|HISTORY OF MEDICINE
|Year : 2009 | Volume
| Issue : 3 | Page : 139-143
The magnificent century of cardiothoracic surgery
M.D., F.A.C.C., F.G.H.A, Consultant, Cardiothoracic Surgery, Department of Cardiology and Cardiothoracic Surgery, Hamad Medical Corporation, Doha, Qatar
|Date of Web Publication||17-Jun-2010|
M.D., Department of Cardiology and Cardiothoracic Surgery, Hamad Medical Corporation, P.O. Box 3050, Doha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chaikhouni A. The magnificent century of cardiothoracic surgery. Heart Views 2009;10:139-43
"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|| |
[Additional file 1]Stephen Hales (1677-1761) 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 [Additional file 2] Claude Bernard (1813-1878) 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 [Additional file 3] Adolph Eugen Fick (1828-1901) 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, [Additional file 4] [Additional file 5] Werner Theodor Otto Forssmann (1904-1974) , 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 [Additional file 6] Otto Klein (1891-1968) 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 [Additional file 7] Andrι Frιdιric Cournand (1895-1988) in 1941, and the American [Additional file 8] Dickinson Woodruff Richards (1895-1973) 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 [Additional file 9] 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.
[Additional file 10] Charles Theodore Dotter (1920-1985) 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, [Additional file 11] Frank Mason Sones, Jr. (1918-1985 ) , 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. Renι 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, [Additional file 12] [Additional file 13] Melvin Paul Judkins (1922-1985) 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, [Additional file 14] William J. Rashkind (1922-1986) , 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, [Additional file 15] Andreas Roland Grόntzig (1939-1985) 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, Grόntzig'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, Grόntzig 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.