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European Perspectives in Cardiology
Pioneer: Robert Anderson, MD, PhD, FRCPath
Responsible for Demonstrating the Location of “Invisible”
Conduction Tissues Within and Clarifying the Morphology of the
Congenitally Malformed Heart
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Robert Anderson, retired professor of paediatric cardiac morphology, Institute of
Child Health, University College London, London, England, talks to Mark icholls.
R
esearch conducted by Robert Anderson, MD, PhD,
FRCPath, retired professor of paediatric cardiac morphology, Institute of Child Health, University College
London, London, England, into the anatomy and development of the normal and congenitally malformed heart has
“played a large part in permitting surgeons to improve the
results of paediatric cardiac surgery.”
Professor Anderson has published on virtually all congenital cardiac malformations1,2 but says, “Probably the
lesion that we have done most to clarify is atrioventricular
septal defect.”3–5 He is most proud of the work clarifying
the morphology of the congenitally malformed heart and
demonstrating within the malformed heart the location of
the otherwise invisible conduction tissues. However, he
looks back at his initial article on the disposition of the
conduction tissues in congenitally corrected transposition
as one that had the most impact on his work.6 He explains,
“This led the way to many subsequent investigations of the
location of the conduction tissues in congenitally malformed hearts and indicated the need to understand the morphology of the hearts and the normal disposition of the
conduction tissues. It has now lent itself to my ongoing
studies of the development of the heart and the conduction
tissues.” Professor Anderson has found the mechanics of
cardiac development7 to be the most challenging, but adds,
“This is now taking shape thanks to the work I have been
able to continue in my ‘retirement’.”
On other pages...
Left, right-sided heart chambers from a patient with congenitally corrected transposition. Professor Anderson’s research showed that the
atrioventricular conduction axis was located in front of and superior
to an accompanying ventricular septal defect (red arrow) rather than
behind and inferiorly, as previously presumed (white arrow with red
border). The arrangement had been described in German literature,
but had been neglected. Right, an ostium primum defect from the right
side, which Professor Anderson showed to be an atrioventricular septal defect extending nearly to the level of the atrioventricular junction
(white arrow) with commonality of the atrioventricular junction and
fusion of the leaflets of the common valve guarding the junction to the
crest of the scooped-out ventricular septum and each other. Shunting
through the defect is largely ventricular (red double-headed arrow),
and the common valve is divided into right- ventricular and left-ventricular components. Photographs courtesy of Professor Anderson.
Spotlight: Georg M. Wieselthaler, MD
Georg M. Wieselthaler, MD, associate professor of surgery in the Department
of Cardiothoracic Surgery at the Medical University of Vienna, Vienna, Austria,
has spent more than 2 decades pioneering work on heart pumps and circulatory
support. He was part of the Viennese team who in 1998 implanted 2 patients
with a rotary blood pump who then became the first long-term survivors of
the technology and its pulseless pattern of blood flow.
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Professor Anderson with his wife,
Christine, whom he married in 1966.
They live in Wandsworth, London,
England, and have 2 children and 3
grandchildren. Apart from medicine,
he enjoys music and playing the
piano. He says, “I am fortunate to
have very good friends who are truly
superb musicians, and they suffer
my poor playing as we explore the
piano trios and quartets of Haydn
and Mozart.” An avid golfer, as is
Christine, Professor Anderson retains
a handicap of 14, having got down
to 4 at one time, and now enjoys
playing at Walton Heath, Walton on
the Hill, Surrey, England, and “the
many fine courses” in South Carolina.
He also enjoys fine wine. Photograph courtesy of Professor Anderson.
A Damascene Moment “Transformed My Career”
Born in Wellington, Shropshire, England, in April 1942,
Professor Anderson was educated at the grammar school in
the town from 1952 to 1960 before studying medicine, with
an intercalated degree in anatomy, at the University of
Manchester, England, qualifying BSc in 1963, and MB
ChB in 1966. He initially intended to become an ophthalmologist, but instead returned to the Anatomy Department,
where he had carried out the work for his BSc thesis, and
became “consumed with cardiac anatomy.”
A chance encounter then led to a Damascene moment
and the work that would prove so influential to the practice
of paediatric cardiology and cardiac surgery. He says,
“While I was still at an early stage, someone showed me a
section from a child undergoing surgery in Liverpool
[England] and sadly dying. The surgeon had put a stitch
around the conducting bundle between the atrial and
ventricular chambers. This was my introduction to the
congenitally malformed heart.” The Liverpool team made
it possible for him to begin his combined studies of the congenitally malformed heart and the conduction tissues.8
The support provided by Anderson’s chief, George
Mitchell, OBE, FRCS, in Manchester, and the cardiac surgeon
David Hamilton, FRCS, in Liverpool, led to a Medical Research
Council (MRC) Travelling Fellowship at the University of
Amsterdam, Amsterdam, the Netherlands, in 1973.
Professor Anderson recalls, “This initial introduction
heralded the research that got me to Amsterdam, and let
one thing happen after another. The experience transformed
my career. With the MRC Travelling Fellowship, I came
into contact with Professor Durrer [MD], who was my initial mentor. He supported me strongly in Amsterdam and
made it possible for me to work with Giel Janse, MD.
Needing pathological material, I was then introduced to
Anton Becker [MD]. This started a collaboration that has
extended throughout my career. My initial research
involved the conduction tissues in the heart and also
included studies of the developing heart. On the basis of
this work, we rediscovered parts of the conduction tissue
that had been described by German pathologists, but then
forgotten. These findings proved of huge significance for
paediatric cardiac surgeons. Elliot Shinebourne [MD,
FRCP] heard me present this work and asked whether I
would work with him as a clinical anatomist. With his support I was able to become a full-time professional clinical
cardiac anatomist. This gave me the opportunity to use my
anatomical skills and expertise in a clinical setting and be
remunerated at clinical rates.”
With funding arranged through the Joseph Levy and
British Heart Foundations, Professor Anderson accepted
the role that provided the basis of his career as professor of
paediatric cardiac morphology. He says it effectively
“cemented the remainder” of his career, with 25 years spent
at the Royal Brompton Hospital and the final 8 years at
Great Ormond Street Hospital Institute of Child Health
until his retirement. He says, “Throughout this period, I
maintained my active collaboration with Anton Becker, and
together we published articles on the morphology of most
congenital cardiac malformations.”9
He says, “As an anatomist, the ‘pathology’ of congenital cardiac disease was a relatively open book because it is
mostly deranged anatomy. Thus, my initial training in
anatomy set me up ideally to become an expert in the structure of the congenitally malformed heart, which proved to
be a largely unpopulated area. My collaboration with all
my clinical colleagues made it possible to perform the crucial clinicomorphological correlations that have been the
bedrock of my career.”
Now in ‘retirement,’ Professor Anderson continues his
research with colleagues. Since 2007, he has been emeritus
professor, University College London; emeritus visiting
professor, University of Manchester; professorial fellow,
Institute of Human Genetics, Newcastle University,
Newcastle, England; and visiting professor of paediatrics,
Medical University of South Carolina, Charleston, SC,
where he teaches fellows paediatric cardiology. He also
retains his collaborations with colleagues at the University
of Pittsburgh, Pittsburgh, Penn, and has established important new collaborations at the University of Florida,
Gainesville, Fla, and the Children’s Memorial Hospital,
Chicago, Ill.
“I Would Like to Be Able to Translate My Expertise in
the Structure of Congenitally Malformed Hearts Into
Elucidating Their Morphogenesis”
Professor Anderson was instrumental in establishing the
British Congenital Cardiac Association, and was president
from 1999 to 2001. He is also involved with the British
Cardiovascular Society, the European Society for
Cardiology, the Anatomical Society, the International
Nomenclature Committee, and the World Society for
Paediatric Cardiac Surgery. He is an honorary fellow of the
Association for European Paediatric Cardiology and the
European Association for Cardiothoracic Surgery.
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Professor Anderson in Pittsburgh, Penn, 2008, with, from left to right, “my old friend” paediatric cardiologist, Bob Zuberbuhler, MD,
from the Children’s Hospital of Pittsburgh, Pittsburgh, who offered him a platform for research at the University of Pittsburgh: Sang Park,
MD; Victor Morell, MD; and Steve Webber, MD. A number of people inspired Professor Anderson and had a role in helping shape his
career. At the University of Amsterdam, the #etherlands, these people included Dirk Durrer, MD, professor of cardiology and clinical
physiology; Michiel (Giel) Janse, MD, PhD, emeritus professor of experimental cardiology; and Anton Becker, MD, professor in the
Department of Cardiovascular Pathology. Other key figures included Elliot Shinebourne, MD, FRCP, consultant paediatric cardiologist
at the Royal Brompton Hospital, London, England; Michael Tynan, MD, FRCP, professor in the Department of Paediatric Cardiology,
Guys Hospital, London; the late Fergus Macartney, MB, FRCP; and Jane Somerville, MD, FRCP, initially from the #ational Heart
Hospital and subsequently at the Royal Brompton Hospital. Professor Anderson also reflects on being inspired by meetings with John
Kirklin, MD, from the University of Alabama in Birmingham, Ala; Francis Fontan, MD, from Bordeaux, France; and Lucio Parenzan,
MD, from Bergamo, Italy. Photograph courtesy of Professor Anderson.
Along with Bill Henry, MD, Professor Anderson founded
the journal Cardiology in the Young, and was editor-in-chief
until 2 years ago. He adds, “While working at the Royal
Brompton, I was able to collaborate with colleagues working
at Great Ormond Street and Guy’s Hospital, and this collaboration led to us produce what is now recognised as the foremost
textbook in paediatric cardiology, now in its third edition.”10
Professor Anderson has received several special awards
including the Excerpta Medica Travelling Award (1977),
the Thomas Lewis Gold Medal of British Cardiac Society
(1982), the British Heart Foundation Prize for Cardiovascular Research (1984), and the James Mackenzie Lifetime
Award of the British Cardiovascular Society (2007).
Within his own field of work, Professor Anderson
believes the major developments will be in cardiac embryology. He says, “The developments in cardiac embryology
are truly spectacular. I would like to be able to translate my
expertise in the structure of congenitally malformed hearts
into elucidating their morphogenesis.”
He advises young people wanting to follow a career in
medicine or cardiology to “work hard and develop an
excellent research portfolio.” As for his own future, his
ambitions are a blend of personal and professional: “to continue research and teaching; to drink more fine wine; to
maintain my golf handicap; and to improve my piano playing so as to include the chamber works of Beethoven,
Schubert; and Schumann.”
References
1. Anderson RH, Becker AE, Freedom RM, Macartney FJ, Quero Jimenez
M, Shinebourne EA, Wilkinson JL, Tynan M. Sequential segmental
analysis of congenital heart disease. Pediatr Cardiol. 1984;5:281–288.
2. Anderson RH, Becker AE, Tynan M, Macartney FJ, Rigby ML,
Wilkinson JL. The univentricular atrioventricular connection: getting to
the root of a thorny problem. Am J Cardiol. 1984;54:822–828.
3. Piccoli GP, Gerlis LM, Wilkinson JL, Lozsadi K, Macartney FJ,
Anderson RH. Morphology and classification of atrioventricular
defects. Br Heart J. 1979;42:621–632.
4. Penkoske PA, Neches WH, Anderson RH, Zuberbuhler JR. Further
observations on the morphology of atrioventricular septal defects. J
Thorac Cardiovasc Surg. 1985;90:611–622.
5. Anderson RH, Ho SY, Falcao S, Daliento L, Rigby ML. The diagnostic
features of atrioventricular septal defect with common atrioventricular
junction. Cardiol Young. 1998;8:33–49.
6. Anderson RH, Becker AE, Arnold R, Wilkinson JL. The conducting tissues in congenitally corrected transposition. Circulation. 1974;50:
911–923.
7. Anderson RH, Webb S, Brown NA, Lamers W, Moorman A.
Development of the heart: formation of the ventricular outflow tracts,
arterial valves, and intrapericardial arterial trunks. Heart. 2003;89:
1110–1118.
8. Latham RA, Anderson RH. Anatomical variations in atrioventricular
conduction system with reference to ventricular septal defects. Br
Heart J. 1972;34:185–190.
9. Becker AE, Connor M, Anderson RH. Tetralogy of Fallot: a morphometric and geometric study. Am J Cardiol. 1975;35:402–412.
10. Anderson RH, Baker EJ, Penny DJ, Redington AN, Rigby ML,
Wernovsky G. Paediatric Cardiology. 3rd ed. New York: Churchill
Livingstone; 2010.
Mark #icholls is a freelance medical journalist.
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Spotlight: Georg M. Wieselthaler, MD
Pioneering Work on Heart Pumps and Circulatory Support
T
Georg M. Wieselthaler, associate professor of surgery and medical director for
mechanical circulatory support, Department of Cardiothoracic Surgery, Medical
University of Vienna, Vienna, Austria, and vice president of the International
Society for Rotary Blood Pumps talks to Jennifer Taylor, BSc, MSc, MPhil.
he introduction of rotary blood pumps ushered in a new
era in the field of mechanical circulatory support, and
Georg M. Wieselthaler, MD, associate professor of surgery
and medical director for mechanical circulatory support in
the Department of Cardiothoracic Surgery, Medical
University of Vienna, Vienna, Austria, was an early investigator of this new technology. Surgeons were using pumps
that produced pulsatile blood flow, and it was believed that
this was needed in the long term. The new pumps produced
a pathophysiological situation of nonpulsatile flow.
The race in 1998 to implant the first miniaturised axial
flow pump was between Vienna and the German Heart
Centre in Berlin, Germany. The pump’s inventor, Michael
DeBakey, MD, of Baylor College of Medicine in Houston,
Tex, asked both centres to identify patients, settle any regulatory issues, and let him know when they were ready.
Professor DeBakey was therefore in Berlin when Professor
Roland Hetzer, MD, PhD, medical director and chair of the
Executive Management Board Deutsches Herzzentrum,
Berlin, implanted the first 2 patients in the world, but neither survived. He was also present when 2 patients were
subsequently implanted in Vienna in 1998 by Professor
Ernst Wolner, Professor George Noon, and Professor
Wieselthaler, and these patients became the first 2 longterm survivors of the new technology and its consequent
pulseless pattern of blood flow.
The Viennese team—Professor Wolner, Professor #oon, and
Professor Wieselthaler—implanting 1 of their first 2 patients, with
the miniaturised axial flow pump in #ovember 1998 watched by
the pump’s inventor Professor DeBakey (centre behind drape).
Both patients survived and were transplanted, though 1 has since
died of cancer. Photograph courtesy of Professor Wieselthaler.
Patients Have Been Supported for 8 Years on Pumps
Professor Wieselthaler and his colleagues summarised the
experiences of the Department of Cardiothoracic Surgery
at the Medical University of Vienna with the new pump in
an article in Circulation in 2000.1 It produced some unusual
situations. When the first patient, a 65-year-old man, was
walking around the hospital with his wife after 1 month
with the pump, he became tired and lay down on the floor
for a rest. The emergency staff rushed towards him, could
not find a pulse, and tried to resuscitate him. Professor
Wieselthaler was called and had to explain that the patient
was fine despite having no pulse.
Professor Wieselthaler was awarded the Medforte–Olsen
Clinical Award from the International Society for Rotary
Blood Pumps (ISRBP) in 1999 at the 7th ISRBP conference in Tokyo for his work on the clinical application of
rotary blood pumps, and again in 2001 for his work on
Professor Wieselthaler’s experience operating on animals and as
an electrical engineer meant that he was well suited for the heart
pump field. His father was a veterinarian, and as a boy, he helped
his father operate on domestic pets, as well as boa constrictors,
pythons, and crocodiles from a nearby snake farm. Here he assists
his father in an operation on a 6-metre long python. After graduating in electrical engineering in 1978 Professor Wieselthaler was
uninspired by his first job, so he decided to pursue medicine
instead, graduating from the University of Vienna in 1987.
Photograph courtesy of Professor Wieselthaler.
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Professor Wieselthaler and the mechanical circulatory support team of the Department of Cardiothoracic Surgery at the Medical
University of Vienna, Vienna, Austria, with 5 patients who have been treated with ventricular assist devices and who remain in close contact with the team. Photograph courtesy of Professor Wieselthaler.
was relaunched, and Professor Wieselthaler was given a
physical rehabilitation training and spiroergometry of
job as a calf sitter in the animal lab of the surgery departpatients with the pump.2,3 The award is named after veteriment in 1984. Pumps were implanted into calves, and the
narian Donald Olsen, a major mentor of the mechanical
calf sitters were doctors for the animals and took care of the
circulatory support community and an early collaborator of
machines. It was then that the department discovered that
Willem Kolff, MD, and Robert Jarvik, MD. He particiWieselthaler not only had experipated in the first long-term total
ence with animals but was also an
artificial heart implantation in Dr
electrical engineer.
Barney Clark in 1982 in Salt
Professor Wieselthaler then
Lake City, Utah.
moved to the engineering lab,
Professor Wieselthaler’s studwhere he met his long-term collaies with his colleagues on the horborator, Professor Heinrich Schima,
monal regulation of patients on
PhD, an engineer. Together they
long-term nonpulsatile support
worked on the driving unit of the
showed that endocrine function
total artificial heart. He says, “In
was not impaired compared with
those days, we believed that if you
age- and-sex matched controls,4
had a patient with end-stage heart
and they also confirmed that
failure, you had to cut out the failnonpulsatile flow is not deleteriing heart and replace it with a total
ous in the long term. Today they
1998 photograph of a centrifugal heart pump.
artificial heart, both ventricles, both
know that the flow is not com- Photograph courtesy of Professor Wieselthaler.
sides, and that was the solution.”
pletely nonpulsatile; rather it is a
The first implant of the total artificial heart they devellow pulsatile flow with a low-pulse pressure amplitude, and
oped was carried out in Vienna in June 1986. It was a
some of their patients have been supported for up to 8 years
bridging procedure to transplantation with a donor heart,
on these pumps.
and they aimed to keep the bridging time short—between
10 and 20 days. The procedure began a series of discusProduction and Implantation of a Total Artificial
sions between himself and Professor Schima about how
Heart in 1986
the pump could be made smaller. They concluded that
Vienna has a long tradition of using circulatory support
there was no way to make pulsatile pumps, and especialsystems, and the chair of the department, Professor Ernst
ly the bulky driving units, significantly smaller, but that
Wolner, MD, was the first person to insert an intraaortic
rotary blood pumps were an alternative that should be
balloon pump into a human in Europe in 1968. During
investigated.
medical school, a programme on the total artificial heart
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that is on the market in
Europe and being considered by the United States.
Professor Wieselthaler
began working with the
Florida-based start-up
company in 2003. A
group of engineers had
built the pump and done
experiments on animals,
but it needed help with
Photographs taken at the seminal 1988 meeting on heart pumps in Austria. Left, Drs Affeld, Olsen, and #ose
clinical application. He
in the seminar room. Right, Enjoying the evening entertainment. Professor Wieselthaler recalls, “This was 1
carried out the first
of the most memorable meetings I have ever had. We had great discussions sitting around the fireplace enjoyimplant worldwide of the
ing a glass of wine or a hot tea. It was very fruitful.” Photograph courtesy of Professor Wieselthaler.
pump in Vienna in 2006.
A Seminal Meeting on Heart Pumps
Both patients were supported for more than 1 year and then
Without the Internet, it was difficult to pull together the
successfully transplanted.
knowledge about nonpulsatile pumps, so the young fellows
Professor Wieselthaler has had a number of visiting felorganised an international meeting on rotary blood pumps
lowships to the United States and Canada to learn how
in 1988. The 3-day meeting was held at a ski resort in the
medicine is practiced in other countries. Today he travels
Austrian mountains in early December. It was the only
extensively, and he particularly enjoys collaborating with
hotel open, and the heavy 1.5-metre snowfall meant no one
different disciplines, including engineering, haematology,
could leave the building. The meeting attracted groups
and haemostaseology. One example is the collaboration
from across Europe and the United States, as well as the big
with the Department of Haematology and Haemostaseology
personalities in the field, including Professor Olsen, MD,
at the Medical University, Munich, Germany, to investigate
Yuki Nose, MD, PhD, and Professor Noon. The meeting
the interaction of blood components with mechanical
changed the direction of their research dramatically, and
pumps that leads to anticoagulation and anti-aggregation.
they switched from the development of pulsatile pumps to
the development of rotary blood pumps. They began workReferences
1. Wieselthaler GM, Schima H, Hiesmayr M, Pacher R, Laufer G, Noon GP,
ing on a miniaturised centrifugal pump and got as far as
DeBakey M, Wolner E. First clinical experience with the DeBakey VAD
long-term animal experiments until they ran out of financontinuous-axial-flow pump for bridge to transplantation. Circulation.
cial support from the university.5 They were able to sell the
2000;101:356–359.
2. Wieselthaler GM, Schima H, Lassnigg AM, Dworschak M, Pacher R,
motor of the miniaturised pump to Baylor College, and it is
Grimm M, Wolner E. Lessons learned from the first clinical implants of
now being used in a pump available in Japan. The meeting
the DeBakey ventricular assist device axial pump: a single center report.
was so successful that there was a follow-up meeting in
Ann Thorac Surg. 2001;71(3 Suppl):S139–S143; discussion S144–S146.
3. Wieselthaler GM, Schima H, Dworschak M, Quittan M, Nuhr M, Czerny
1991, also in Austria, and in 1992, the International Society
M, Seebacher G, Huber L, Grimm M, Wolner E. First experiences with
for Rotary Blood Pumps was founded. Professor
outpatient care of patients with implanted axial flow pumps. Artif
Wieselthaler is vice-president of the International Society
Organs. 2001;25:331–335.
4. Wieselthaler GM, Riedl M, Schima H, Wagner O, Waldhäusl W, Wolner
for Rotary Blood Pumps and will be president in 2 years.
E, Luger A, Clodi M. Endocrine function is not impaired in patients with
He says, “The society arose out of the spirit that was crea continuous MicroMed-DeBakey axial flow pump. J Thorac Cardiovasc
ated out of these 2 meetings we had here in Austria.”
Surg. 2007;133:2–6.
5. Schima H, Trubel W, Wieselthaler G, Schmidt C, Müller MR, Siegl H,
Rotary pumps are high sheer stress machines that can
Losert U, Wolner E. The Vienna implantable centrifugal blood pump.
interfere with von Willebrand’s factor. The factor is cleaved
Artif Organs. 1994;18:500–505.
into smaller parts that circulate in the blood so platelets can
6. Steinlechner B, Dworschak M, Birkenberg B, Duris M, Zeidler P, Fischer
H, Milosevic L, Wieselthaler G, Wolner E, Quehenberger P, Jilma B.
no longer be activated, leading to an artificial, acquired von
Platelet dysfunction in outpatients with left ventricular assist devices.
Willebrand’s disease.6 One of Professor Wieselthaler’s
Ann Thorac Surg. 2009;87:131–137.
primary goals is to be an interdisciplinary scientist and cliContact details for Professor Wieselthaler: Medical
nician. He says, “Sometimes you get great ideas to work
University of Vienna/Vienna General Hospital,
on, or all of a sudden you get a solution for 1 of the quesWaehringer Guertel 18-20, A-1090 Vienna, Austria.
tions you’ve had for quite some time. Therefore, I really
E-mail: [email protected];
like that kind of interdisciplinary collaboration.”
tel: +43 1 40400 6835; fax: +43 1 40400 6735.
Another exciting piece of work is a collaboration with a
U.S. company to develop a left ventricular assist device
Jennifer Taylor is a freelance medical journalist.
Editor: Christoph Bode, MD, FESC, FACC, FAHA
Managing Editor: Lindy van den Berghe, BMedSci, BM, BS
We welcome comments. E-mail [email protected]
The opinions expressed in Circulation: European Perspectives
in Cardiology are not necessarily those of the editors or of
the American Heart Association.
European Perspectives
Circulation. 2010;121:f133-f138
doi: 10.1161/CIR.0b013e3181dfbe9b
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