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Indian Journal of Thoracic and Cardiovascular Surgery logoLink to Indian Journal of Thoracic and Cardiovascular Surgery
. 2020 Mar 7;37(Suppl 1):9–16. doi: 10.1007/s12055-020-00921-4

Pioneers of congenital heart surgery in India: historical perspective

Mumbai - The Gateway of Congenital Heart Surgery to India

Krishna Manohar S R 1,
PMCID: PMC7859003  PMID: 33584024

Abstract

Congenital heart surgery was born in the USA and then spread all over the world in the second half of the twentieth century. The speciality was brought to India by foreign-trained Indian surgeons as well as American and Canadian missionary surgeons. The first generation Indian surgeons were trained in the USA, Canada, Australia, and New Zealand. In this article, an attempt is made to explore how the pioneer surgeons established this speciality in India by reviewing the published literature, visiting institutions of historical significance, and also interviewing few surgeons who took the key role in both laying the foundation as well as training the next generation surgeons.

Keywords: Congenital, Heart, Surgery, India, History

Masina: The Boston Children's of India

The Masina Hospital in Byculla (Fig. 1) was the first private hospital in Mumbai, started by Dr. Masina FRCS in 1902. Dr. Bomi R Billimoria FRCS was the thoracic surgeon who started the Department of Thoracic Surgery in Masina Hospital and did the first persistent ductus arteriosus (PDA) ligation in 1949 [1]. He was also attached to St George Hospital, Parsi General Hospital, Pune Military Chest Hospital (Aundh) and Belair Tuberculosis Sanatorium in Panchagni. Unfortunately, he died at a young age and could not contribute more [2].

Fig. 1.

Fig. 1

Masina Hospital, Byculla

KEM Hospital: the first direct vision intracardiac surgery

King Edward Memorial Hospital in Mumbai was established by the British in 1926. Dr. Prafulla Kumar Sen was the cardiothoracic surgeon in KEM who received training under Rockefeller Foundation from Pennsylvania (1950–1952) under Dr. James Hardy. After coming back from the USA, Sen did the first repair of coarctation of aorta in 1953. In 1956, he did the first direct vision closure of atrial septal defect under inflow occlusion and hypothermia [3].

KN Dastur: The Gibbon of India- Make in India Hrudayayaan Success

BYL Nair Hospital, established in 1921, is the first medical college hospital in Mumbai fully created by Indians. It is interesting to note that exactly 40 years later, in 1961, in this hospital, the first open-heart surgery in India was performed with the use of totally indigenous “heart-lung machine” built by Indian engineers [4]. Dr. Kersi Nusserwanji Dastur, who had only general surgical training abroad (FRCS), did the first series of open-heart surgeries in India without any formal foreign training in cardiac surgery. Inspired by the work of John Gibbon of Philadelphia, working with engineers of National Steel Company, Mumbai, for 2 years, Dastur made the country’s first totally indigenous roller pump with disc oxygenator (Fig. 2) in 1959. Following successful dog experiments, Dastur successfully closed the large atrial septal defect of a 19-year-old girl Hem Lata on February 16, 1961, and opened the flood gates of open-heart surgery in India. Dastur’s contribution was appreciated by all pioneer surgeons of the world when they visited his team in Nair Hospital later.

Fig. 2.

Fig. 2

Dastur Heart Lung machine with disc oxygenator

Contribution of Canadian Christian medical mission: Wanless Mission Hospital, MIRAJ

This oldest missionary hospital in Miraj, near Mumbai, was started by the Canadian missionary doctor William James Wanless in the nineteenth century (1894). Dr. Archibald Fletcher, an American-trained thoracic surgeon, started the Thoracic Surgery Department in 1950. Dr. Radha Krishna Padhi from Kerala (Fig.3), MBBS from Calcutta and surgical training (FRCS-C) and cardiothoracic training from Canada, joined Wanless Hospital in 1961 as head of the department. On April 13, 1962, Dr. Padhi with the help of Dr. Fletcher did the intracardiac repair of congenital pulmonary stenosis under cardiopulmonary bypass in a 9 year old boy [5]. The patient did well and survived for 30 years. Dr. Padhi went back to Canada in 1968 (personal communication with Dr. Shirish S Pargaonkar, the present head of department).

Fig. 3.

Fig. 3

Dr. Radhakrishna Padhi

Madras: the Minnesota of India

The birthplace of open-heart surgery in mid-1950s was the state of Minnesota in the USA, where the two leading institutions (University of Minneapolis of Walton Lillehei and Mayo Clinic of Kirklin) were only about 140 km apart. It is interesting to note that even in India, congenital heart surgery had the real beginning and development in two neighbouring institutions in Madras (present Chennai), one in Vellore and the other in Perambur, and they are also separated by about the same distance.

Christian medical college hospital, Vellore

The second major Christian mission hospital in the country was established at the very beginning of the twentieth century (1900) by the American missionary doctor Ida Scudder in Vellore, in the outskirts of Madras (present Chennai).The Department of Cardiothoracic Surgery was started in 1948 by the American missionary Thoracic Surgeon Dr. Reev H Betts. Betts did his first PDA ligation in 1950 (second in India) and Pott’s shunt for Tetralogy of Fallot in 1951 and classical Blalock-Taussig shunt in 1953. The first direct vision pulmonary valvotomy under inflow occlusion was also done in 1953.

Nagur Gopinath: the Lillehei of India

An interesting point in history was that two people who were instrumental in developing congenital heart surgery in India, N Gopinath from Karnataka and Thayil John Cherian (TJC) from Kerala, were classmates during their college days in the late 1930s at Madras Christian College, Tambaram. Their friendship later helped the development of our specialty in a great way [6].

Gopinath joined Reev Betts in Vellore as a resident in 1951 and also got training under Walton Lillehei in Minneapolis for 1 year (1957) under Rockefeller Fellowship. He passed the MS (Thoracic Surgery) course which was started by Madras University in 1958 and became the first Indian trained cardiothoracic surgeon in 1960 (Fig.4). Gopinath did the first ventricular septal defect closure under cardiopulmonary bypass using disc oxygenator on 28th July 1961. The first total correction of Tetralogy of Fallot was done on 13th November 1962 (Fig.5) through the transventricular approach using disc oxygenator and intermittent fibrillatory arrest, starting the golden era of congenital heart surgery in the country.

Fig. 4.

Fig. 4

First list of cardiac surgery trainees of CMCH Vellore

Fig. 5.

Fig. 5

First operation register of CMCH Vellore

When his old friend Dr. T J Cherian, the then DMO of Perambur Railway Hospital, wanted to establish a cardiac surgical unit there, Dr. Gopinath offered him all the help and support, including training in Vellore for 2 years (1962–1964) [6]. A decade later, while visiting St. Vincent’s Hospital in Sydney, Australia, Gopinath was impressed by a young Indian resident there, who was independently doing cardiac surgeries. When Dr. TJ Cherian wanted a foreign-trained open-heart surgeon to start the program in Perambur Railway Hospital, Gopinath, without a second thought, recommended an Indian resident at St. Vincent’s hospital in Sydney for the post. The resident was none other than Dr. K M Cherian (KMC). Talking about it, KMC says there was definitely “God’s hands” which helped him join the right place at the right time and take the specialty towards more complex infant and neonatal cardiac surgeries in India [7] (personal communication).

Stanley John: the father of tetralogy surgery

After completing medical degree and post-graduation in surgery from Vellore, Stanley John joined under Dr. Gopinath in 1961. After passing MS Thoracic surgery in 1964, he went to Minneapolis to train under Dr. Walton Lillehei for a year(1965–66) where he learned transventricular closure of ventricular septal defects and Tetralogy of Fallot repair (Fig. 6). He headed the department in CMC Vellore for a quarter century (1967–1992). In addition to training a lot of residents from all over the country, his main contribution to congenital heart surgery was the successful establishment of transventricular repair technique of Tetralogy of Fallot. The first report was in 1986 about 200 adult tetralogy patients, which was one of the largest series in world literature at that time [8].

Fig. 6.

Fig. 6

Stanley John with Walton Lillehei in Minneapolis

Before Dr. Christopher Lincoln (UK paediatric cardiac surgeon) brought cardioplegia (St Thomas) for the first time to Vellore in 1977, all cases were done with intermittent aortic cross-clamping and fibrillatory arrest. Since blood products were not available those days, after seeing off their children shifted to the operation theatre, parents and close relatives used to go to the blood bank for donating fresh blood for their children. This fresh blood was given after the surgery for bleeding problems, especially in older children and adults (personal communication with Dr. Vinayak Shukla).

In 1993, Vellore reported 840 cases where the analysis revealed excellent results in terms of residual ventricular defects (0.68%) and heart blocks (0.4%) [9]. The dome theatre where most of these cases were done with facility for viewing surgery from above is still functional in Vellore. Dr. Stanley John used to stand on the left side of the table, like his mentor Dr. Walton Lillehei, while doing tetralogy repairs. This explains the perfect visualization of ventricular septal defects from that approach and the excellent results (personal communication with Dr. Vinayak Shukla, former Head and senior professor, CMCH, Vellore).

Perambur Railway Hospital

Though the railway hospital was established by the British in 1928, the Cardiothoracic Department started functioning in 1960 and TJ Cherian, DMO was given the responsibility of developing it.

Thayil John Cherian : the Wangensteen of India

In the 1960s, TJC took a keen interest in establishing a world-class cardiac surgical centre in Perambur Railway Hospital. After his basic training from Vellore, with the help of the then cardiac surgeons in Chennai, closed procedures in congenital heart surgery were routinely carried out. Dr. Stanley John from Vellore, Dr. CS Sadasivam and Dr. Solomon Victor from Madras Medical College extended all help to TJC for his mission. The stage was set for open-heart surgery in 1974 when he could get the heart-lung machine with disc oxygenator and an echocardiography machine, which was one amongst the first three in India at that time. TJC gets the full credit for bringing, in 1975, the two most well-trained Indian surgeons, Dr. K M Cherian, FRACS with Greenlane training, and Dr. MR Girinath, M Ch (AIIMS) with Greenlane training, the right people at the right place at the right time, which helped the further development of congenital heart surgery in India towards infant and neonatal corrections [7].

Kotturathu Mammen Cherian (KMC): the father of paediatric cardiac surgery in India

Before joining Railways in 1975, KMC had his paediatric cardiac surgical training from Timothy Cartmill of Australia and Sir Brian Barratt Boyes of New Zealand. In February 1976, with the help of the supporting teams from both Australia and New Zealand, 11 infants (2 months to 7.5 kg) were operated in Railway Hospital under deep hypothermic circulatory arrest, for the first time in the country with good results.

In 1978, KMC did 1-year paediatric cardiac surgery fellowship under Dr. Kirklin in Alabama. Coming back after US training, in June 1979, trans-atrial repair of Tetralogy of Fallot and also double outlet right ventricles were done. In July, the same year, KMC did the first successful Senning’s operation for transposition of great arteries. He did Rastelli’s operation later in the same year with right ventricle to pulmonary artery conduit (fresh antibiotic sterilized homograft) in another child with transposition-ventricular septal defect and pulmonary stenosis. He also did the first truncus arteriosus using fresh homografts (personal communication).

The first successful arterial switch operation for transposition of great arteries with ventricular sepal defect with single coronary artery was done in October 1980 [7]. In 1982, KMC did the first anomalous left coronary artery from pulmonary artery (ALCAPA) repair in a 18-month-old child with severe mitral regurgitation. Through left thoracotomy, KMC replaced the mitral valve with 1 M Starr Edwards valve and anastomosed the left subclavian artery to the left coronary button under fibrillatory arrest. After 35 years, this patient is doing well even today [10].

After shifting to Madras Medical Mission, the homograft valve bank was established, and conduit corrections were done routinely from 1988 onwards. Another significant contribution of KMC, which helped more and more young surgeons from all over India to get attracted towards congenital heart surgery, was the regular international cardiac surgery workshops every year in Chennai starting from 1990 onwards. This helped trainees and young surgeons to watch leading paediatric cardiac surgeons from all over the world operating live on big screens, interact with them and learn a lot from them. In 1999, KMC was instrumental in founding the Paediatric Cardiac Society of India along with Prof. RajendraTandon of AIIMS who is considered the father of paediatric cardiology in India, which has more than 1000 members now. The first paediatric cardiac transplant was done by KMC in a 1.5-year-old child with dilated cardiomyopathy in 2009 at Frontier Lifeline Hospital, who survived for 1 year [7] (Fig.7).

Fig. 7.

Fig. 7

Baby Yatharth, the first paediatric cardiac transplant

All India Institute of Medical Sciences, New Delhi (AIIMS)

Though the premier institution of India started in 1956, the Cardiothoracic Surgery Department opened in 1964 with Dr. N Gopinath as the head. The congenital heart surgery program picked up momentum when two of his trainees, Dr. IM Rao and Dr. P Venugopal, joined the faculty in 1970.

Panangipalli Venugopal: helping to reach the unreached

Having headed the prestigious Cardiothoracic Centre of AIIMS for more than a quarter of a century and trained a number of surgeons, Dr. Venugopal feels that his greatest contribution in this specialty is probably helping Sri Sathya Sai Baba start the chain of state-of-the-art totally free cardiac surgical institutions, which gave a second life to thousands of underprivileged cardiac crippled children of India. Dr. N Safaya, the then Medical Superintendent of AIIMS, was instrumental in making Dr. Venugopal and his team of AIIMS help setting up the cardiac surgery department at the first Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS) at the remote village of Puttaparthi in Andhra Pradesh in 1990. The construction of twin operation theatres, intensive care units, catheterization laboratories and wards were completed in record time. On 23 November, 1991, Swami’s birthday, Dr. Venugopal and his dedicated team of AIIMS did four open-heart operations successfully. The first case was the closure of an atrial septal defect done by Dr. Venugopal, assisted by Dr. KS Iyer (Fig. 8). The chain of Sathya Sai Hospitals does the maximum number of free congenital heart surgeries in India today.

Fig. 8.

Fig. 8

First congenital heart operation in Puttaparthy by Prof. Venugopal and Dr. KS Iyer

Ivatury Mritunjay Rao (IM Rao): the Dronacharya of dedicated paediatric cardiac surgery

During his overseas training in paediatric cardiac surgery under Dr. Brian Barratt Boyce in Auckland, New Zealand (1973–1975), IM Rao’s co-residents were Dr. Roger B Mee and KMC – a friendship which later helped the training, development and spread of neonatal and more complex congenital heart surgery in the country [11]. Back in the institute, he established the Fontan palliation for single ventricles and trans-atrial correction of tetralogies, in addition to attracting and training more residents towards dedicated paediatric cardiac surgery.

Krishna Subramony Iyer: leading towards the twenty-first century

Almost like our Vellore-trained surgeon (Stanley John) was mentored by Dr. Gopinath to lead the speciality in the 1970s, an AIIMS-trained surgeon Dr. Krishna Subramony Iyer was attracted towards paediatric cardiac surgery by Prof. IM Rao who sent him to his old friend Dr. Roger Mee in Melbourne for training in neonatal and more complex congenital heart surgery (1989).

After joining back in AIIMS, Dr. Iyer did the first neonatal arterial switch operation in October 1990.The first two-stage arterial switch operation for transposition with regressed left ventricle was done in 1992. The first double switch operation for congenitally corrected transposition was done in 1993. The first aortic root transfer (Nikaidoh-Bex) for transposition with ventricular septal defect and pulmonary stenosis was also done around the same time, and the experience and training helped many junior surgeons to successfully lead the specialty of congenital heart surgery towards the twenty-first-century achieving world-class results in many paediatric cardiac units in India.

An interview with the pioneer

As part of this article, KMC was interviewed at his favourite Biomedical park – Frontier Mediville in Chennai. He did most of the complex congenital heart surgeries for the first time in the country at Perambur Railway Hospital in the late 1970s and early 1980s when none of the modern diagnostic and operative facilities were available. Unlike most of his contemporaries, KMC continued to face and enjoy the challenges of congenital heart surgery continuously for about four decades. When asked what was the secret of his special interest in congenital heart surgery, he said, “even today, it is the results.” The remarkable recovery of those otherwise dying small children and their unbelievable growth towards normal development and fully productive adult lives gave him the energy and satisfaction to enjoy the speciality and pursue it with passion. Many of his firsts in Railway Hospital were reviewed and reassessed after about three decades in Frontier Lifeline Hospital.

The first Senning’s operation child (1979) is the mother of an 8-year-old child now, and a 3D heart model done in 2017 showed unobstructed venous pathways (Fig.9). The first ALCAPA baby, 28 years later, has a well-functioning 1 M Starr Edwards mitral valve prosthesis with a patent left subclavian-left coronary anastomosis on the computed tomography angiography (CTA) (Fig. 10) [10]. KMC quoted Kathy Davis’s famous quote which is the favourite of all neonatal and paediatric care givers:

“A hundred years from now it will not matter what my bank account was

The sort of house I lived in or the kind of car I drove…..

But the world may be different because I was important in the life of a child.”

Fig. 9.

Fig. 9

3D print of first Senning’s operation after 28 years

Fig. 10.

Fig. 10

First ALCAPA with patent left subclavian-left coronary anastomosis on CT angio after 28 years

Conclusion

Half a century after the Americans walked on the moon, our Chandrayaan could take us only up to just 2 km away from moon. But in congenital heart surgery, we could follow them successfully within a decade’s gap in most of the procedures and catching up much faster today. It can also be compared to the popularity of the game of cricket in independent India, started with test matches in few cities to 1-day matches in more cities and now the most popular twenty-twenty Indian Premier League matches in almost all cities. During the latter half of the twentieth century, the congenital heart surgery started slowly by the Mumbai Indians in the first decades, established by the Chennai Super Kings in the mid decades and during the last decade actively pushed to the twenty-first century by the Delhi Dare Devils.

As in any other neonatal and paediatric surgical specialty, most of our patients survive beyond our lifetime. As we, the congenital heart surgeons, touch a child’s heart during operation, the child touches our hearts also – a touch which will remain throughout our lifetime – a blessing which makes ours a specialty “truly divine”.

Dedication

There may or may not be a second chance for anything in life. But hundreds of children born with congenital heart disease get a second life by corrective surgery in India every day, and many more are in waiting. This article is dedicated to the millions who are waiting for a second life and to the young congenital heart surgeons who are also waiting to get a chance to give the new gift of life to them.

Acknowledgements

In writing this article, my heartfelt gratitude and sincere appreciation go to the following pioneers, stalwarts, mentors and colleagues who were part of the history at different places and different times and were promptly willing to give their valuable time to share their experiences and roles in the development of congenital heart surgery in our country:

Dr. Stanley John (Bangalore), Dr. P. Venugopal (New Delhi), Dr. PS Jairaj (Bangalore), Dr. K M Cherian (Chennai)

Dr. Ganesh Mani (New Delhi), Dr. KS Iyer (New Delhi), Dr. Vinayak Shukla(Vellore), Dr. Rajesh Sharma (New Delhi)

I also wish to thank Dr, Zainulabdeen, Director of Masina Heart Institute, Mumbai; Dr. Shirish S Pargaonkar, Head Department of CVTS, Miraj Heart Institute, Wanless Hospital, Miraj; and Dr. Roy Thankachan, Head Department of CVTS, Christian Medical College, Vellore, for their invaluable inputs and contributions.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval, funding, human and animal rights statement, informed consent

Not required being a review article.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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