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Objective: To provide a brief review of the development of cardiopulmonary bypass., Methods: A review of the literature on the development of extracorporeal circulation techniques, their essential role in cardiovascular surgery, and the complications associated with their use, including hemolysis and inflammation., Results: The advancement of extracorporeal circulation techniques has played an essential role in minimizing the complications of cardiopulmonary bypass, which can range from various degrees of tissue injury to multiple organ dysfunction syndrome. Investigators have long researched the ways in which cardiopulmonary bypass may insult the human body. Potential solutions arose and laid the groundwork for development of safer postoperative care strategies., Conclusion: Steady progress has been made in cardiopulmonary bypass in the decades since it was first conceived of by Gibbon. Despite the constant evolution of cardiopulmonary bypass techniques and attempts to minimize their complications, it is still essential that clinicians respect the particularities of each patient's physiological function.

Extracorporeal oxygenators are artificial devices that substitute for anatomical lungs by delivering oxygen to, and extracting carbon dioxide from, blood. They were first conceptualised by the English scientist Robert Hooke (1635-1703) and developed into practical extracorporeal oxygenators by French and German experimental physiologists in the 19th century. Indeed, most of the extracorporeal oxygenators used until the late 1970s were derived from von Schroder's 1882 bubble oxygenator and Frey and Gruber's 1885 film oxygenator. As there is no intervening barrier between blood and oxygen, these are called 'direct contact' oxygenators; they contributed significantly to the development and practice of cardiac surgery till the 1980s. Membrane extracorporeal oxygenators introduce a gas-permeable interface between blood and oxygen. This greatly decreased the blood trauma of direct-contact extracorporeal oxygenators, and enabled extracorporeal oxygenators to be used in longer-term applications such as the intensive therapy of respiratory distress syndrome; this was demonstrably beneficial for neonates but less so for older patients. Much work since the 1960s focused on overcoming the gas exchange handicap of the membrane barrier, leading to the development of high-performance microporous hollow-fibre oxygenators that eventually replaced direct-contact oxygenators in cardiac theatres.

From the 1950s to the 1980s, the most widely used oxygenator in the clinical field was the disposable bubble oxygenator. However, membrane oxygenators have become the preferred clinical choice over the years. In the United States, membrane oxygenators used in cardiopulmonary bypass operations account for the majority of clinical oxygenator use. Membrane oxygenators have an equal capability for oxygenating venous blood compared with other type of oxygenators such as the bubble type and film type; however, the membrane oxygenator requires a smaller volume for priming to achieve a sufficient gas transfer rate and results in less blood trauma such as hemolysis because it uses a similar mechanism to the natural lung. In the 1980s, the first capillary-type oxygenator adopted the system of intracapillary blood perfusion. However, this induced high pressure resistance in the module and caused hemolysis. Thus, at present, capillary oxygenators commonly adopt the system of extracapillary blood perfusion. Microporous hollow-fiber membranes are primarily used for short-term cardiopulmonary bypass application, whereas nonmicroporous hollow-fiber membranes are primarily used for long-term extracorporeal membrane oxgenation application.

Open heart surgery was not possible before the early 1950s. The development of controlled cross-circulation at the University of Minnesota in 1953 was a major contributing factor toward operating safely on the interior of the heart. Cross-circulation required connecting a donor's arterial and venous blood vessels to those of a smaller recipient whose heart could then be opened for corrective surgery. At that time no mechanical system was available to serve the role of the donor. The need to replace the donor was recognized. The author describes his experience with the development of the helical reservoir bubble oxygenator, which replaced the donor in cross-circulation supported open heart surgery. Other sidelights of the author's experience during the early days of open heart surgery at the University of Minnesota Department of Surgery are also recounted.

Intracardiac surgery requires the use of a pump-oxygenator to maintain life while the heart is taken out of its usual circuit. Open-heart surgery became practical with the introduction of perfusion systems in the early 1950s. Many factors merged at this time to initiate the beginnings of open-heart surgery.

From 1953 when Gibbon first successfully supported a patient with extracorporeal circulation to about 1980 many different types of oxygenators were developed. Since their introduction in the early 1980s, microporous hollow fiber oxygenators with blood flow outside the fiber have become the dominant type of oxygenator in use. Their success has been due to both the ability to specify the required properties for a good oxygenator and the application of modern design tools, especially computational fluid dynamics, to the design process. The result has been the availability of many oxygenators from different manufacturers that differ to some extent in their performance but all of which provide adequate performance for successful and safe clinical use.

This paper is a brief biography of two of the most important contributors to the development of open heart surgery. In 1952, John Lewis performed the first successful open heart surgical procedure of any kind, repairing an atrial septal defect under general hypothermia in a 5-year-old girl. In March 1954, Walt Lillehei, utilizing controlled cross circulation, embarked on a series of 45 consecutive patients. The bubble oxygenator appeared in 1955, and open heart surgery was introduced to many of this nation's major medical centers.

Cardiopulmonary bypass has evolved from an extremely risky procedure into a safe systematic process, and is practiced daily in thousands of centers throughout the world. Numerous individuals, from diverse specialities, have contributed to the knowledge of the processes of extracorporeal flow. The developmental sequence of advances in cardiopulmonary bypass has been divided into three nonexclusive periods based on the major changes observed during the time: (1) a conceptual and developmental period, consisting of events that occurred before 1950; (2) an applied technological period, 1950 to 1970; and (3) a refinement period, 1970 to present. Within each time frame, the major findings regarding biological and technical challenges, extracorporeal device development, and applied clinical practice will be explored. Technological advances in cardiopulmonary bypass have permitted surgeons to treat patients with both congenital and acquired heart disease, and anesthesiologists to identify appropriate mixtures of treatment regimens, whereby the risks associated with managing this challenging patient population could be minimized.

Convinced that the high risk of operation using the early heart-lung machines was due to a toxic effect of the oxygenators in use in the 1950s, Charles Drew of Westminster Hospital in London devised a circulatory support system in which the patient's own lungs functioned as the oxygenator. With this support, body temperature was reduced to the point where circulatory arrest could be tolerated for the time required to carry out the intracardiac operation. He used only this technique for the rest of his surgical career, a period of 22 years. We have attempted to record how this came to pass and to describe the qualities of this man that led him to be original and creative.

During the late nineteenth and early twentieth centuries, gas-pipes were among the most popular therapeutic devices available to an unhealthy public. Spurred on by the explosion of print advertising, mail-order gas-pipes were questionable remedies promoted for such diverse conditions as pneumonia and neurasthenia. Though they are an interesting part of the social history of questionable therapeutics, no historian has recently looked in depth at these devices. This paper examines the clinical, social, and economic environment that facilitated the success of the most ubiquitous gas-pipe, the Oxydonor, and its proprietor, Hercules Sanche.

The development of open-heart surgery has been reviewed beginning with general body hypothermia and inflow stasis, then continuing with extracorporeal circulation by controlled cross-circulation. The successes with the latter technique stimulated rapid development of the simple disposable highly effective bubble oxygenator for extracorporeal circulation to permit correction of virtually all forms of congenital and acquired heart disease. For the few conditions not amenable to corrective procedures, heart replacement became a practical reality. The creation of chronic heart block in the early operations had a very deleterious effect upon survival until highly effective electrical pacing was developed.