Pacesetter

Dr. Laman Gray Jr.'s 1935 Packard coupe was nearly unrecognizable when he first hauled it home for restoration nearly 14 years ago. Decades of neglect had reduced the once-hulking Super Eight to a stripped-down chassis of rusted-out parts. But Gray, director of thoracic and cardiovascular surgery at UofL, was intrigued by the classic car's potential.

So the heart surgeon, who knew nothing about automobile restoration, characteristically decided it was time to learn something new.

"The car was an absolute rust heap when I found it up in Massachusetts," Gray recalls. "I took it all the way down to the frame and started rebuilding it at my home. Mechanically, it was a disaster, too. So I tore the engine down myself, found an engine shop that re-bored the block for me, and I put the thing back together from there.

"I'd never done anything like that before, but I was attracted to the challenge of learning how to do it. And I enjoy tinkering."

In fact, the Louisville native spent most of his childhood tinkering with one thing or another, learning as much as he could before moving on to new pursuits.

"I used to build a fair amount of pretty sophisticated electronics," Gray recalls. "I was at the point where I could certainly service a TV or radio very nicely. And I've always enjoyed working with mechanical devices."

His childhood interests also included medicine, a field Gray seemed destined to enter if only because of familial association. His uncle, grandfather and father -- a UofL faculty member -- all were physicians, and his mother was a nurse.

When it came time for Gray to choose a specialty following medical school, cardiac surgery seemed an obvious choice. "The heart is," Gray notes, "the most mechanical of all organs."

Dr. Robert Dowling, a fellow heart surgeon who has worked alongside Gray for more than seven years, calls his friend "one of the most multi-faceted people I've ever met."

"He comes to work and performs cardiac surgery; then he goes home and restores a Packard in his garage, which is so well-equipped it would rival just about any metal shop around. He's also an avid airplane pilot, an expert amateur photographer and an electronics buff.

"There's just this insatiable quality about him," Dowling says. "He's always looking for something new."

Such voracious curiosity has served Gray well through the years, providing a cross-disciplinary foundation upon which he's built a reputation as one of the country's leading experts in ventricular assist devices.

These devices, which combine electronics, mechanics and medicine into one life-saving package, serve as temporary pumps that supplement failing hearts until transplants can be found. And now, surgeons like Gray are beginning to implant permanent artificial hearts built on the same technology.

On July 2, Gray and Dowling, an associate professor of surgery at UofL, made medical history when they implanted the world's first self-contained artificial heart in the chest of a man during a seven-hour surgery at Louisville's Jewish Hospital.

The titanium-and-plastic heart, known as the AbioCor, was just recently approved by the FDA for clinical trials in humans, thanks in part to research conducted on animal models at the University of Louisville over the past three years under the guidance of Gray.

The surgeon had been working toward this moment since 1984, when he performed Kentucky's first heart transplant at Jewish Hospital. That same year, Gray approached the manufacturers of the Thoratec ventricular assist device and suggested using it as a "bridge to transplant."

The Thoratec, which helps a heart's ventricle pump blood, had been used only to support patients who couldn't be removed from heart-lung machines. Gray, however, wanted to use the Thoratec in patients who were waiting for viable donor hearts. These patients sometimes die before a suitable organ can be found, and Gray proposed using the Thoratec to keep them alive until a transplant was possible.

"I approached the FDA with this idea, but they didn't know what a 'bridge-to-transplant' was because it had never been done," Gray recalls. "Eventually, the FDA gave me and another doctor, Don Hill, permission to do it. Don Hill put in a left ventricular assist device and bridged to a heart transplant out in San Francisco, and about a week later, I put in a bi-ventricular assist device here in Louisville at Jewish Hospital. These were the first truly successful bridge-to-transplants in the world."

The Thoratec proved the value of Gray's premise, but the external device was much too large for implantation. By the late 1980s, however, Gray began running clinical trials for an implantable ventricular assist device called the Novacor. The device eventually was approved by the FDA as a bridge to transplant and is still in use today.

"It's exciting to be involved in the development of these devices," Gray says. "However, one of my goals ever since I started was not to use these devices as a bridge to transplant, but as a permanent implantable device. That's where this huge need is.

"A bridge to transplant stabilizes a patient until a heart becomes available for transplantation. You certainly save lives, but the numbers are small. In the entire United States there are only about 2,000 heart transplants a year because there are so few available hearts. So the number of bridge to transplants would certainly be no more than 500 per year -- a very small percentage of the population.

"Nonetheless, they've taught us how to use artificial assist devices and how we can treat people who are on them. And now, permanently implantable devices like the AbioCor have been developed on the foundation of bridges."

The implications are tremendous.

About 300,000 people die in the U.S. each year from congestive heart failure, Gray says. Of that number, maybe 100,000 could benefit from some type of circulatory support, and about 30 percent of those would respond to the type of support provided by a totally artificial heart like the AbioCor, which Gray calls "the most sophisticated medical device ever built."

"I personally think, as this becomes more feasible over the next 10 years, we'll be looking at a paradigm shift," Gray says. "This is a new method of treating chronic congestive heart failure, which up to now has not been very treatable. It's a tremendous step forward.

"I think we're going to see a major change over the next decade, with the potential to save tens of thousands of lives each year. Doctors will be able to examine patients with congestive heart failure and simply pick a device off the shelf to treat the disease."

Such promise was a long way off in 1974 when Gray completed his residency in thoracic and cardiovascular surgery at the University of Michigan. At the time, now-routine practices like coronary-artery bypass surgery were just being developed.

"I basically had to teach myself how to do the procedure because it was such a new concept," recalls Gray, who became an assistant professor at UofL later that year when he joined the university's three-doctor Division of Thoracic and Cardiovascular Surgery.

In April 1975, Gray was named acting director of the division after his two colleagues left the university. ("I was chief of myself," the surgeon recalls with a smile. "There were never any arguments, and I always had unanimous support.") One year later, the director's title became permanent.

Today, Gray's state-of-the-art division performs about 25 heart transplants a year and boasts a staff of 35, four of whom are residents. Gray, a professor of surgery at UofL, relishes the chance to share his knowledge with those residents because they challenge him constantly.

"I enjoy teaching very much because it forces me to keep up with medical advances," Gray says. "The residents keep making me justify what I do, which is one of the reasons I've had to change my surgical techniques over the years. I've kept very, very current on everything."

Such passion for excellence comes as no surprise to Dowling, who describes Gray as a "master surgeon."

"He's always looking for ways to improve everything," Dowling says. "For example, the AbioCor used to stop pumping briefly when it was switched from external to internal power. Dr. Gray asked why it couldn't be configured differently and offered suggestions for improvement. The AbioCor engineers implemented his suggestions, and today the AbioCor is a better device."

Dowling says it's too early to tell if the AbioCor will be one of the great milestones in medical history, but he's sure of this: Whatever the future holds for cardiac care, Gray will be part of it.

"Dr. Gray's contributions to the field have just been tremendous," Dowling says. "I know he'll continue to expand the boundaries of cardiovascular medicine for many years to come."