In the meantime, scientists focused on perfecting nonsurgical treatments for patients who’d suffered heart attacks. In 1961, Desmond Julian, a cardiology fellow at the Royal Infirmary in Edinburgh, Scotland, published the first paper on the benefits of housing heart attack patients in a special cardiac care unit. “Many cases of cardiac arrest associated with acute myocardial ischemia could be treated successfully if … the cardiac rhythm of patients with acute myocardial infarction were monitored by an electrocardiogram linked to an alarm system,” Julian wrote. Before the advent of such monitoring, most patients who suffered heart attacks were housed for weeks in rooms off the main medical ward, far from ringing phones and the hustle and bustle of the nurses’ station, to give their hearts peace and quiet and a chance to heal. This benign neglect exacted a heavy toll, however. Senior cardiologists from that era have told me that when they would come to the medical wards early in the morning to draw blood, they’d often find one or two cardiac patients who had died quietly during the night.
Like other CCUs, Bellevue’s had a bank of EKG monitors that continuously tracked patients’ heart rhythms. Defibrillators and other resuscitation equipment were on standby. The nurse-to-patient ratio was 1:3 or sometimes even 1:2. Such vigilance saved lives. One morning, soon after my fellowship began, a middle-aged woman in her third day after a heart attack went into ventricular fibrillation, the chaotic rhythm that killed both my grandfathers. She had been feeling well and was eager to go home; her only complaint was of the EKG stickers irritating her skin. Then she slumped over. Her eyes rolled up in her head, and her face turned bluish, like an old bruise. If I had opened her chest at that point and held her fibrillating heart in my hand, it would have felt like a bag of swarming worms. I stepped into the hallway and shouted for an external defibrillator. An attending physician ran in and delivered two hard punches to her chest, “precordial thumps” that can sometimes terminate fibrillation, though that morning they did not. We inserted a board under the patient’s body and started chest compressions. When the defibrillator was brought in, I applied the metal paddles to her bony frame. One 360-joule shock was all it took. She coughed twice, her pulse reappeared, and she took a deep breath. Her eyes opened wide, and she turned her head to face us, looking sheepish, puzzled by all the commotion. She had no idea we had saved her from certain death. Her roommate in fact was more traumatized. Rocking back and forth in her bed, she quietly asked me to draw the curtain closed.
* * *
So, by the early 1960s, cardiologists could image a coronary obstruction. But how to fix it? Surgeons were already bypassing vascular obstructions in the legs and in the heart using vein grafts harvested from various sites in the body. However, mortality and morbidity rates in these bypass operations were unacceptably high. So a cadre of zealots began to try to figure out ways to create new channels of blood flow, not around a blocked artery but through it.
One of these doctors was Charles Dotter, a radiologist at the University of Oregon. At a conference in Prague in 1963, Dotter predicted that the angiographic catheter could be “more than a tool for diagnostic observation. Used with imagination, it can become an important surgical instrument.” Dotter—“Crazy Charlie,” to some—was an odd bird: a mountain climber, ornithologist, and amphetamine addict. He fashioned guide wires for his procedures out of guitar string, and at conferences he blowtorched catheters out of Teflon tubing at his hotel. Once, in the middle of delivering a lecture on cardiac catheterization, he rolled up his shirtsleeve to reveal to the audience that he had placed a catheter in his own heart that morning. Then, as he continued to lecture, he connected himself to an oscilloscope to record the pressures from his cardiac chambers.
Dotter performed the first therapeutic procedure with a catheter, which he called angioplasty, on January 16, 1964, when an eighty-two-year-old patient named Laura Shaw, who had a blocked artery in her leg that had resulted in gangrene, was brought to his radiology lab. Her limb was crusty, dusky, and infected. Even though she was in terrible pain, she refused amputation. As a palliative measure, Dotter inserted a wire through the skin on the back of her knee and into the blocked artery and then sequentially passed concentrically enlarging plastic catheters over the wire to dilate the vessel, relieving the obstruction by packing the plaque onto the vessel wall “like footprints in the sand.” The procedure was successful. Shaw’s pain subsided, and the infection resolved. She succumbed two years later to a heart attack.
For this and subsequent leg procedures, Dotter received widespread publicity. In August 1964, Life, the most widely circulated periodical in the country, published a photo spread of Dotter posing oddball during one of his clog-clearing procedures. “Things have been both rewarding and at times frustrating,” Dotter told the magazine. “In the early days of … angioplasty I had to accept a lot of unpleasant backbiting, such as ‘He’s a nut, you can’t trust his uncontrolled, poorly documented case experience,’ and worse. I’m glad I was thick-skinned enough to stick with it.”
Angioplasty was simply unclogging a pipe, and in fact Dotter frequently referred to himself as a plumber. “If a plumber can do it to pipes, we can do it to blood vessels,” he said. But his technique was coarse and crude, often resulting in a sort of snowplowing of plaque down the artery, where it could filter into smaller branches, obstructing them. Vessel injury was common, resulting in tears, bleeding, and scarring. Sometimes the plaque would dislodge and travel down the artery, causing infarction and tissue death. Though Dotter suggested that a more controlled dilation would be safer and more effective, he was never able to develop this method.
That critical step was left up to another German physician, Andreas Gruentzig, who began toying with Dotter’s catheters in the late 1960s. Like so many of the great cardiac innovators, Gruentzig was an engineer at heart. His two-bedroom flat in Zurich was across the street from where James Joyce wrote much of Ulysses, and his kitchen table, laid out with drawings, knives, plastic tubing, air compressors, and epoxy glue, was in fact a portrait of an artist’s work space. Gruentzig often worked all night fashioning prototype catheters. When colleagues would visit—at all hours, to the chagrin of Gruentzig’s long-suffering wife—he would lead them to his kitchen and put them to work. With a mane of black hair and a burly mustache, Gruentzig was handsome and charismatic. Like Forssmann, his legendary predecessor, he was a risk taker, winging his single-engine plane low over the Swiss Alps on weekend getaways. But unlike Forssmann, he worked systematically and inspired followers.
Gruentzig set as his task adding an inflatable balloon to the end of his catheters that was thin but strong enough not to compress or burst when encountering arterial walls studded with plaque. He first tested these balloon catheters on anesthetized dogs that he smuggled into the hospital on gurneys under drapes. The dogs’ arteries were stitched half closed to mimic an atherosclerotic blockage. When those experiments proved successful, Gruentzig went to work on human cadavers. On February 12, 1974, ten years after Dotter’s first angioplasty, Gruentzig used one of his catheters to perform the first human balloon angioplasty on a sixty-seven-year-old patient with a severe stricture of the iliac artery, a major vessel in the leg. After the balloon was inflated, relieving the blockage, an ultrasound showed free-flowing circulation, and the patient’s incapacitating leg pain vanished. Following this triumph, Gruentzig began to perform balloon angioplasty on a regular basis, handcrafting catheters for every new patient and meticulously tracking his results to deny voice to his critics. It was difficult, painstaking work. “If I had an enemy, I would teach him angioplasty,” he wearily told a colleague.
However, the ultimate goal for Gruentzig and others was the coronary artery, whose disease was responsible for so much death around the world. “The legs were only my testing ground,” Gruentzig said. “From the beginning I had the heart in mind.” Dotter himself wrote that the development of coronary angioplasty was “one of radiology’s most pressing responsibilities.” However, the idea of balloon coro
nary angioplasty was heretical in the extreme. There were so many potential pitfalls. The balloon could puncture the artery, causing rapid hemorrhage and pericardial tamponade. The vessel could recoil and close, causing a massive heart attack. The heart could develop fibrillation and stop beating altogether. For years, Gruentzig’s ideas were met with disdain, motivated by fear and perhaps not a small amount of jealousy. But he was a man of conviction, and there was nothing Gruentzig believed in more than himself.
Gruentzig meticulously pursued his vision. He forged collaborations on steerable catheters with American manufacturers, including the company that would eventually become the multibillion-dollar conglomerate Boston Scientific. He practiced on the coronary arteries of cadavers, then later on living patients undergoing bypass surgery, but only in vessels that were already bypassed or about to be bypassed, or were small and inconsequential. Gruentzig presented his results at cardiology meetings but, like Werner Forssmann, encountered skepticism and derision. Nevertheless, he bided his time, waiting for the right opportunity to present itself, a living person on whom to demonstrate his technique.
He finally got his chance on September 16, 1977, when Adolph Bachmann, a thirty-seven-year-old insurance salesman, was transferred to the University Hospital in Zurich with chest pains. A coronary angiogram revealed a short obstructive plaque in the beginning portion of the left anterior descending artery. An emergency coronary bypass operation was scheduled for the following day, but Gruentzig persuaded Bachmann, who was afraid of open-heart surgery, and his doctors to allow him to perform balloon coronary angioplasty instead. The following morning, as a dozen cardiologists, surgeons, anesthesiologists, and radiologists looked on, Gruentzig threaded one of his balloon-tipped catheters into Bachmann’s femoral artery, up his aorta, and into the opening of his LAD. Two out of Gruentzig’s three balloons burst during preparations, but the third one remained intact. Two quick balloon inflations inside the coronary artery and blood began to flow normally down the vessel. The surgeons in the audience stared in disbelief. Gruentzig had restored blood flow to heart muscle without scalpel, saw, or heart-lung machine. It seemed impossible. Gruentzig was prepared to inject the LAD with Bachmann’s own blood to wash away any dislodged plaque, but he did not have to. Bachmann’s chest pains immediately subsided. A post-procedure angiogram showed almost complete resolution of the obstruction. (Ten years later, the artery remained open.) The only complication was a transient EKG abnormality that cleared up spontaneously.
At the American Heart Association conference in Miami that year, Gruentzig presented the results of his first four coronary angioplasties. True to his iconoclastic form, he presented his data (to raucous applause) wearing sandals. Afterward, Mason Sones, teary-eyed and by then battling lung cancer, told a colleague, “It’s a dream come true.”2
After years of working in obscurity, Gruentzig quickly became one of the most famous cardiologists in the world. In 1980, three years after the first coronary angioplasty, he moved his research enterprise to Emory University in Atlanta, Georgia. Over the next five years, he helped to popularize angioplasty in the United States by performing approximately twenty-five hundred procedures. He had so much faith in his technique that he once had a cardiology fellow perform a coronary angiogram on Gruentzig himself. Gruentzig climbed onto the cath table at 5:00 p.m., underwent the procedure, and then went to pick up his wife, arriving at the department’s Christmas party by 7:00. Incidentally, his coronary arteries were normal.
Gruentzig’s procedure ushered in the field of interventional cardiology. In 1980, Marcus DeWood and colleagues used coronary angiography to show that patients suffering heart attacks have arterial clots that obstruct coronary blood flow. This discovery quickly led to the development of clot-busting drugs and the refinement of angioplasty procedures for the treatment of acute myocardial infarction. In 2001, when I began my fellowship, coronary angioplasty was already a sprawling business. One evening, wearing bloodstained scrubs, I ran into Bert Fuller, the kindly chairman at Bellevue. He was sporting his usual maroon sweater and pants that were at least a size too small. We walked together, chatting about my cath lab experiences. Outside Bellevue, it had snowed, and the sidewalk was slushy. “How little we knew,” Fuller said, shaking his head as we waited in line in front of a truck to buy a cup of coffee. “When we started, cardiac catheterization was used only for unremitting chest pains. Now it has become routine.”
Today several million angioplasties are performed worldwide every year, one million in the United States alone. In 1994, the Food and Drug Administration (FDA) approved the release of coronary stents, tiny metallic coils that are used in the clear majority of angioplasties today to keep ballooned arteries open. In the early years of the twenty-first century, stents began to be coated with chemicals that prevent scar tissue from forming. The first drug that was used was rapamycin, an antibiotic discovered in a soil mold on Easter Island that stops cell division. Nowadays, most stents used in the United States are coated with rapamycin or a similar drug, which has nearly eliminated in-stent scarring.
From a self-surgery in a tiny operating room in Eberswalde, Germany, cardiac catheterization has been transformed into a hugely profitable, multibillion-dollar industry. Unfortunately, Gruentzig never got a chance to witness this revolution. He and his second wife, a medical resident, died on October 27, 1985, when the private plane he was piloting crashed in a storm in rural Georgia. He was forty-six years old. That year was a tragic one for interventional cardiology. Smoking caught up with the field’s heroes. Mason Sones died of metastatic lung cancer; Charles Dotter, ironically, of complications of coronary bypass surgery.
9
Wires
And pale and wan, and of all strength bereft,
…
My heart, as with an earthquake, then is cleft,
Which makes my pulse leave all its life behind.
—Dante Alighieri, from Sonnet IX
The old man shuffled slowly into my clinic room. He took off his hat and collapsed into a cracking vinyl chair. I had seen him before, last about two weeks ago. He had never looked this bad.
He leaned forward, a bearded, wispy-thin gentleman in a vintage suit whose bowler and neckerchief lent him an arcane, vaudevillian air. “The shortness of breath is getting worse,” he growled in a raspy voice, not unlike Bob Dylan’s. “The medications you prescribed aren’t helping.”
Jack, as he was called, had been a beneficiary of the pioneering heart surgeries of Walt Lillehei and others in the 1950s. A diseased valve was surgically repaired when he was a child. With no heart-lung machine, the surgeon used his little finger, wedged into the wall of the right ventricle, to free up the motion of the congenitally rigid valve.
Smoke flowing in cold air (From James N. Weiss et al., “Chaos and the Transition to Ventricular Fibrillation,” Circulation 99 [1999]. Reproduced by permission)
The procedure was successful, but over the years the valve leaked, eventually causing Jack’s heart to weaken and enlarge like a worn-out balloon. Now his heart was pumping much less efficiently than normal, about 30 percent of full strength. He was getting winded after only a few steps. Several weeks prior, he’d collapsed on the stairs leading to his third-floor walk-up and had to be carried up by neighbors.
Gripping my hands like a banister, Jack hobbled onto the exam table. I put the rubber buds of the stethoscope in my ears. His waterlogged lungs crackled like Rice Krispies in milk. With my fingertips, I made tiny craters in his edematous legs. I asked him to take off his shirt so I could listen to his heart. Then I noticed it, rolled up in a yellow vest, strapped to his chest like some sort of talisman. “What is this?” I asked.
He took it off and handed it to me. “My magnet,” he replied. It was wrapped in duct tape and must have weighed three or four pounds. I waved it at a cart sitting next to my desk. My arm wavered and then jerked gently as the magnet stuck to the metal.
“It’s heavy,” I said. He nodded. “Why do you have i
t?” I asked.
Magnetic fields dilate blood vessels, he explained. (I didn’t know.) In fact, they have a host of salutary effects on the body, he told me.
He had first heard about magnets a few years back on shortwave radio; he had been using them ever since to relieve headaches, heal minor cuts, and now support his failing heart. He even wore a magnetic belt—made with tiny domino magnets that he purchased from Radio Shack—to treat an abdominal hernia, which had gotten smaller. “Could it just be the pressure of the belt?” I asked.
“A plain belt didn’t work,” he replied.
He told me that ever since he started putting the magnet on his chest, his heart failure had improved. I reminded him that when we first met in the Bellevue Emergency Room a few months earlier, he was near death, literally drowning from the congestion in his lungs. “Just imagine where I would have been without the magnet,” he said.
I had heard of magnets being used to treat chronic pain—even here the evidence was sketchy—but never to treat advanced heart failure. I wasn’t sure what to say. “You should have told me,” I said finally.
“You never asked,” he replied.
He went on to say that I had given off a negative vibe whenever the subject of alternative medicine had come up. Remember when he had asked about milk thistle and taurine? (I didn’t.) Apparently, I had been dismissive, almost scornful. He had asked me to call Gary Null, one of his “natural healers,” to review his treatment protocol, but I never did. He had even considered switching doctors because I had seemed “too dogmatic.”
Heat rose to my face. Too dogmatic? Me? I remembered the book he had lent me, The Clinician’s Handbook of Natural Healing, which lay on my coffee table, unopened. Now I wished I had looked at it, if only to show him what an open-minded doctor I was.
Heart--A History Page 13
