr. Cooley did more than anybody in the world of course in that first era and here he is with, you were supposed to have three visitors you couldn't have more than three visitors and St. Luke's ER, OR at that time so Dr. Cooley didn't quite confirm to that he's hidden in here somewhere anyway he also did the first successful heart transplant in the U.S. not the first one, in some way did two encounterments did one but they both died in the hospital all three died in the hospital, Cooley did one in April and the luck of the hour is the guy lived over a year his longest lived and as you can see Houston between Dr. Cooley and Dr. DeVay he did about 25% of all the world's heart transplants then but the problem was of course they failed had very poor immune suppression at the time but one of the things that Dr. Cooley did was he got tired of working with Dr. DeVay he would never sew in a total heart he came and sewed some in which he never reported when I was a medical student but it took like two hours on the heart lung machine if you put a calf on the heart lung machine particularly at the bowl oxygenator in those days they all died so they all died but the pump worked well and Leona knew that and he came to Cooley and Cooley used it as a bridge to transplant it actually worked pretty well the pump worked for 40 actually 60 something hours and it was a very valuable at least potentially valuable because he was able to transplant and he was way over immune suppressed so when he got his heart transplant his white count was 2,000 so he died of overwhelming sepsis which was the main cause this is the Leota I'm sorry the oh what's the name of this building water water it was a Cooley water valve until it started popping out they never tested it in animals and it started popping out after about 6 months and that's why the FDA is involved in all devices because prior to that the FDA never had to approve a device that never went to any testing but when they realized that they never tested this valve and the animal or any way and it failed they required that's how they got it involved so that's the but that was the valve that was used in the first tone heart that Cooley implanted and there was a patient he actually woke up the extroverted he looked great they should have left him on the pump they were just afraid and of course there was worldwide attention they wouldn't do the transplant as soon as possible and they transplanted him too soon whether he was over immune suppressed this is chest x-ray right after the surgery none of the total hearts ever looked that good today and we do the pump actually looked very good they thought the pump was caught in some mimosis toward the end but it was probably related to the long pump time because he was on the pump the bubble oxygenator for over 2 2 hours it started this fight between Dr. Cooley and Dr. DeBakey that was very well publicized in those days and of course Dr. Cooley reported this and you can see Dr. DeBakey who did he got all the research money for it and you don't see his name on this anyway this was a very spectacular event and surgery and medicine they had this all over the world people were talking about this I was in Vietnam everybody said it was a safer place I was in an assault helicopter company we're doing combat assaults I flew on all the combat assaults 12 of them I was there and I said it was a safer place I think and my daughter says I was in a little better shape then so anyway they went on and on this is interesting if you could hear it Dr. DeBakey says Dr. Cooley was a good surgeon but that's all he had no interest in research and he was right Dr. Cooley had no interest in research but he did show the feasibility of the artificial heart and he wanted to get out of Baylor Dr. DeBakey was very predictable so he knew that if he prolonged the heart that Dr. DeBakey would fire him which is what he wanted he was trying to figure out a way to get out of Baylor and that worked perfectly for him and so that's why the Texas Heart Institute became independent now what Dr. Cooley didn't exactly count on he should have thought about it because Dr. DeBakey was predictable in these ways he fired Leota too because Leota was involved with the pump so then he had to have a lab well he didn't know how to deal with that and Dr. Cooley would never spend a nickel that was one of his two bit worse traits which he was so tight and but he got money from the Cullins he knew some people on the Cullin Foundation and the first lab was built right where we were sitting on this space it was a tin lab they made it with the tin that they used in World War II and it eventually moved it over into the main building and Domingo Leota ran it for about two years and then Jack Norman came in and was recruited and it's interesting because if it wasn't for that I'm sure these pumps that we used were never been developed because if I were trying to develop them under DeBakey that would have been impossible nobody believed in a continuous flow pump certainly for long-term use the heart transplant as I said failed in that first era nearly all of them were dead within the first year and so again the cardiac transplants just stopped except for Stanford basically so again they went back to long-term mechanical pumps and again this was a big grant that they gave from the NIH and that resulted in the first postural LVAD to be approved which we developed all these LVADs here because Jack Norman left the lab in the 70s and I took it over in 79 actually and the first 22 patients we put LVADs in all died but also the first 31 patients we put balloon pumps in all died so if we had an FDA then we would never even have the balloon pump today I'm sure anyway we finally got patients discharge on LVAD transcutaneously powered or percutaneously powered or percutaneously powered patient I did in 91 and he was discharged from the hospital so and these were the first pumps to be implanted now I don't want to belabor the postal pumps won't work long more than about two years at most we did get one last four years to take that flexing so that was one of the reasons I started to work on these continuous flow pumps and you obviously can't have the problem of durability but they were also big pumps they had size limitations as well and some way always said they had no real epidemiologic significance because they were only bridges to transplants although they could survive they saved many patients they couldn't really be a long term pump and the question came with whether we needed a pulse or not and the general thought was that you had to have a pulse for normal physiology and on these postal pumps then I spent over a billion dollars on the postal pump and they didn't spend a nickel on the continuous flow which has come to plague us to this day but there were five different centers utilizing postal pumps and there's been none other than ourselves that worked on the continuous flow but we did have to develop a smaller pump and I knew the only organ that really needed a pulse was the heart and if you were replacing the heart then that became smooth and Jarvik made a great contribution to these implantable pumps about developing the first and only non-livercated bearing in the world is the one that we use in these implantable pumps today and the Hemopump which Rich Womper did settled the high RPM question that you could have RPMs above 25,000 without causing homolysis these are the reasons we got into continuous flow pumps the Hemopump and the Jarvik and there have been nearly 100,000 of these pumps implanted worldwide now and those are the two technologies that were developed in our lab and first implanted here on the basis of all this these are the bearings these are the little red things you have to have bearings which you go from something that's moving to something that's not moving that's why you have to have oil in your car and again that was why the engineers all said you can't have a non-livercated bearing in the bloodstream Jarvik and I did about 60 animals and we worked on it a little over 5 years in our lab down there in the basement before he figured out a way to do it and he deserved a lot of credit for that and the Heartmade 2 was an offshoot of the Hemopump and it's the most widely used pump today as a bridge to transplant I want I'm not sure it's the best pump but the company was the best run company that was why it was so widely used probably both the Jarvik and the Heartware had advances over it but they weren't run if you have a product you have to have a company that can manufacture the pump and sell it this is a guy that went 5 years on the Heartmade 2 here he is out playing tennis he did want a transplant because he was a smart guy he was an engineer we put the pump in when he was 26 and he probably wouldn't see 40 with a heart transplant the 10 year survival is only about 50% 15 is about 15% so he wanted me to remove it and he was doing everything he wanted to do he got married he had a couple of kids with that pump and he's we took the pump out after 5 years and he's like 8 years now after removal of the pump which most of these young patients with idiopathic cardiomyopathy will heal just by resting the heart there's been over a thousand of these pumps and planted over 10 years we've had patients over 15 years with one pump totally well so the pumps don't wear out which was the first goal is to have a pump that was smaller of course and that was more durable and the failures of the pump are always related to the manager of the patients they're all mismanaged in my mind every time I make rounds I see patients here I think I would manage differently but anyway anatomically they're put in they're tricky to put in if you have the internal canyon against the septer or against the mitral then you get hypercoagulability and that's why you have thrombosis but not the pump the durability of these pumps we haven't seen a failure mode yet and certainly 20 years it's probably easy to reach one that's properly implanted now the future of the two things I just want to talk to you one I always hate to talk to the cardiologists about this is a pump we've been working on since 2005 this little pump to be implanted through the sub-clavian vein I got this idea because Clarence Dennis who was one of the worst he did a lot of crazy things but one of them was he implanted a pump through the internal jugular vein it was 1958 and it went down to the frameroval and he cut a hole in the frameroval and put the pump in the only place the two atria joined the frameroval and he put it in eight patients and in seven of them he was able to put the pump into the left atrium bring the blood out put it in the femoral area and support the patient and one he missed in the heart ruptured of course but this was 1958 so he showed the feasibility of it they were all nearly dead when he put them in so they didn't survive but the pump worked and it became obvious to me as the cardiologists were able to put all these long-term wires into the jugular vein we could put a small pump in through the jugular vein and put it into the left atrium just like Dennis did and we're working on this we don't want to have bearings you don't have to have bearings you can magnetically suspend these things we've got an NIH grant right now working on it up on the 9th floor it was this very clever Dr. Wang who is I'm sure in the next two years will have this ready to implant in patients Billy's done some implanted temporarily in some animals that we were going to sacrifice we had no funding for this either but now we have an NIH grant R01 grant study this so I think this will be something that I'm sure in the professional lifetime of most of you in here the cardiologists will to implant this through the subclavian vein and it should go into the left atrium that shouldn't be a problem and it's be a lot easier than doing it blind as Clarence Dennis did so this I think will be implantable I hope within the next two years we'll have this ready for patients don't open the chest it'll be a lot easier of course to get through the FDA and it can make a lot better argument for a class 3 cardiac you know someone since you don't have to open the chest I think we'll use about a 4mm graft to come through that and unload into the subclavian artery which again the first LVAD that was successfully employed was when I was a medical student with Dr. Devaki and it went from the left atrium to the right axillary artery actually subclavian and this should work and I think it can be easily powered I think without any I'm confident it can be powered transcutaneously without even breaking the skin but even if you have to break the skin it'll just be a small incision but I as I said I hope we'll see this in patients next two years now the total heart replacement we've been working on as an idea for continuous flow pumps for years the first thing is different because it's a totally different physiology the LVADs are different physiology but once you totally replace the heart with a continuous flow pump you've really made a big jump and it does this is one of the advantages you know the left and right ventricles don't pump the same amount of blood I used to ask cardiologists but they never knew the answer but technically it doesn't matter that much because the left side gets the bronchial circulation directly the pulmonary veins sit with each contraction it's about one cc more on the left and the right which doesn't matter but once we started making totally implantable artificial hearts it really mattered because 100,000 beats every 24 hours then you're 100,000 cc's out of sync if you don't adjust for that continuous flow pump since they have an automaticity to just increase inflow pressure without doing anything whereas with the postal pump with the Abucor we had to go through all sorts of generations to get that to work and I'm not sure how long it would have worked but and it was very challenging now I guess we we put Billy and I put this in a patient in 2011 two continuous flow pumps and actually the patient did well this isn't the patient this is a calf this is the first animal we did with two jarvics and you can see there's still a team involved we reported that this is the first animal and this was in this was in 2004-2005 and it was the first demonstration of continuous flow pump and this actually was the patient we put the pump in and it worked beautifully he was intubated and he was dying he was an engineer we got permission from the family to try this and here he was about a month afterwards he was back working on his computers and he was doing beautifully but unfortunately he had to amyloid and it turned out it was we thought it was just going to be in the heart and we could do a heart transplant but he had it in the liver and lungs and kidney and he cut himself off actually now Daniel Timps is here today he's been working on a continuous flow total heart for a number of years in Australia and he brought this to us in 2011 you can see this only has one moving part this center thing here this is a better demonstration of it as it is hmm oh yeah there it is so this is a smaller pump than the old Abbey Core it's about half the size only has one moving part and it's not touching anything it's magnetically suspended and it supplies both the pulmonary and the systemic circulation the systemic circulation comes off the bottom of it and the pulmonary on the top and it's very sensitive just like continuous flow pumps are an inherent starlings mechanism it is the you know a very clever technology we're doing the final FDA trials for this now now we can we can make this look like a pulse with this which may be of some psychological value for the cardiologist and the nurses anyway not having to look at just a straight line I'm not sure physiologically it makes that much difference but it does we can do that and it's rather easily integrated into this technology you know the problem with Dr. Vakie in 1964-65 thinking by 1980 we'd have it at 100,000 patients the technology just wasn't there then and so there's been a lot of technological advances with this magnetic suspension and this thing centers itself and Daniel tells me it has information 20,000 times a second so I don't believe that but I don't believe I don't believe the cell phones work either but I still use them this is an animal with total heart replacement with one of these pumps and at rest it has a pump and it's about 11 on the left and 13 on the on the right it has a slight left to right shock but you start the animal walking without any change in the RPM no change in the RPM and you can see the right side now is up to 15 and the left is up to 14 that's an automatic starling to response and it works just the way we thought it would work this is of course the size difference compared to and you can hear Dr. you'd say I'm convinced we will have an artificial heart in our lifetime well it wasn't in his and it may not be in mine but I think all of you will see one you know if we don't blow ourselves up in the next four to five years we will see I think a valuable adjunct to the treatment of heart failure patients I remember talking to this Irishman this singer one time and he was a very interesting guy and he I actually didn't know much about him I had to call my daughter and find out who he was he was interested in how you know I came upon what I did and I said you know I just did it and he said that he was the same way with his with his music because he writes all the music you know copy music they wrote it and he said and one of the problems with being creative is you can't be creative looking back I think that's one of the problems even with our educational system we test people on things looking back but we don't don't test them on creativity and I think one of the things that helped me a lot in my history exposure is I remember Jonathan Swift said in 2011 that if you have a good idea and he said a person with a good idea you can always tell they've got a good idea because they'll be surrounded by a confederacy of dunces telling them they couldn't it can't be done so if you have an idea and all your friends say well that's a great idea and it's really going to help it's probably not a good idea but as they all tell you just like they all told me he couldn't possibly have an unpostaled pump that would last you know I knew that Jonathan Swift you know to me that was a good sign that maybe it would work anyway I'd be glad to take any questions