Nazih Zuhdi, M.D.
PERFUSION'S FINAL FRONTIER OPEN TO ALL
 
TOTAL INTENTIONAL HEMODILUTION
CONCEPT—NAZIH ZUHDI 1959
 

EXPERIMENTAL ANIMAL RESEARCH--
MERCY HOSPITAL RESEARCH LABORATORY, OKLAHOMA CITY, OKLAHOMA—NAZIH ZUHDI 1959;
 

CLINICALLY APPLIED, THE FIRST TIME IN THE WORLD, BY NAZIH ZUHDI, ALLEN GREER, AND JOHN CAREY, FEBRUARY 25, 1960—PATIENT TERRY GENE NIX, PERFUSIONIST MODINE PIERCE, RN—MERCY HOSPITAL, OKLAHOMA CITY, OKLAHOMA.

 
OPENED THE GATES FOR OPEN-HEART SURGERY IN EVERY NOOK AND CRANNY OF THE WORLD AND FOR BLOODLESS SURGERY FOR ALL
 
THE FOLLOWING QUOTES ARE FROM CHAPTER SIX, THE LIFE OF NAZIH ZUHDI—UNCHARTED VOYAGE OF A HEART BY BROOKS BARR—UNLESS OTHERWISE INDICATED.
 
“During 1959-1960, in Oklahoma City, Dr. Nazih Zuhdi laid the foundation and opened the gateway for bloodless surgery for all patients.  This had been a major goal of all surgeons since surgery began.  Zuhdi’s “Total Intentional Hemodilution,” for which he has been accorded incontestable status worldwide, solved the worry of the proper management for procedures requiring cardiopulmonary bypass and paved the way for this application to be used globally for all forms of surgery when possible.

 

The principles he used allowed for a more flexible understanding of blood hematocrit (the level of red blood cells), thereby making all variations, including transfusion-free surgeries, not possibilities but immediate realities.

 

At first Zuhdi’s basic principles of Total Intentional Hemodilution astounded the medical profession, but in time they were globally accepted, and in turn, benefited all patients of all colors, races, philosophies, and religions.  As soon as Zuhdi’s success became known, physicians from throughout the world began to beat a pathway to Oklahoma City.  Today the Nazih Zuhdi Transplantation Institute at Integris Baptist Hospital here ranks high in the world according to certified federal government statistics. And across the world millions of patients annually are served through Zuhdi’s Total Intentional Hemodilution.”[1]

CLIFTON WARREN, EDITOR—DISTINCTLY OKLAHOMA, NOVEMBER, 2007

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The origins of any new principle or procedure are often lost in the complex of medical science.  Dwight A. Harken “warned against anecdotal medical testimony, frequently inaccurate, poorly recalled, and colored by will, emotion, dramatic or selfish motivation.”

LAEL WERTENBAKERR, TO MEND THE HEART, 1980

 

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Richard Green, profiling Allen Greer, for the Oklahoma State Journal of Medicine, in March of 1966, stated, “Greer does credit Zuhdi with the idea and the research for the group’s single most important innovation, Hemodilution. Priming the heart-lung machine with sugar water almost eliminated the need for cross-matched blood and turned out to be beneficial to the surgical patient.”  That breakthrough occurred experimentally in late 1959, and clinically, for the first time on February 25, 1960.

Zuhdi’s position as an independent, researching and operating as he did outside the confines of a university or teaching hospital, sometimes heightened the emotional climate in which the reservations about his system were expressed. 

The Life of Nazih Zuhdi—Uncharted Voyage of a Heart by Brooks Barr, page 120

 

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Zuhdi still remembers his feelings before the first clinical application,

Experimentally, total intentional hemodilution had worked.  It should work on Terry Nix.  The first time, however, has a certain spirit of anticipation, the lure of the unknown and the trepidation of what might happen.  There are surprises in a usual cardiopulmonary bypass that may play a role in the outcome—system failures that are unrelated to the workings of hemodilution.  This run, I hoped and prayed, should be as smooth as it could be.  After all, my whole life’s work and dreams were at stake, and I was afraid that any failure would not be mine alone, that Greer and Carey, even though versed in the proceeding, may go down with me, a thought I hated.  Even more important now was the safety of a seven-year old boy, Terry Gene Nix.  A deep breath, and away we went.

The Life of Nazih Zuhdi—Voyage of a Heart by Brooks Barr, page 31

  

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(Starting early in 1960), Zuhdi kept a five-by-three foot map of the world on his office wall.  As news of another doctor or institution using total intentional hemodilution came to him whether by media or personal contact, Zuhdi put another pin in the map on the wall.  In this way, he kept track on the spread of the principles of total intentional hemodilution.  It started slowly—two or three in 1960, around a dozen in 1961—but by 1965, the map had become so covered with pins that its effectiveness as a marker came to an end.  The pin-encrusted map was evidence that, outside of some dormant universities still in Rip Van Winkle’s somnolence, total intentional hemodilution was no longer news; it had become common practice.  Even the University of Oklahoma had yielded to the inevitable and quietly without fanfare adopted it.  The path of heart surgeons everywhere had moved through Mercy Hospital and Oklahoma City and out to the entire world.  A representative letter to Zuhdi on June 19, 1962 from R. D. Sautter of the Marshfield Clinic, Marshfield, Wisconsin, illustrates the course of the avalanche:  “You can now place another pin on your map in your office, for last week I successfully completed my first open-heart surgery.  The run was smooth as silk”.

*WORLD MAP, from the The Life of Nazih Zuhdi—Voyage of a Heart by Brooks Barr, page 136, TO BE INSERTED

 

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The excerpts were taken from physicians in universities, research centers, and community hospitals around the world.  The diversity of date, geography, and origin illustrated the depth and breadth and interest in Zuhdi’s pioneering concept of Total Intentional Hemodilution with its interlocking arms of physiological low flow rates and moderate internal hypothermia.

The Life of Nazih Zuhdi—Voyage of a Heart by Brooks Barr, page 124

 

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“I should also like to take the opportunity to do something I have been intending to do and that is to tell you how much I have admired your improvements in perfusion technique.  As you know, if anything we were a little skeptical until Dick DeWall was down and visited you and he came back fully sold on it.  I certainly consider it one of the most important advances in perfusion techniques.   As you doubtless know from Dick, we have been advocating this enthusiastically to all whom have visited here at the clinic and thus I am sure that others will come to appreciate its values.”

C. WALTON LILLEHEI, M.D., PROFESSOR OF SURGERY,

UNIVERSITY OF MINNESOTA wrote, on July 21, 1961, a letter to Nazih Zuhdi, M.D.

  

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Following the publication of the works on Total Intentional Hemodilution in 1960 and afterwards, the response in the medical community was both lively and heated.  Many seized on Zuhdi’s work as an answer to problems that had baffled open-heart surgery since its inception a decade before, but many others were equally vocal in their condemnation of him.. As noted before, in January of 1959, Dr. Frank Gollan, a Zuhdi supporter, expressed his doubts about the feasibility of even mild hemodilution in a review article in the Journal of the Michigan State Medical Society: “ …dilution of blood with Ringer’s solution to a hematocrit of about 35 percent would seem a priori to be an objectionable or even dangerous step since hemoglobin and plasma proteins are temporarily reduced to unphysiologic levels.  However, blood volumes studies with radioactive iodinated albumen indicate that the entire volume of the less viscous, diluted blood is available for the artificial circulation…”  After hearing of Zuhdi’s work, he summarized, with a touch of awe, the wider effect of the physiological principles of total intentional hemodilution for open-heart surgery when he wrote Zuhdi in December 26, 1960, a scant few months after the first reports of the new technique:

 

     But to dilute the blood to such an extent in a human being was a different matter and I did not think anybody would do it because it was against all of our conditioned reflexes as physicians.  Of course, I am very gratified that you did so successfully…

The Life of Nazih Zuhdi—Uncharted Voyage of a Heart by Brooks Barr, page 119-120

 

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These “conditioned reflexes” were vividly demonstrated by the meticulous avoidance of hemodilution by W. B. Neptune and F. G. Panico in their method obviating blood priming by making blood circulate in a discreet, underfluid current.  

The Life of Nazih Zuhdi—Uncharted Voyage of a Heart by Brooks Barr, page 101

 

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These conditioned reflexes are also reflected by

“Injectable iron was given prior to and after operation in addition to oral ferrous sulfate.”

DENTON A. COOLEY, MD; ROBERT BLOODWELL, MD; ARTHUR BEALL, JR, MD; AND GRADY HALLMAN, MD.  Cardiac Valve Replacement without Blood Transfusion, AMERICAN JOURNAL OF SURGERY; VOLUME 112, NOVEMBER 1966.
 

Nazih Zuhdi, MD, states that pre and postoperative iron was fast eliminated.

 

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“A major breakthrough came when Nazih Zuhdi and colleagues demonstrated that priming the extracorporeal circuit with blood was not only unnecessary, but potentially hazardous.”

DENTON A. COOLEY, MD; O. H. FRAZIER, MD, The Past 50 Years of Cardiopulmonary Surgery, CIRCULATION, 2000; 102: IV-87.
  

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“I have been very much impressed and interested in your experimental and clinical works in open-heart surgery with the use of low flow hypothermic perfusion.  Since Dr. W. J. Kolff came back from a visit to your hospital in May, we have done five perfusion experiments with your technique.  Four of five dogs survived, and in two of them, venae cavae were occluded for 30 minutes, in the other for 60 minutes.  We intend to use this technique in total replacement of the natural heart with an artificial heart inside the chest, one experiment being done last week with success.  I would appreciate it very much if you could send me all your papers…. Thank you very much for your consideration.”

DR. TETSUZO AKUTSU, Research Associate at the Cleveland Clinic, Ohio, on July 5, 1961

 

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Using Zuhdi’s Total Intentional Hemodilution, “The hemodilution technique of cardiopulmonary bypass using dextrose prime has reduced the need for massive blood transfusion in open heart surgery including total cardiac valve replacement.  Seven patients, were Jehovah’s Witnesses with religious convictions against blood transfusion, underwent successful valve replacement.  Twelve other patients also underwent successful valve replacement without blood transfusion…The successful surgical management of 19 patients undergoing valve replacement for advanced cardiac valvular disease without blood transfusions demonstrates the wide margin of safety offered by this technique of open heart surgery.”

DENTON COOLEY, ET AL, CARDIAC VALVE REPLACEMENT WITHOUT BLOOD TRANSFUSION,  AMERICAN JOURNAL OF SURGERY, NOVEMBER, 1966 

 

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The world’s first heart transplant by Christiaan Barnard, M.D., December 3, 1967,

“We then quickly connected the donor’s circulation to a heart-lung machine to cool the heart to a low temperature using the hemodilution technique developed by my long-time friend and present colleague, Dr. Nazih Zuhdi, and thus protect the heart cells from damage during transplantation.  I then removed the heart from the chest and carried it to the adjacent recipient operating room.”

CHRISTIAAN N. BARNARD, M.D., PhD, AS TOLD TO DAVID K.C. COOPER, M.D., PhD, HEALTH SIGNS, DECEMBER 4, 1987

 

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“During this period of time, Zuhdi was using total intentional hemodilution for his own Zuhdi-Ritchie experimental artificial bypass hearts.  From 1988(7) onward, his transplant institute would be using total intentional hemodilution, when indicated, for human artificial bypass heart surgeries.”

The Life of Nazih Zuhdi Uncharted Voyage of a Heart, by BROOKS BARR, 2005

 

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“Dr. Zuhdi, in the late 1950’s, was the originator, creator, and inventor of the concept of hemodilution and the non-blood prime of the pump oxygenator for open heart surgery…These days 2,000 [such] operations are done every 24 hours, 7 days a week worldwide.  It is a safe and accurate assumption that not a single one is done without hemodilution.  It’s ironic that the history of a technique so effective and so universally used has been largely lost upon the recent generation of surgeons and cardiologists, not to mention our patients.”

DR. C. WALTON LILLEHEI, PROFESSOR OF SURGERY EMERITUS UNIVERSITY OF MINNESOTA, 1994

 

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“What were the benefits which come to me from all this effort, aside from the information and the devices?  They were many, but mostly young people I have had the opportunity to watch learn and contribute…persons such as Nazih Zuhdi...who worked with us during his training and who later conceived and introduced the technique of hemodilution in open heart work...”

DR. CLARENCE DENNIS, 1985 LAUREATE ADDRESS, SOCIETY OF ARTIFICIAL INTERNAL ORGANS

 

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“In the 1963-1964 Yearbook of General Surgery, Michael DeBakey summarized approvingly another of Zuhdi’s articles on "Total Intentional Hemodilution” and in his commentary added, “Many physiologic studies related to cardiopulmonary bypass with pooled, homologous blood will require re-evaluation…”

DR. MICHAEL DEBAKEY, 1963-1964 YEARBOOK OF GENERAL SURGERY
 

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Noted researcher and medical historian Dr. Richard J. Bing of the University of Southern California addressed a similar and of course surprising implication decades later by Dr. Richard DeWall that surface again in a book of which he was editor, writing Zuhdi on September 5, 2003,  “As I wrote you, I deeply regret any errors that have clouded the particular chapter in the book.  I regret this particularly since I have tremendous admiration for your work that as Dr. Lillehei has stated, was a tremendous discovery.  I assure you that our mutual feelings for each other as well as my respect for you remain high.”

RICHARD J. BING, MD, PROFESSOR OF MEDICINE, USC (EM), DIRECTOR OF EXPERIMENTAL CARDIOLOGY, HUNTINGTON MEDICAL RESEARCH INSTITUTES, VISITING ASSOCIATE IN CHEMISTRY, CALIFORNIA INSTITUTE OF TECHNOLOGY

 

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“I believe your method deserves to be called [the] ideal one.

GORO MIYAZAKI, MISHIMA, JAPAN, LETTER TO DR. NAZIH ZUHDI, JUNE 20, 1961

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“Of all [the firsts in your career] your early investigations of blood substitutes in cardiopulmonary bypass was the most useful and practical.  Your courage to apply this principle in clinical surgery made open heart surgery safer and available to a large number of patients.  Although skeptics of this departure from standard practice were vocal and often emotional, you persisted and convinced the entire surgical profession of the validity of this technique.”

DR. DENTON COOLEY, AUGUST 28, 1999

 

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Those of us who followed have been heaping the rewards of Dr. Zuhdi’s endeavors for the past 30 years on a scale unimagined in the pre-Zuhdi era.

DAVID K.C. COOPER, ANNALS OF THORACIC SURGERY, 53:180-2; 1992

 

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[1] Zuhdi explains, “The United States Department of Health and Human Services contracted with UNOS, the United Network for Organ Sharing, to conduct an analysis on the business of transplantation in the nation.  According to the study conducted, the statistics show the Nazih Zuhdi Transplantation Institute ranked high in the nation.”