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In the early 1960s, the National Institutes of Health began to fund research programs for the design and development of implantable circulatory support devices, which were studied experimentally in animal models. In 1963, the first implantable circulatory support device was implanted at Baylor College of Medicine for temporary support of a post-cardiotomy patient. This device was developed under the auspices of Dr. Michael DeBakey to improve post-cardiotomy support. A later iteration of this technology successfully supported a similar patient for 10 days in 1966.
The first heart transplant in a human being was performed by Christiaan Barnard in December 1967. The media attention surrounding the procedure led to inflated hopes that transplantation would be the ultimate solution for treating patients with heart failure. However, a limited donor supply and numerous immunological barriers (still problems today) posed serious challenges for advancement of the field. This initial era of heart transplantation, therefore, reached its peak in the early 1970s, and until the introduction of cyclosporine in the 1980s, heart transplantation continued at only 2 sites in the United States (Stanford and Medical College of Virginia), both of which had experimental programs with NIH support.
As a result, mechanical assist emerged as a potentially applicable choice for chronic support of patients with severe heart failure. The National Heart, Blood Vessel, Lung, and Blood Institute Act of 1972 reaffirmed the responsibility for research in the development of devices (and instrumentation) not only as temporary support for post-cardiotomy patients but also as long-term support for patients with chronic heart failure. The ultimate goal was to have these devices readily available for use, without the dependencies and complexities associated with transplantation.
John C. Norman, MD, who established and directed the Cullen Cardiovascular Surgical Research Laboratories at the Texas Heart Institute in 1972, was a leader in the initial work in this field. The article reproduced in this issue, exactly as it was published in 1974, outlined the goals of the early ALVAD program, described the experimental techniques for implanting and removing the device, and discussed the potential problems associated with implantation. The device described was the first iteration of what eventually became the world's most widely used implantable left ventricular assist device: the HeartMate® (Thoratec Corp; Pleasanton, Calif). Dr. Norman accurately explained the research challenges—in biomaterials, surgical technique, patient selection, and economic considerations. His prescient observations have stood the test of time and still express the difficulties, and the hopes that are only now being realized clinically. This landmark article should be familiar to all researchers involved in the field of mechanical circulatory assistance and also to the clinicians who still struggle with the day-to-day management of chronic congestive heart failure. Despite our efforts since this article's initial publication 30 years ago, finding a meaningful therapy for the large number of terminal heart failure patients remains a challenge, but help is on the way.
The article that follows this commentary has been reprinted from Cardiovascular Diseases: Bulletin of the Texas Heart Institute 1974;1:251–64.