100,000 Hearts: A Surgeon's Memoir by Denton A. Cooley, MD

During the 1930s and 1940s, a group of outstanding surgeons arose to introduce extracardiac and closed-heart procedures for the relief of congenital and acquired heart disease. In the second half of the 20th century, especially after the introduction of cardiopulmonary bypass, a second generation arose, most of whom have now died: people like John Kirklin, E. Walton Lillehei, Christiaan Barnard, René Favaloro, Michael DeBakey, and Norman Shumway. Denton A. Cooley, now 91 years of age, remains the sole survivor from this group of pioneers. The term “living legend,” so often tritely applied to many individuals, in this case is the most apt description of this outstanding individual. He has now rewarded us with a highly informative and readable account of his professional and personal life.

Denton Cooley was born in Houston in 1920. In a description of his early years, Cooley informs us that he grew up in reasonably comfortable economic circumstances despite the fact that so many other Americans were suffering during the Great Depression. His father was a successful dentist; his maternal grandfather, a physician. Despite such relative affluence, early on Cooley developed a frugality that extended into his later life when he saved whenever he could and even resorted to blood donations to supplement his meager income as a houseofficer.

The relationship of any boy to his father is crucial and, in this respect, his father was far from ideal. Although Cooley “learned many of life's important lessons” from his father, he describes the relationship as “complicated.” The successful dental practitioner at home was often intemperate and demanding, finally dying prematurely from the complications of alcoholism, as did Denton's beloved older brother. In contrast to this, Cooley was a remarkable athlete as well as a scholar. This combination of gifts won him recognition on and off the field despite a shyness that seems so out of tune with his later reputation as a successful cardiovascular surgeon.

From the age of 17, upon graduation from high school, the young Denton embarked on a decade and a half–long professional journey that molded him into a surgeon of great promise. The series of events that filled his life during this time, either by choice or by chance, in summary read like the scenario of a surgical Horatio Alger story.

After high school Denton attends the University of Texas (Austin) as a predental student. Then, on a dare, he visits a nearby emergency room where the intern allows him to suture his first lacerations. He switches to premed. He begins medical studies at the University of Texas Galveston Branch. Academic unrest there motivates him to go elsewhere. Although he had not previously settled on this choice, his family physician, who has friends at Hopkins, directs him to Baltimore. At Hopkins he attracts the attention of Alfred Blalock, who becomes the father figure so sorely missed in the past. Cooley eventually becomes Blalock's chief surgical resident and assists at the first Blalock-Taussig procedure performed for tetralogy of Fallot. This experience is temporarily interrupted by 2 years of army service as a surgeon in Linz, Austria. After Hopkins he spends a year in London at the Brompton Hospital as senior surgical registrar under Russell Brock. When Brock's associate is sidelined by tuberculosis, Cooley takes over the practice and doubles the number of cases performed on that service. In 1951, at the age of 31, he returns to the United States to begin a tumultuous 18-year relationship with his new chief, Michael DeBakey, at Baylor Medical School in Houston.

What is surprising is not that the relationship with DeBakey came to an end, but that it lasted as long as it did. Aside from outsized egos and equally large competitive spirits, the two men had little in common. When it came to research, DeBakey was usually inclined to the more traditional approach, beginning in the animal laboratory and then, only gradually, proceeding to clinical trials. For Cooley, his laboratory was often represented by the patients appearing before him on the operating room table. There he had the uncanny ability to assess the nature of the presenting problem, adopt a method of solving it, and do it faster and more successfully than anyone else.

DeBakey's interests and influence extended far beyond the surgical suite. He established and maintained close connections with Washington, serving on a number of policymaking panels. For example, he was instrumental in the establishment of the National Library of Medicine in Bethesda. At Baylor, he became chairman of surgery, then president, and then chancellor in establishing a first-rate medical institution. In contrast, Cooley's focus was mainly on the operating room where, in addition to the work on aortic aneurysms where he collaborated with DeBakey, he extended his expertise to congenital heart disease in response to the tremendous backlog of such cases that had developed in anticipation of open heart repair. He tackled the problem of open heart surgery in Jehovah's Witnesses by popularizing nonblood priming of the pump (introduced by Nazih Zuhdi), which also allowed for streamlining services to other patients awaiting such treatment. His administrative skills were devoted, in large part, to the formation and growth of the Texas Heart Institute. Cooley was also responsible for a number of surgical innovations and devices for use in heart surgery. He is the author or coauthor of over 1400 journal articles and eight textbooks.

Their treatment of subordinates was very different. DeBakey, in his quest for perfection, terrorized his housestaff, while Cooley attempted to lead by inspiring example. Yet trainees emerging from both programs established surgical societies in honor of their respective mentors. Excellent journals emerged from both camps (the Texas Heart Institute Journal under Cooley and the Methodist DeBakey Cardiovascular Journal under DeBakey).

No doubt challenged by the gifted newcomer, DeBakey often slighted his junior associate. Cooley recalls that he was excluded from plans to develop a total artificial heart. When a committee was established by DeBakey to plan for a transplant program, Cooley was again prevented from participation. As a result of such actions, a growing resentment developed in the younger man, long in advance of the debacle surrounding the implantation of a total artificial heart in Haskell Karp. This surgery was performed in April 1969. The patient survived 64 hours with the implanted device and another 32 hours after it was replaced with a donor heart.

In the months preceding this, it was not only Cooley who was chomping at the bit. Domingo Liotta, an Argentinean surgeon, had been hired in 1961 as a research fellow by DeBakey to develop a total artificial heart. As the years passed, it seemed less and less likely to DeBakey that the total artificial heart would work out. He began to favor a left ventricular assist device, and Liotta saw his life's work being cast aside. It became increasingly difficult for him even to gain an audience with DeBakey, much less gain approval for the desired clinical trial. Liotta turned to Cooley, who by this time had founded the Texas Heart Institute based at St. Luke's Episcopal Hospital and the Texas Children's Hospital within a few hundred yards of Methodist Hospital. He was already performing the bulk of his surgery at the Institute, operating more or less independently of DeBakey, although still on the Baylor faculty.

A reading of Cooley's account of the affair is unlikely to change many minds. Some will continue to look upon Cooley as having performed an heroic act in a humanitarian effort to save a dying patient's life. What others cannot ignore is that in order to perform such a procedure, the support of the principal investigator (DeBakey) was required along with approval of the institutional human research committee at Baylor as well as that of the National Institutes of Health (NIH). None of these approvals were obtained.

Of course DeBakey, who was out of town when the surgery was performed, felt betrayed and was furious. He feared at one point that all the research support from the NIH would be withdrawn. Reviews were conducted by the American College of Surgeons, the National Heart Institute, and Baylor University. All three groups found grounds for censure, the most severe rebuke coming from Baylor. Cooley resigned his faculty position at Baylor. The break between Cooley and DeBakey was now complete. Despite repeated overtures from Cooley, DeBakey refused even to acknowledge his presence for 38 years until 2007 when peace was finally declared, with DeBakey accepting honorary membership in the Denton A. Cooley Cardiovascular Surgery Society and appearing to accept the award with a handshake from Cooley. This was shortly before DeBakey's death in 2008, only 3 months short of his 100th birthday.

Although there are no new startling revelations to be found in Cooley's account, elsewhere, earlier in the book, are possible harbingers of his future behavior. He recalls that, while in the army, he performed a cesarean section without ever having done one before, and during his first operation for a complex skull fracture, a textbook he consulted was his only support in the operating room. At the Brompton he recalls accepting an assignment to perform a bronchoscopy when he had never done one previously. Of course, he succeeds in these escapades, making one wonder, in retrospect, about actions often deemed “daring” when they are successful and “reckless” when they are not. By 1969 restrictions on such autonomy were in place for the protection of patients while, admittedly, at times, the price paid was the stifling of initiative among medical investigators.

Cooley appears to have recovered from the artificial heart episode while hardly missing a beat. He seemed to follow in the footsteps of another prominent southerner, Confederate General Nathan Bedford Forrest, the cavalry commander whose motto was “get there first with the most.” Cooley lists 33 personal firsts in cardiovascular surgery, although surgical scholars might take issue with some of these claims. However, even when not the first, Cooley indisputably followed up with the most. His telegram to Christiaan Barnard after the first human heart transplant characteristically read, “Congratulations on your first transplant, Chris. I will be reporting my first hundred soon.”

The title of the book attests to the success of that goal of 100,000 open heart cases performed by 2001 at the Texas Heart Institute, more than accomplished by any other surgical group in the world. Key to this accomplishment were equipment modifications, scheduling, and innovations such as nonblood pump priming. Not least of all these factors was Cooley's own energy and enthusiasm. He reports overseeing as many as 30 operations daily, correcting 8 or 10 of the most difficult cases himself. He has personally repaired about 12,000 aortic aneurysms, a remarkable record in itself.

The strength of this book lies in both the candor and completeness of the memoir, with many gaps filled in for those of us only slightly acquainted with Dr. Cooley's past history. The lucid prose also makes the book as easy to understand for the general reader as for the professional. For those with medical backgrounds, several appendices are included for further reference. It is hard to find any faults with what Dr. Cooley has written. For those of us with historical bent, at times further background and other viewpoints might have been desired. However, a memoir, by its very nature, is a one-sided affair, and Cooley has done well by it.

The personal touches of the author are particularly engaging. Toward the end of the book he writes of his successful marriage and the joy taken in the five lovely daughters it produced. He reveals that he has made a lot of money, but he has also lost a lot. What he never seems to have lost is his sense of humor.

Once, as a defendant in a medical liability trial, he was asked by the plaintiff's lawyer if he considered himself the best heart surgeon in the world. When Cooley answered in the affirmative, he was then asked if he was being rather immodest. “Perhaps,” Cooley replied, “but remember, I am under oath.”

And who could argue with that?