“Those who practice
without science are like sailors who enter a
ship without a helm or a compass.”
Leonardo da Vinci
Modern cardiac surgeons know very well that
practicing cardiac surgery without a cathlab
is like riding a ship without a compass. In
such a situation, it is hard to tell where
we are and in what direction we need to go.
This magnificent diagnostic and therapeutic
technique evolved over the past two
centuries with the progressive effort of
many great scientists and remarkable
pioneers. They proceeded with persistence
against many odds and strong opposition at
times, yet in some other times, they were
helped by lucky events that illuminated the
way for their alert minds.
Early steps
Stephen Hales (1677-1761)
Stephen Hales
(1677-1761) an English physiologist
who was first to place catheters
into the right and left ventricles
of a living horse.. |
was an English
physiologist, chemist and inventor. In 1711,
Hales placed catheters into the right and
left ventricles of a living horse. However,
cardiac catheterization was so named by
Claude Bernard. In 1844, the great French
physiologist Claude
Bernard (1813-1878)
Claude Bernard
(1813-1878) the great French
physiologist who measured
intracardiac temperature and
pressures in a variety of animals. |
inserted a mercury
thermometer into the carotid artery of a
horse and advanced it into the left
ventricle to measure blood temperature. He
adapted this experiment for measuring
intracardiac pressures in a variety of
animals. Although Bernard may not have been
the first to perform cardiac
catheterization, his careful application of
scientific method to the study of cardiac
physiology using the cardiac catheter
demonstrated the enormous value of this
technique.
Another major step in the development of
cardiac catheterization was taken in 1870 by
Adolph Eugen Fick
(1828-1901)
The
German scientist Adolph Eugen Fick
(1828-1901) was the first to devise
a technique for measuring cardiac
output in 1870. |
in Germany. His
famous brief note on the calculation of
blood flow is still the basis for today’s
procedures in measuring cardiac output and
hemodynamic flow data.
Early human cardiac
catheterization
Probably the earliest published descriptions
of human cardiac catheterization were those
performed in 1912 by Frizt Bleichroeder, E.
Unger and W. Loeb. They were among the first
to insert catheters into the blood vessels,
unfortunately, their attempts were not
documented with x-ray images. Unger passed
ureteric catheters into the arm veins of 4
human subjects, including Dr. Bleichroeder
himself, and also from the femoral vein into
the inferior vena cava.
In 1929, Werner
Theodor Otto Forssmann (1904-1974)
The German
urologist Werner Theodor Otto
Forssmann (1904-1974). Pioneer of
cardiac catheterization. Nobel Prize
1956. |
One X-ray for a
Nobel Prize ! This chest X-ray image
was taken by Forssmann in 1929 to
document the position of the
ureteral catheter he introduced from
his left antecubital vein to the
right atrium. |
, at age 25 while
receiving clinical instruction in surgery at
Eberswalde in Germany, experimented on human
cadavers and realized how easy it was to
guide a urological catheter from any arm
vein into the right atrium. He went so far
as to dissect the veins of his own forearm
and guide a urological catheter into his
right atrium using fluoroscopic control.
This made Forssmann the first to document
right heart catheterization in humans using
radiographic techniques. During the next two
years, Forssmann performed catheterization
studies including 6 additional attempts to
catheterize himself. In return for his
experiments, he was fired from his position
at the hospital. Nevertheless, for his
contribution and foresight, he shared the
Nobel Prize in physiology and medicine in
1956 with Andre Cournand and Dickinson
Richards.
Forssmann’s primary goal in his
catheterization studies was to develop a
therapeutic technique for direct delivery of
drugs into the heart. He wrote:
“If cardiac action ceases suddenly, as is
seen in acute shock or in heart disease, or
during anesthesia or poisoning, one is
forced to deliver drugs locally. In such
cases the intra-cardiac injection of drugs
may be life saving. However, this may be a
dangerous procedure because of many
incidents of laceration of coronary arteries
and their branches leading to cardiac
tamponade and death… Because of such
incidents, one often waits until the very
last moment and valuable time is wasted.
Therefore, I started to look for a new way
to approach the heart, and I catheterized
the right side of the heart through the
venous system.”
His 1929 paper states, “These are reasons
why one often hesitates to use intercardiac
injections. Often, time is wasted with other
measures. This is why I kept looking for
different, safer access to the cardiac
chambers: the catheterization of the right
heart via the venous system.” He goes on to
say:
“I confirmed these facts by studies on a
cadaver, catheterizing any vein near the
elbow, the catheter would pass easily into
the right ventricle....
After these successful preliminary studies,
I attempted the first experiment on a living
human, performing the experiment on myself.
In a preliminary experiment, I had asked a
colleague to puncture my right brachial vein
with a large-bore needle. Then I advanced a
well-lubricated No. 4 ureteral catheter
through the cannula into the vein.... One
week later I tried it again without
assistance this time. I proceeded with vena
puncture in my left antebrachial vein and
introduced the catheter to its full length
of 65cm....
I checked the catheter position
radiologically, after having climbed stairs
from the OR to the radiology department. A
nurse was holding a mirror in front of the
x-ray screen for me to observe the catheter
advance in position. The length of the
catheter did not allow further advancement
than into the right atrium. I paid
particular attention to the possible effects
on the cardiac conduction system, but I
could not detect any effect.”
Forssmann, in that same report, goes on to
present the first clinical application of
the central venous catheter for a patient in
shock with generalized peritonitis.
Forssmann concludes his paper by stating, “I
also want to mention that this method allows
new options for metabolic studies and
studies about cardiac physiology.”
In a 1951 lecture, Forssmann discussed the
tremendous resistance he faced during his
initial experiments. When he requested to
pursue physiological studies using cardiac
catheterization, the answer was: “Such
methods are good for a circus, but not for a
respected hospital”. His progressive
research pushed him into the position of an
outsider with ideas too crazy to give him a
clinical position, and he eventually became
a urologist.
The Czech cardiologist
Otto Klein (1891-1968)
The Czech
cardiologist Otto Klein (1891-1968)
has to be credited for the first
clinical diagnostic right-heart
catheterization in 1929. |
has to be credited
for the first clinical diagnostic
right-heart catheterization. In 1929,
applying Forssmann’s technique, he performed
11 successful right-heart catheterizations,
including passage of catheters into the
right atrium and right ventricle, and he
estimated the cardiac output using the Fick
principle. Klein presented his data during
lectures in Prague in 1929, and at the
Congress of the German Society for Internal
Medicine in 1930. He published this work in
1930. Unfortunately, he was not allowed to
continue these studies by his professors at
Charles University in Prague.
About a decade later, the French/American
André Frédéric
Cournand (1895-1988)
The
French/American physician
physiologist André Frédéric Cournand
(1895-1988). Nobel Prize 1956. |
in 1941, and
the American
Dickinson Woodruff Richards (1895-1973)
The American
physician and physiologist Dickinson
Woodruff Richards (1895-1973). Nobel
Prize 1956. |
in 1945, applied
Forssmann’s ideas in New York, and used
right heart catheterization on a regular
basis for comprehensive investigation of
cardiac function in both normal and diseased
patients. In 1956, Cournand, Richards and
Forssmann shared the Nobel Prize in
physiology and medicine for their
contributions to the advancement of cardiac
catheterization. The pioneer contributions
of Bleichroeder and Klein were recognized
much later.
More progress
Until the 1950s, placing a catheter into
either the arterial or venous system
involved a “cut down” procedure. The
percutaneous approach that is widely used
today was developed in 1953 by the Swedish
radiologist Sven-Ivar
Seldinger (1921-1998)
The Swedish
radiologist Sven-Ivar Seldinger
(1921-1998). |
. This method was
used initially for the visualization of the
peripheral arteries. Percutaneous access to
enter an artery or a vein, or to enter a
cavity or a mass, or to drain a fluid
collection is now commonly known as the
Seldinger technique.
By 1960, diagnostic catheterization became
established as the best method for
confirmation of clinical findings prior to
cardiac surgery for valvular or congenital
heart disease. We were still unable to have
good images of the illusive coronary
arteries. Actually in those days, it was
believed that injecting even a small amount
of contrast agent within a coronary artery
would be fatal.
Good luck factor in
coronary angiography
During the late 1940’s and early 1950’s, a
number of indirect methods were developed to
enhance visualization of the coronary
arteries. These included the flooding of the
aortic root with a large quantity of
contrast material that flowed into the
coronary arteries.
Charles Theodore
Dotter (1920-1985)
Charles Theodore
Dotter (1920-1985), vascular
radiologist who is generally
credited with developing
interventional radiology and
cardiology. |
was a vascular
radiologist who is generally credited with
developing interventional radiology. In
1958, he began working on methods to
visualize the coronary anatomy via
sequential radiographic films. He invented a
method known as occlusive aortography in an
animal model. Occlusive aortography involved
the transient occlusion of the aorta and
subsequent injection of a small amount of
radiographic contrast agent into the aortic
root and subsequent serial x-rays to
visualize the coronary arteries. This method
produced impressive images of the coronary
anatomy. Dotter later reported that all the
animals used in the procedure survived.
Later that same year, while performing an
aortic root aortography in a 26 year old man
with rheumatic heart disease,
Frank Mason Sones, Jr.
(1918-1985)
Frank Mason Sones,
Jr. (1918-1985), a pediatric
cardiologist at the Cleveland Clinic
pioneered selective coronary
arteriography in 1958. |
, a pediatric
cardiologist at the Cleveland Clinic, noted
that the catheter had accidentally entered
the patient’s right coronary artery. Before
the catheter could be pulled back, 30cc of
contrast agent had been injected. The
patient went into ventricular fibrillation,
and the dangerous arrhythmia was terminated
by Dr. Sones promptly performing a
precordial thump, and/or asked the patient
to cough, which restored sinus rhythm. This
became the world’s first selective coronary
arteriogram. He used image amplification and
optical amplification with high speed
cine-technique, and developed a catheter to
selectively enter the coronary arteries. The
catheter had a relatively rigid body for
torque control and a tapered tip which made
it easier to enter the coronary ostia. Sones
improved the technique of performing
selective coronary arteriography to become
the gold standard for the diagnosis of
coronary artery disease. Subsequently in
1967, Sones’ Cleveland Clinic colleague, Dr.
René Geronimo
Favaloro (1923-2000) performed
the first coronary artery bypass graft (CABG)
operation. Favaloro called Sones, “The most
important contributor to modern cardiology,”
and said that without his work, “all our
efforts in myocardial revascularization
would have been fruitless.”
By the late 1960s,
Melvin Paul Judkins (1922-1985)
Melvin Paul Judkins
(1922-1985) |
Melvin Paul
Judkins (1922-1985) perfected
selective coronary arteriography
through the percutaneous femoral
approach. |
simplified
selective coronary arteriography by the use
of percutaneous femoral approach, and by
creating catheters that were specially
pre-shaped to easily reach the coronary
arteries.
Therapeutic
potentials?
Therapeutic potentials of cardiac
catheterization were considered in the mid
1960s. Charles Dotter’s accidental catheter
recanalization of a peripheral artery in
1963 probably initiated the era of
interventional cardiology. In 1964, Dotter
used percutaneous dilation of peripheral
arterial lesions using progressive axial
solid dilators and balloons.
In 1966, William J.
Rashkind (1922-1986)
William J.
Rashkind (1922-1986), father of
nonsurgical repair of congenital
heart defects using catheter
techniques. |
, a brilliant
pediatric cardiologist at the Children’s
Hospital of Philadelphia, developed
life-saving balloon catheter technique
(balloon atrial septostomy) to improve
mixing of blood in neonates with
transposition of the great arteries. Later
on he also developed devices to close atrial
septal defects and patent ductus arteriosus.
He was the chief of the Division of
Pediatric Cardiology at the Children’s
Hospital of Philadelphia until his death in
1986 from malignant melanoma. Rashkind was a
pioneer and a founding father of nonsurgical
repair of congenital heart defects using
catheter techniques.
PTCA
The use of a balloon-tipped catheter for the
treatment of atherosclerotic vascular
disease was first described by Charles
Dotter and Melvin Judkins in 1964, when they
used it to treat a patient with
atherosclerotic disease in the superficial
femoral artery of the left leg. Building on
their work and his own research involving
balloon-tipped catheters in peripheral
arteries, Andreas
Roland Grüntzig (1939-1985)
Andreas Roland
Grüntzig (1939-1985) performed the
first successful percutaneous
transluminal coronary angioplasty on
September 16, 1977 in Zurich,
Switzerland. |
performed
the first successful percutaneous
transluminal coronary angioplasty (PTCA) on
September 16, 1977 at the University
Hospital in Zurich. In the first successful
coronary angioplasty, Grüntzig’s used his
special balloon catheter to expand a short 3
mm lesion in non-branching section of the
left anterior descending coronary artery
with 80% stenosis. The results of the
procedure were presented at the American
Heart Association meeting two months later
to a stunned audience of cardiologists. In
the subsequent three years, Grüntzig
performed coronary angioplasty in 169
patients in Zurich. It is interesting to
note that ten years later, nearly 90 percent
of these carefully selected patients were
still alive. By the mid 1980s, over 300,000
PTCAs were being performed, equaling the
number of CABG operations performed for
treatment of coronary artery disease.
Stents and more
The inventor of the coronary stent was also
Charles Dotter, who developed his first
stent in 1969 that was implanted in a dog.
In 1983, Charles Dotter, together with
Andrew Craig, invented an expandable stent
made out of nitinol, the material that is
used in some stents today. By 1989, the
Palmaz-Schatz balloon-expandable
intracoronary stent was developed, and by
1999, nearly 85% of all percutaneous
coronary intervention (PCI) procedures
included intracoronary stenting. One of the
first products of the new focus on
preventing in-stent restenosis and
thrombosis was the heparin coated Palmaz-Schatz
stent. These heparin-coated stents were
found to have a lower incidence of subacute
thrombosis than bare metal stents.
By 2000, the Cypher stent, a stent that
releases sirolimus (chemotherapeutic agent)
over time was also developed. The first
study in which this stent was used revealed
an incredible lack of restenosis (zero
percent restenosis) at six months. However,
further trials revealed that restenosis did
occur, but at a rate that was significantly
lower than that with bare metal stents.
The Cypher stent was the first drug-eluting stent approved for use in the
United States. By the end of 2004, drug
eluting stents were used in nearly 80
percent of all percutaneous coronary
interventions. Still, restenosis remained
the most difficult problem to solve in PCI
procedures.
Interventional cardiologists and brilliant
bioengineers developed more techniques to
advance the therapeutic potentials of
cardiac catheterization, and introduced
sliding wires, drills, cutting balloons,
perfusion balloons, coronary suction,
protection devices, and mitral balloon
valvuloplasty. Pediatric cardiologists also
used VSD closure devices and applied
stenting for treatment of some congenital
heart diseases.
Hybrid rooms equipped for both cardiac
catheterization and open heart operations
started to show advantages. In such hybrid
theaters, high risk combined CABG/PCI
procedures are performed. Also, aortic
stented grafts, endo-vascular operations,
percutaneous or trans-apical aortic valve
placement and complex procedures for
treatment of difficult congenital heart
diseases, such as modified Norwood procedure
for hypoplastic left heart, became safer and
more successful. Heart surgeons and
cardiologists found themselves working
together in the same theatre area to deliver
the best possible care for cardiac patients.
In his Nobel lecture of 11th Dec., 1956,
Andre Cournand remarked: “the cardiac
catheter was … The key in the lock”. By
turning this key, Cournand and his
colleagues led us into a new era of
understanding normal and disordered cardiac
function, and expanded new horizons of hope
to help the ailing hearts. We should always
remember that the first open heart operation
which was performed by Gibbon in February
1952, for a 15-month-old girl with an
alleged ASD, died on the operating table
because she did not have an ASD, but a large
patent ductus arteriosis. The worst
situation a heart surgeon may face in the
operation theater is an unexpected,
inaccurate, or incomplete diagnosis of the
disease. Cardiac catheterization generates
the road map that we follow to plan safe and
hopefully successful operations.¨
References:
1. Robert S. Litwak. “The growth of cardiac
surgery: Historical notes”. Cardiovasc Clin
1971;3:5-50.
2. Richard H. Meade. “A History of Thoracic
Surgery”; 1961, Bannerston House.
3. Louis Acierno. “The History of
Cardiology: Men, Ideas and Contributions”;
1994, Informa Health Care.
4. Stephen Westaby and Cecil Bosher.
“Landmarks in Cardiac Surgery”. 1998,
Informa Health Care.
5. Donald S. Baim and William Grossman.
“Grossman’s Cardiac Catheterization
Angiography and Intervention”. 2005.
Lippincott Williams and Wilkins.
6. Mueller RI, Sanborn TA. “The history of
interventional cardiology: Cardiac
catheterization, angioplasty, and related
interventions”. AM Heart J. 1995;129-146.
7. Forssmann W. “Experiments on myself:
memoirs of a surgeon in Germany”. 1974. New
York, St. Martin’s Press.
8. Mueller RL and Sanborn TA. “The history
of interventional cardiology: cardiac
catheterization,