Author + information
- Spencer B. King III, MD, MACC∗ ()
- ↵∗Address for correspondence:
Dr. Spencer B. King III, Saint Joseph’s Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342.
Today I got a phone call. My assistant said it was from an old patient who had been meaning to call me for 37 years but had not gotten around to it. I am not actually following patients now, but in order to respond to those who want a second opinion or a referral, I always try to call them back. But what could prompt a 37-year-old follow-up call?
When I rang him up, he said that I had taken him to Miami 37 years ago today, January 25. It all began to come back. In the first week of 1980, I had travelled to Zurich with a cine film (yes, actually a 35-mm film) to show Andreas Gruentzig and to discuss whether this patient would be a good candidate for angioplasty because I had not previously done one, and in fact, did not have a balloon catheter with which to do it. The left anterior descending coronary artery (LAD) had a proximal stenosis. Andreas said that the lesion looked similar to his first patient who was 36 years-old. He asked the age of my patient. I told him, “32.” “Does he smoke?” “Yes,” I said, “for the last 14 years.” “It should work and I will get you a balloon,” said Andreas. The week we spent in Zurich was instructive as I continued to think about how each case Andreas demonstrated would inform my treatment of this first case.
When we returned to Atlanta after a holiday week in Paris, I told the patient that he was a good candidate, and because he was convinced that I had gotten “extensive training,” he would defer his plan to travel to San Francisco to have it performed by Richard Myler, who had done about 60 procedures. Encouraged by my patient’s false confidence, I needed a place to do it because we had agreed that I should not perform my first case in the Emory lab but do it under supervision of someone who had some experience. I called Jim Margolis at South Miami Hospital and told him I had a case and would like to have him scrub with me in his lab. Jim agreed, and my patient boarded a flight to Miami to be admitted to the hospital. The next morning, I flew down, packing my balloon catheter. I don’t remember too many details but the Gruentzig fixed-wire DG catheter was easily advanced into the LAD, positioned in the lesion and expanded to probably 8 to 10 atm pressure. The lesion responded with expansion of the balloon, the distal pressure measured through the pressure port of the balloon catheter rose, and after it was removed, the LAD was open with 30% to 40% residual narrowing. Success! I don’t remember being especially exhilarated but “mission accomplished,” so I boarded my flight back to Atlanta. The next morning I called Jim to inquire about the patient. “How is he?” I asked. Jim said, “He is fine. We sent him to surgery.” “What!” I exclaimed. “What did the repeat cath show?” Jim said, “We did not cath him, we just thought to be safe we would bypass the LAD and the right coronary artery.” “OMG!” My first case was now a failure. In any case, I was glad that the patient was okay. Throughout the next several years, the result, “the patient is okay,” was the important news. Often it included a stop in the operating room for an inadequate result or often as an urgent procedure because of acute vessel closure. In fact, in the first couple of years at Emory, we sent 6% of our angioplasty patients to surgery because of failed procedures. Fortunately, all that changed with the advent of stents so most of you have not shared this experience.
So it was a pleasant surprise on January 25 to hear from my patient. He told me that after his adventure he was informed that the LAD bypass graft would probably last to 8 years. However, he was free of angina for 24 years when he began to experience exertional symptoms. He then underwent 2 stent placements and another stent 2 years later and has remained asymptomatic since. I said that Andreas’s first patient was also well after very late stenting. What about the smoking? “I continued to smoke for a couple of years. Then a fat man came huffing up my driveway. I was smoking a cigarette while helping my son steady a bicycle,” he said. The fat man said, “That boy will not have a father if you keep smoking.” “That was my last cigarette.” These young men who were heavy smokers made up the majority of the 169 patients Andreas treated with angioplasty in Zurich. Many of them had discreet accessible single lesions. Following angioplasty, as Maria Schlumpf established, the vast majority stopped smoking. Their long-term outcome was very good (1,2).
Angioplasty, as we practiced it back then, was crude and unpredictable. But when it was accompanied by stopping what had produced the lesion in the first place, it was highly successful. It was great to hear from my first angioplasty patient and to learn this “initial failure” has become a long-term success.
- American College of Cardiology Foundation