In 1962, I founded the Texas Heart Institute (THI) with the goal of establishing a research and educational facility affiliated with St. Luke's Episcopal Hospital (SLEH) and Texas Children's Hospital (TCH), in the Texas Medical Center. From the beginning, the Institute's mission has been to reduce the devastating toll of cardiovascular disease through innovative programs in treatment, education, and research.
I consider THI to be my greatest achievement. In the early 1960s, there were several reasons why I felt that such a center was necessary. At the time, I was practicing at SLEH and TCH, which had been founded in 1954 to deliver primary and tertiary health care. In 1956, my team and I performed the first open-heart operations in Houston. By 1962, SLEH and TCH had the most active open-heart program in the world. Nevertheless, they were still regarded as general hospitals. The Methodist Hospital, affiliated with Baylor College of Medicine, was trying to catch up and was getting a great deal of support and grant money. I feared that SLEH and TCH would eventually lose the race if they didn't do something to identify themselves not just as general hospitals, but also as heart and vascular centers. So I conceived of a cardiac facility that would include research and education as part of its overall program. It would have no patients of its own but would draw patients to SLEH/TCH for treatment there. The idea of affiliating a specialty institute with 1 or more preexisting hospitals had a strong precedent at my alma mater, Johns Hopkins Hospital, in Baltimore.
I called my friend, attorney Bill Taylor of the law firm Butler & Binion, explained my idea, and asked him to prepare a charter. I then asked an architect to design a THI building that would be attached to SLEH/TCH. On 13 July 1962, at a joint meeting of the 2 hospital boards, I presented my proposal for the project.
At SLEH/TCH, income is derived from patient care, and expenses must be met with hospital fees. In seeking an affiliation between these hospitals and THI, I assured them that it would be mainly to their benefit, not THI's. I didn't want to touch their income, so I planned for THI to rely heavily on philanthropy. Various other institutions at the Texas Medical Center—including M.D. Anderson Cancer Center and TCH itself—had always attracted philanthropists, and I believed that a cardiovascular center could do the same. The joint boards tentatively approved my plans. On 3 August 1962, the THI charter was officially registered in Austin, the state capital.
I immediately began to seek contributions from wealthy patients and other donors. It took me several years to gain the necessary financial backing. At first, I was unable to raise enough money to construct the type of building I wanted. Eventually, however, SLEH and TCH agreed to incorporate THI within their own expansion programs. Its official name was to be the Texas Heart Institute of St. Luke's Episcopal and Texas Children's Hospitals. (Later, TCH developed its own administration and built its own new hospital, separate from SLEH and THI.)
Originally, the plans for THI entailed a 10-story tower, which would be a south extension of SLEH. At the urging of Leopold L. Meyer, then president of TCH, the plans were expanded to allow for a 21-story tower. In speaking with the builder, however, I learned that once the tower had been completed, no further upward expansion would be possible. Therefore, I again went before the hospital boards and requested that 7 additional stories of shell construction be added to the tower, to be finished when the space was needed. Accordingly, the final plans allowed for 28 stories.
The remaining necessary funds were obtained in 1966, after I learned that the Ray C. Fish Foundation, a relatively new charitable group, was seeking a worthy project. The foundation had been established on behalf of a man who had died of heart disease. Its director, Robert R. Herring, agreed to donate $5 million to THI. On hearing of that gift, various other philanthropic groups and former patients chipped in, providing the full amount that we needed. These donors included Gus Wortham, Houston Endowment, Inc., and the Clayton, Brown, and Abercrombie Foundations.
Fig. 1 Open Heart Era, 1962, oil painting by Mary Cooley Craddock, commissioned by Denton A. Cooley, MD, for the 5th-floor lobby of the Texas Heart Institute at St. Luke's Episcopal Hospital – The Denton A. Cooley Building.
One of the most memorable personal contributions came from Harry S. Blum, chairman of the Jim Beam Distillery. Mr. Blum had come to Houston from Chicago to have me repair a ruptured abdominal aneurysm. Ten days later, he invited me to stop by his suite at the Shamrock Hilton. After I examined him and confirmed his complete recovery, he asked what my fee was. I replied that there was no fee—I couldn't put a price on his life. Remarking that he had seen the model in the lobby for the new hospital expansion, he asked, “How much would it cost to endow the whole thing?” I asked for a contribution of a million dollars. He agreed, and we drew up a simple contract on the spot. With that paper in hand, I went straight to the TCH auditorium, where a fund-raising meeting was in progress. Waving the contract, I told the leader, “I don't know how much you will raise today, but I just raised a million dollars from a single individual.”
The groundbreaking ceremony occurred on 26 June 1967, and the new operating suites were opened for surgery in January 1972. As further sections of the tower were completed, the THI team moved into them. It was originally allotted 100 patient beds by SLEH and 25 beds by TCH. Pharmacy, patient admitting, purchasing, accounting, and administrative services were shared with SLEH/TCH.
Soon after its founding, THI became the most prolific heart surgery center in the United States and possibly the world. Coronary artery bypass grafting had recently been introduced for treating atherosclerotic disease, and THI was deluged with patients who needed that procedure. The nearby Shamrock Hilton Hotel, where many of them stayed, became known as the “Cooley Hilton.” Our surgeons were an enthusiastic group and got along harmoniously with the cardiologists and other staff.
Early on, formal divisions were organized and chiefs of service appointed: Drs. Edward B. Singleton, Radiology; Arthur S. Keats, Cardiovascular Anesthesiology; Dan G. McNamara, Pediatric Cardiology; and Robert D. Leachman, Adult Cardiology. Dr. Robert J. Hall was appointed medical director, while I was president and surgeon-in-chief. At first, I shared an office next to the surgical operating suite with Jerry Maley, THI's head administrator (later president and chief executive). That office was so small, we couldn't both occupy it at the same time.
During its brief history, THI has substantially advanced the diagnosis, treatment, and prevention of cardiovascular disease. Table I lists some of the milestones attained by our center. Perhaps the breakthroughs that most galvanized public attention were the 1st successful cardiac transplantation in the United States (1968) and the 1st clinical implant of a total artificial heart (1969).
Table I. Texas Heart Institute: Some Milestones
The THI staff members promoted the Institute by publishing papers and speaking at meetings all over the world. In addition, THI began to hold its own educational symposia. In 1971, the Institute established a school of perfusion technology to train perfusionists in the use of the heart–lung machine. At the same time, we started a separate, accredited residency program in cardiothoracic surgery. After the arrival on staff of Dr. Hall, a similar residency in cardiology was established. Training programs in anesthesia, under Dr. Arthur Keats, and in pathology, under Dr. Carl Lind, soon followed. Over the years, the academic programs have been one of THI's chief successes.
Research has become increasingly important at THI. From the beginning, we have had excellent research and animal laboratories. In 1974, the 1st issue of the Texas Heart Institute Journal emerged from an office housed in the depths of the Cullen Cardiovascular Surgical Research Laboratory—where for several years thereafter copies were actually wrapped and labeled by any lab workers who happened to be available. A major focus of our laboratories has been the development and testing of mechanical assist devices and cardiac substitutes. Recently, our researchers have pioneered the use of stem cells for the treatment of heart disease.
To symbolize the Institute's past accomplishments and future goals, a 7-foot-tall, red granite, abstract heart was erected in front of THI in 1977. This statue, named A Symbol of Excellence, was created by Theodore H. McKinney, a grateful patient. Not only had I performed coronary artery bypass surgery on him in 1972, but I had also operated on his young daughter in 1954.
In December 1982, a $33 million campaign was begun to add the final 4 stories to THI. The new space enabled the addition of nearly 60 intensive-care beds, as well as space for departments of cardiology, neurophysiology, respiratory therapy, biomedical instrumentation, and other ancillary activities and services. The plan included additional room for the School of Perfusion Technology; for medical students, residents, and fellows; and for research and treatment facilities.
By 1983, THI surgeons had performed 50,000 open-heart procedures, about half of which were coronary artery bypass operations. Until the advent of computerization in the 1990s, our statisticians kept track of all procedures by recording the data on 3×5-inch index cards. When surgical activity was at its peak, I oversaw as many as 30 operations a day and performed up to 10 of the most difficult ones myself. As a result, I worked for up to 15 hours a day, every day. One way I was able to maintain a high volume of cases was to let other surgeons do the routine parts of the operation—opening the patient's chest, retracting the ribs, establishing the connections to the heart–lung machine, and closing the chest postoperatively—while I performed only the repair itself. Although this approach reminded some observers of an assembly line, it allowed me to benefit the most patients within the time available.
In THI's early days, I occasionally agreed to barter my services. One man paid for surgery on a family member by agreeing to build a garage onto my house. I had to provide all the materials, but the man did an excellent job—for the first half. Then he came to me and said he couldn't afford to feed his family. He requested $75 for groceries, which I gave him. He never showed up again. Unfortunately, he left in the middle of August, forcing me to complete the work myself. It was the hottest, most humid time of the year. I would climb the ladder, pound a few shingles, then get a call that I was needed at the hospital. That happened time and time again until the garage was finally completed. About 6 weeks later, my wife stopped the family station wagon in the driveway, which was on an incline. She forgot to set the parking brake, and the car later began to roll, picking up speed until it smashed into the garage wall, bringing the roof down on top of it. I sold the damaged car and vowed never again to accept a barter arrangement for my work.
I would get all sorts of poignant letters from people in India, the Philippines, and other countries who needed heart surgery but couldn't afford it. In every case, I told them that they wouldn't have to pay a surgical fee; if they could just pay half of the hospital bill, I would find a donor to take care of the rest. In 1976, at the suggestion of Dr. Peter J. van der Schaar, a Dutch cardiac surgeon who periodically worked with my team, THI initiated a twice-monthly airlift of 8 to 10 patients from The Netherlands, who were flown to Houston for heart surgery. Most of these patients were men, 45 to 60 years old. Within the next 5 years, 1,500 Dutch patients would be involved in the airlift. The arrangement was extended to other countries. So THI has had an active foreign practice, as well as a domestic one.
In 1984, I conceived of a packaged plan called Cardiovascular Care Providers, which THI worked out with SLEH. It was the first-ever packaged-pricing plan for cardiovascular surgery. Under this plan, a global payment package (bundled service) covers all services, including physician and hospital charges. The resulting flat fee is lower than the sum of the individual charges. It not only reduces cost while maintaining a high quality of care but also increases patient access, enables payers to predict their expenses, and streamlines the billing process. Patients are able to choose their own providers.
Since 1984, the plan has been offered to the non-Medicare population through contracts with self-insured corporations, prepaid health plans, union trusts, and foreign governments. Since 1993, it has been extended to eligible Medicare patients. Several other cardiovascular centers have adopted similar packaged-pricing plans.
Of all my developmental programs, this packaged-pricing plan may have had the greatest overall impact on health care. It has been successful because it is simple, physician directed, and organ specific, involving many related specialties; moreover, it benefits from our hospital's large patient population and extensive database. Indeed, much of our reputation is based on the volume of patients we can handle. As an admirer of Sam Walton, the founder of Wal-Mart, I am happy to be dubbed the “Sam Walton of heart surgery.”
Over the years, the competition for heart patients has greatly increased. In the early days of cardiac surgery, surgeons had no competition. With the clinical introduction of balloon coronary angioplasty in 1978, however, cardiologists began to revascularize the myocardium in the catheterization laboratory. As a result, surgeons had to compete with cardiologists and thus began to lose coronary bypass patients.
In THI's early days, only 2 or 3 other institutions in the southern United States specialized in cardiac surgery. Today, in Houston alone, 7 or 8 open-heart programs are available. Also, instead of sending patients to the United States for heart surgery, as in the past, most other countries now have their own cardiac programs, some of which are headed by former THI trainees. For economic reasons, Americans sometimes even go abroad for cardiovascular surgery. Because of these factors, THI's volume of open-heart operations has steadily diminished since the 1980s, when we were doing 5,000 such operations per year. At present, we are doing about only about half that many—2,500 per year. Nevertheless, ours is still a very active program; in terms of numbers, it equals any of the other major institutions in this part of the world. For 18 consecutive years, we have been ranked among the top 10 heart centers in the United States by U.S. News & World Report's annual guide to “America's Best Hospitals.” As of this writing, THI's 160-member professional staff has performed more than 100,000 open-heart operations, 200,000 cardiac catheterizations, and 1,000 heart transplants. These record numbers could not have been achieved without the support of more than 10 staff surgeons, 100 surgical residents, cardiologists, radiologists, fellows in training, and devoted nurses and personnel.
A milestone in THI history occurred in 2002, when The Denton A. Cooley Building opened. Thanks to a successful $75 million campaign, this 10-story, 327,000-square-foot building, located next to SLEH, provides the full spectrum of cardiovascular services, including 12 new operating rooms, a postinterventional floor, a transplantation floor, a progressive-care floor, cardiovascular recovery beds, an imaging facility, a telemedicine center, 2 floors dedicated to research, a 325-seat conference center (the largest in the Texas Medical Center), a Heart Information Center, and a museum.
On 22 August 2007, my 87th birthday, I performed my last surgical operation. I don't remember what type of procedure it was—probably a conventional coronary artery bypass. At first, I missed the operating room greatly, but, as an octogenarian, I believed that it was time to step aside. As the saying goes, “It's better to quit a month too soon than a minute too late.”
More recently, on 1 August 2008, I stepped aside to become president emeritus of THI, and my good friend and associate, Dr. James T. Willerson, took over as president. He and I have worked closely together for at least a decade, and I am delighted that he has become my successor. The fact that Dr. Willerson is a cardiologist, not a surgeon, reflects the current emphasis on interventional rather than surgical treatment of cardiovascular disease and the growing belief that basic-science breakthroughs, such as stem-cell and genetic therapy, offer the best hope for preventing and treating such disease in the future. Dr. Willerson's goal is to make THI the top cardiovascular center in the United States.
I would be remiss if I did not acknowledge those who have contributed to the growth and development of the Texas Heart Institute. Throughout THI's 46-year history, the Board of Trustees—which comprises outstanding business and civic leaders—has supplied effective leadership and generous financial assistance. Physicians on THI's Professional Staff, who represent the best and brightest that medicine has to offer, have provided exceptional patient care, helped to educate succeeding generations of heart specialists, and stimulated new discoveries. Employees, many of whom have been with THI for more than 20 years, have contributed to THI's mission through their dedication, determination, and enthusiasm. In addition, THI has benefited from the extraordinary generosity of thousands of benefactors. It has been my privilege to be associated with all of them.
Throughout THI's history, the discovery of new knowledge to improve patient care and to prevent cardiovascular disease has been the Institute's motivating force. Our physicians and scientists have worked tirelessly to unfold the mysteries of cardiovascular disease, to understand its mechanisms, and to envision solutions that will ultimately lead to effective treatments. As long as cardiovascular disease remains a threat to human life, these efforts will continue.
Denton A. Cooley, MD
Founder, Surgeon-in-Chief, and President Emeritus, Texas Heart Institute