In Memoriam

The international medical community mourns the loss of pioneering cardiac surgeon Adrian Kantrowitz, who died on 14 November 2008, at age 90, in Ann Arbor, Michigan. Having helped initiate a new era in the treatment of heart failure in the 1960s, Dr. Kantrowitz himself ultimately succumbed to that disease.

Born in New York City in 1918, Adrian Kantrowitz was 1 of 4 children born to Bernard Kantrowitz, a general practitioner, and his wife Rose, a costume designer for the Ziegfeld Follies. Adrian used to say that he became a doctor because his mother told him he always wanted to be one. As a boy, Adrian worked with his older brother Arthur to create an electrocardiographic machine out of spare radio parts. After earning a mathematics degree from New York University in 1940, Adrian enrolled at the Long Island College of Medicine (now part of the State University of New York [SUNY] Downstate Medical Center). Because World War II produced an urgent need for physicians, Adrian pursued an accelerated course, receiving his MD degree in 1943. He then served as a battalion surgeon for 2 years in the U.S. Army Medical Corps. After being discharged from the service at the rank of major and discovering that the waiting list for the neurosurgery residency position of his choice was several years long, he decided to enter general surgery.

From 1948 to 1955, Dr. Kantrowitz practiced surgery at Montefiore Hospital, in the Bronx. In 1951, he presented the 1st moving images ever taken inside the human heart. His pioneering film, shown before the New York Academy of Medicine, depicted the motion of the mitral valve.

In 1955, Dr. Kantrowitz became a professor at the SUNY Downstate Medical Center and Director of Cardiovascular Surgery at Maimonides Hospital, a 600-bed community hospital in Brooklyn. During his 15 years at Maimonides, he helped develop many new medical devices, including an electronically controlled heart–lung machine, a diaphragm booster heart, the intra-aortic balloon pump (IABP), a miniature radio transmitter that caused the paralyzed bladder to empty, an internal cardiac pacemaker, and a neuro-stimulator that enabled paraplegic patients to move their limbs by electronically triggering their muscles.

In February 1966, Dr. Kantrowitz rose to international prominence when he performed the world's 1st permanent implantation of a partial mechanical heart (left ventricular assist device). Unfortunately, the 1st patient died of advanced liver disease after only 24 hours. Then called an “auxiliary ventricle” or “booster heart,” the device was U-shaped and implanted in the ascending aorta. Three months later, Adrian implanted this device in a 63-year-old woman, who lived for 12 days. As the device was turned on and off, this patient was repeatedly taken out of, and kept out of, heart failure, which demonstrated the potential of mechanical circulatory assistance.

At about that time, Dr. Kantrowitz's group began development of an IABP for temporary use in cardiogenic shock—which then was 100% fatal. In contrast to the earlier balloon pumps developed by others, his was nondistensible, nonocclusive, and powered with helium. In June 1967, he used it in a 45-year-old woman who had unobtainable blood pressure. She was comatose, anuric, cold, and cyanotic. After 7 hours of pumping, she was stabilized. She recovered and was discharged from the hospital. Cardiologists were excited by Dr. Kantrowitz's early reports, and this led to his organization of a 9-center cooperative study of the hemodynamic effects of IABP, which was reported later in the New England Journal of Medicine.

During the same period, Dr. Kantrowitz began work on cardiac transplantation. Because he could not envision a mechanical device that would grow with a child, he thought that heart transplantation would play its most important role in infants born with lethal congenital heart defects. By 1966, he had already performed more than 400 heart transplantations in puppies. On 30 June 1966, he was ready to transfer the heart of a brain-dead infant to a baby who had a number of congenital heart defects. In the operating room, the procedure was called off at the last minute, because the donor heart could not be resuscitated. In early December 1967, Dr. Kantrowitz was again expected to perform the 1st human heart transplantation. Only by a quirk of fate did Dr. Christiaan Barnard, of Cape Town, South Africa, beat him to this goal, on 3 December 1967. Three days later, Dr. Kantrowitz performed the world's 2nd transplantation (the 1st such operation in the United States), in an infant who survived for 6.5 hours. In January 1968, he did the 5th heart transplantation worldwide. Ironically, although Shumway, Lower, and he had laid the groundwork for Barnard's success, Dr. Kantrowitz was strongly criticized for “jumping on Barnard's bandwagon.” However, he was philosophical about the situation, stating, “You can't always be first. Some races you lose, some you win.”

By 1970, the Maimonides community-hospital setting had grown too small for Dr. Kantrowitz, so he moved his entire team of 25 surgeons, engineers, and nurses to Sinai Hospital in Detroit, where he remained for the rest of his career. He also began teaching at the Wayne State University School of Medicine, where he served as clinical professor until his death. During this period, he continued improving the IABP, the device for which he is best known, concentrating mainly on the development of a permanent version of the IABP for treatment of chronic heart failure. The IABP designed for treatment of acute heart failure is a 6-inch catheter-mounted polyurethane balloon, generally inserted into the aorta through the femoral artery in the leg. The IABP uses the principle of counterpulsation, or diastolic augmentation, to deliver a pressure pulse to the root of the aorta. At the start of diastole, the balloon inflates, augmenting coronary perfusion. At the beginning of systole, the balloon deflates; blood is ejected from the left ventricle, increasing cardiac output by as much as 40% and decreasing left ventricular stroke work and myocardial oxygen requirements. In the late 1980s, Dr. Kantrowitz joined with Aisin Seiki Co. Ltd. (of the Toyota family of companies) to develop a totally automatic, closed-loop IABP system, his original concept for the device. Aisin Human Systems (now Senko Medical) brought it to market in Japan in 1993.

Introduced into general use in the 1980s, the IABP remains the most widely used cardiac-assist device ever; it has been implanted in at least 3 million people, most of whom might otherwise have died. The concept of counterpulsation was first described by Adrian Kantrowitz in a paper cowritten with Arthur. Published in 1953, it remains a landmark contribution.

The development of the IABP was pursued separately by Arthur, a renowned physicist who helped advance the United States' space program. After sustaining a heart attack on 28 November 2008, at age 95, Arthur Kantrowitz himself received an IABP. Unfortunately, it did not save his life, and he died on 29 November—15 days after Adrian's death.

Adrian Kantrowitz undertook the challenge of developing a counterpulsating, blood-compatible left ventricular assist device without valves, which could be turned on and off without the use of anticoagulants and which kept the electromechanical power source (driver) outside the body, for easy replacement. For ambulatory use, his original U-shaped pump was revised to be implanted in the wall of the descending thoracic aorta and was called a “dynamic aortic patch.” In 1971, at Sinai Hospital in Detroit, it was implanted in a 64-year-old man who was in terminal heart failure. This patient was the 1st to be discharged with an implanted left ventricular assist device intended for a patient living at home. At 3 months, this patient succumbed to an infection that had originated at the site of the drive-line exit. After losing another patient at 3 months from the same cause, Adrian suspended further patient implants of the system and devoted the next 2 decades to developing, with University of Michigan investigators, a tissue-engineered, infection-resistant percutaneous access device. After achieving multiyear, infection-free survival in animals, Adrian resumed human trials of the heart- assist system. He conducted a feasibility trial in 12 terminally ill patients. In 2008, he gained U.S. Food and Drug Administration approval to initiate a pilot trial of the latest version of the device in those heart-failure patients who would benefit most: high-risk patients whose illnesses were not yet terminal.

During his career, Dr. Adrian Kantrowitz was granted patents on more than 20 medical devices. With his wife Jean, to whom he was married for 60 years, he established his own medical device company, L·VAD Technology, in 1983. His many honors include a Lifetime Achievement Award from the American Society for Artificial Internal Organs (2001) and honorary doctorates from Polytechnic Institute of Brooklyn; Michigan State University; and his alma mater, SUNY Downstate Medical Center.

Dr. Kantrowitz is survived by his wife, 3 adult children, and 9 grandchildren. All 3 children are physicians: Niki is a cardiologist, Lisa is a radiologist, and Allen is a neurosurgeon.

Along with the rest of the medical community, I salute Dr. Kantrowitz for his pioneering surgical innovations, which have contributed so much to human well-being. Because of his legacy, untold numbers of heart-failure patients will continue to be restored to productive lives in the years to come.