Author + information
- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions⁎ ()
- ↵⁎Address correspondence to:
Spencer B. King, III, MD, MACC, Saint Joseph's Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342
Fellows-in-training know a lot. They study for boards and cram in the information that they guess will be on the examination. But, do they know anything about what cardiology was before they were born, and do they care? A rather senior interventional cardiologist colleague of mine said that the interventional fellows do not even know who Andreas Gruentzig was! Even as they expertly evaluate the hemodynamic significance of ischemia-producing lesions and deftly deploy modern stents to alleviate the obstruction, they seem to assume that this is the obvious solution to the patient's problem without reflecting on how foreign this concept was throughout almost all of the history of medicine. I was recently asked to write a brief history of coronary revascularization for a European publication (1). Here are some of the “Cliff's Notes.”
The concepts of Galen regarding circulation were based on speculation in the second century, but were embraced until the renaissance when William Harvey dispelled them in the 17th century. One of the first to accurately link angina pectoris with coronary obstruction was Edward Jenner (1749 to 1823), the discoverer of a vaccination for smallpox. Sir James Mackenzie (1853 to 1925) advocated the ischemic origin of angina and its relevance to obstructed coronary arteries. So, finally, we knew the cause of angina but were far from having the most logical solution, namely coronary revascularization. Until there were tools for seeing inside the patient (thank Röntgen), and until methods to visualize the coronary (thank Forssman, Klein, Cournand, and Richards for catheterization, and finally Sones for coronary visualization), there was no way to conceive of the solution of coronary obstructions. When coronary imaging became available, some ideas sprung to light. First, Vineberg placed the bleeding internal mammary artery into a tunnel dug in the myocardium to await collaterals to form, connecting with the coronary arteries. This was rapidly replaced by direct coronary revascularization with Rene Favaloro of the Cleveland Clinic leading the way. Others had previously performed vascular surgery on the coronary arteries. Ake Senning of Zurich introduced patch grafting, and perhaps the first bypass was done by Garrett and DeBakey in 1964 for complications of coronary endarterectomy. Dudley Johnson of Milwaukee was among the most aggressive in placing multiple grafts, and George Green of New York performed direct internal mammary artery grafting to the left anterior descending coronary artery. The 1970s was the decade of extensive growth of coronary revascularization by surgery, and the conflicts then were between surgeons and enthusiastic cathing cardiologists on one side, and more conservative cardiologists on the other. The CASS (Coronary Artery Surgery Study) enrolled 780 stable patients to surgery or medical therapy. When the results were presented in Anaheim, I remember the enthusiasm of the conservative group when the overall results did not show a survival benefit with surgery. This trial, however, did show which patients benefited and they were those with the most extensive coronary disease and worst left ventricular function. Other trials, such as the VA-Cooperative Trial and the European Coronary Surgery Study, further emphasized the benefit of coronary artery bypass graft surgery for patients with more extensive disease. Throughout the 1970s, symptomatic patients in these studies and many registries were experiencing significant relief of angina, and bypass surgery flourished.
The idea of an endovascular approach to coronary revascularization developed for peripheral vascular disease. Charles Dotter of Portland, Oregon, observed improvement in claudication in patients with iliac disease after diagnostic angiography with fairly bulky catheters. This led him to use larger coaxially delivered catheters to further enlarge the lumen, and the Dotter technique was born. It was a crude method, and to some he was a controversial enthusiast, so the procedure died out in the United States. In Europe, especially Germany, the procedure had advocates including Eberhard Zeidler of Nuremberg. Zeidler's work was observed by a young physician with an interest in vascular disease and a fertile imagination. Andreas Gruentzig, realizing the Dotter technique would only open the obstructed peripheral artery to the size of the catheter, conceived of a small catheter that, when in the obstructed artery, would become big. The balloon catheter was born. In 1977, following animal experimentation and very limited work on patients undergoing bypass surgery, he performed the first coronary angioplasty. The traffic to Zurich to observe the technique grew and, in 1980, Andreas immigrated and joined our lab at Emory to teach, develop, and evaluate the technique. I have previously relayed much of that story in this page, and therefore will not repeat it here. Only to say to those who do not know who Gruentzig was, he was the father of your subspecialty. Among the many who have moved our specialty forward are John Simpson, who advocated the guidewire method for delivering the balloon catheter, and the engineers from several companies who subsequently made the cumbersome guidewire the fine instrument we have today. The most dramatic clinical presentation for coronary revascularization has been ST-segment elevation myocardial infarction. Raymond Erbel and Geoffrey Hartzler were pivotal in perfecting this method. Our main limitation of endovascular therapy was acute artery occlusion due to vascular and plaque recoil and dissection. Stenting had several advocates, but Ulrich Sigwart's work on the first coronary stent used in human arteries must be recognized. Many other dramatic contributions to our specialty are worthy of learning about.
These tools and many others that have been added are now commonplace in practice, and like the jet plane I will board tomorrow, many seem to fly effortlessly. But, for the pioneers who first conceived of the opportunity to try something that had not previously been done, the feeling was more like the Wright brothers preparing to take off. It is said that we should study history so as not to repeat it. I say there are many ideas that initially could not grow to maturity, but with improved technology, now may. In the beginning, coronary pressure gradient was the main measure of successful percutaneous transluminal coronary angioplasty (today, think fractional flow reserve). Study the history of your specialty, not to repeat it, but to improve it.
- American College of Cardiology Foundation