The Heart Healers (19 page)

The origin of cardiac catheterization is the most improbable story in all of cardiology, maybe in all of medicine. It begins just before World War II in a small German hospital less than an hour’s drive northeast of Berlin in the forest town of Eberswalde (literally, “Forest of the Boars”).

In 1929 unknown twenty-four-year-old resident-in-training Dr. Werner Forssmann became obsessed with an idea. He reasoned that the concentration of drugs acting on the heart would be much higher if they were delivered directly into the heart’s chambers rather than being diluted by injection into a peripheral vein. He could push a tube from an arm vein all the way into the right atrium. No one had ever tried this, or if they had, never admitted it. Conventional wisdom held that like surgery on the heart, pushing a tube into the heart carried a great risk of inducing ventricular fibrillation and certain death. Forssmann’s support for his idea was gossamer-thin: he had read that seventy-five years earlier some Frenchman had conducted this very experiment in a horse. Nonetheless he proposed his idea to Dr. Peter Schneider, the hospital’s chief physician.

Schneider’s answer was swift, appropriate, and unequivocal.

“I cannot possibly allow you to carry out such an experiment on a patient.”

Forssmann’s response to his rejection suggested a touch of insanity. He countered that his commitment to his idea was so profound that he would accept the risk by passing a catheter on himself. Schneider, shocked by the young doctor’s absurd and grandiose response, countered with the finality of the Kaiser.

“My no is final and absolute.” Forssmann was absolutely prohibited from pursuing his crazy idea further.

Forssmann pretended to be humble, accepting his rejection. After all, he was completely boxed in because he had no catheter. He did not even have access to the necessary surgical supplies, which the hospital kept under lock and key. But he had one asset that Schneider had failed to consider. Werner Forssmann was an eligible young doctor in a sea of nubile nurses. He hatched a scheme of headstrong defiance.

“I let a few days go by and then started to prowl around Nurse Gerda Ditzen like a sweet-tooth cat around the cream jug … it was easy to find something to gossip about and she’d invite me back to her little office … So little by little I won over my essential disciple,” he said. She was indeed essential. Nurse Gerda was the keeper of the keys to the hospital’s closet of sterile supplies.

After two weeks of Forssmann’s amorous charm, Nurse Gerda Ditzen was so thoroughly smitten that she seemed bereft of all judgment. What followed is almost beyond imagination. She walked to a cabinet, unlocked it, and extracted a scalpel, a vial of local anesthetic, and a catheter designed to empty urine from the bladder. Nurse Gerda and Forssmann then strolled to an isolated empty hospital room and closed the door behind them. Nurse Gerda lay down supine and helpless before Forssmann. He had convinced her to be the first subject in his mad scheme. With Nurse Gerda willingly defenseless, Forssmann moved with the alacrity of an obsessed scientist.

“With the speed of light I strapped her down so tightly that she couldn’t reach the buckle. Then I tied down her hands. Amazingly enough she accepted my explanation that I had to take all these precautions against her falling off the table since I had no one to assist me. I had pushed the instrument table behind her head so she couldn’t see what I was doing,” he said.

Did Forssmann possess the charm of Rasputin, able to separate an apparently well-adjusted nurse from her most basic impulse of self-preservation? Having mesmerized his prey, was he actually going to proceed with an unthinkable assault on a healthy young woman? Every doctor, regardless of his native language, knows primum non nocere. First do no harm. Was Werner Forssmann really prepared to sacrifice his career, and even worse, endanger the life of an infatuated woman, possibly kill her, just for his idea? What happened next made medical history.

“In the twinkling of an eye I had anesthetized my left elbow … I quickly made an incision in my own skin … and pushed the catheter about a foot inside. I packed it with gauze and laid a sterile splint over it. Then I released Gerda’s right hand and loosened the straps around her knees.”

With the urinary catheter protruding from his arm like an emerging snake in a horror movie, he and a pale and speechless Gerda hustled past disbelieving nurses all the way to a fluoroscopic X-ray suite in the hospital basement. The X-ray technician, wanting no part of what was happening, bolted from the room. Moments later, Forssmann’s drinking buddy, Dr. Peter Romeis, awakened from an afternoon nap by the terrified X-ray technician, barreled into the room screaming at Forssmann to terminate his rendezvous with death. Forssmann, always stubborn and reckless but now deeply invested in his plot and righteous in his crusade, was adamant. He turned on the fluoroscope.

“As I’d expected the catheter had reached the head of the humerus (the tip of the shoulder). Romeis wanted me to stop at this point and remove it. But I wouldn’t hear of it. I pushed the catheter in further, almost to the two foot mark … Romeis tried to pull the catheter from my arm. I fought him off, yelling Nein, Nein, I must push it forward. I kicked his shins and pushed the catheter until … the tip had reached my heart.”

And … nothing happened. No sudden arrhythmia, no ventricular fibrillation, no collapse to the floor. The catheter just curled up and went to sleep.

Forssmann ordered, “Take a picture.” The X-ray image showed the catheter in the right atrium. The tube was too short to be advanced further.

Now Forssmann had to face Dr. Schneider. Schneider flew into Teutonic rage when he learned of Forssmann’s rank disobedience. Yet his fury abated as he stared in astonishment at the young doctor’s X-ray images. Forssmann had put a catheter in the heart and suffered no problem whatsoever. Schneider was of two minds. Did Forssmann’s act of disobedience represent a medical curiosity or an important advance? Could a tube within the heart itself be of value in treating a deathly ill patient?

Forssmann’s boss Schneider had to admit he did not know, because no one had ever been treated in this way. So he actually allowed Forssmann to catheterize a young woman dying from a botched abortion. In an era before antibiotics her condition appeared to transiently improve with intracardiac drug therapy before she died. The result was inconclusive. Schneider decided the risk of continuing the experiment exceeded the benefit. He terminated Forssmann’s studies on patients. Forssmann, his immunity to criticism so similar to the postwar American surgeons he preceded, was entirely undeterred. He puttered around further, injecting X-ray contrast dye to outline the chambers of the heart in dogs, and he continued his own self-experimentation. According to legend Forssmann only quit his research on himself when he used up all of his veins after cutting into his blood vessels seventeen times.

Forssmann published his results in Germany’s premier medical journal
Deutsche Medizinische Wochenschrift
in 1929. The medical establishment’s reaction covered the spectrum from an indifferent shoulder shrug to intense scorn. A catheter in the heart provided no conceivable value and carried huge potential risk. Forssmann’s image among his colleagues transmogrified from stubborn misfit to dangerous madman, a misfit who had disregarded the norms of his profession. His research summarily dismissed by the medical establishment, Forssmann discovered that the doors of German cardiology were firmly and irrevocably closed to the Eberswalde troublemaker. He could go no further in cardiology training.

In Berlin he found a different specialty. Forssmann had used a urologic catheter to probe the heart, and now in a bizarre twist, he entered training as a urologic surgeon. He never looked back, never returned to cardiovascular research. Forssmann had proven that right heart catheterization could be safe and could be used to create primitive images of the heart’s chambers. For the next ten years, however, the judgment of the medical establishment was outright contempt. A pigheaded fool in a small German town had provided no useful scientific insight about the heart. Forssmann had performed a dangerous parlor trick, nothing more.

As the storms of war engulfed Europe, American investigators Drs. André Cournand and Dickinson Richards at Bellevue Hospital in New York reasoned that they could marry Forssmann’s ridiculed catheterization method to their methods of recording pressure, flow, and images of the heart chambers. Richards focused on pressures and flow; Cournand made images by injecting an X-ray-dense dye, a process dubbed angiography. As war erupted, their arcane research was suddenly transformed into a medical imperative. Measurement of intracardiac pressures and cardiac output guided treatment of soldiers dying of traumatic shock. War had transformed Forssmann’s primitive technique into a practical tool.

After the war, with the birth of cardiac surgery, misdiagnosis became a plague. Clarence Dennis in Minnesota and John Gibbon in Philadelphia both failed on their very first attempt to use their heart-lung machines because their cardiologic colleagues had misdiagnosed the nature of their patient’s heart defect. Tragically in both cases the child died on the operating table. To visualize the anatomic abnormalities of a child’s heart prior to opening the chest, surgeons needed detailed images of its four heart chambers and the major vessels. In response cardiologists reached for the techniques that Cournand and Richards had used on the battlefields of Europe.

At Johns Hopkins in Baltimore, at the behest of cardiac surgeon Dr. Alfred Blalock, Dr. Richard Bing opened the nation’s first cardiac catheterization laboratory. In Boston, Dr. Lewis Dexter, working with Dwight Harken, also opened a lab. The early cardiac angiographic images, however, were desperately primitive. The heart was in constant motion, yet images could only be acquired one at a time. The surgeons needed movies, not photographs. Industry quickly responded by creating automatic film cassette changers that produced a stack of photographs in rapid succession, and trumped that the following year by recording images on movie film. The first films were recorded at a paltry two images per second. It wasn’t a movie, but it was a start. Today we manipulate digital images of the heart and its vessels in colorful three-dimensional displays. Our early images were Charlie Chaplin silent flicks compared to today’s
Star Wars
. When I entered cardiology, we spent hours debating diagnosis; today we know the diagnosis: we debate treatment.

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AND THE REST
of the Story? In 1932, three years after his Eberswalde escapade, Forssmann joined the Nazi Party. When war erupted in Eastern Europe, he joined the troops as a doctor on the Russian front. As the Wehrmacht collapsed in the snowfields of Leningrad, he fled before the onslaught, ultimately reaching the river that separated Russian and American forces. Fearing imprisonment in the notorious Russian prisoner-of-war camps, Forssmann dove into the bone-chilling water and swam to the opposite bank, to be captured trembling and humiliated by American forces. He had reached the low point in his life. Released at war’s end, Forssmann returned to the private practice of urology. In later years, he repeatedly apologized for his involvement in the Nazi party.

In 1956 Werner Forssmann, with no other important contribution to medical science in the years that followed his act of youthful duplicity in the Forest of the Boar, shared the Nobel Prize in Medicine with Cournand and Richards. Only eight years after Charles Bailey’s first mitral valve surgery, the world of medical science had completely reversed its opinion about the events on that day in the Forest of the Boar. History had decreed that the German youth who defied authority, tricked a smitten nurse to provide forbidden supplies then strapped her to a bed, and proceeded with a potentially lethal experiment on himself was right, and the rest of his world was wrong. He had, the Nobel Prize proclaimed, made a monumental contribution to science.

Some have diminished Forssmann’s glory by sniping that he is the least intellectual person ever to win the Nobel Prize in Medicine. Perhaps, but who among us would have done what he did? Werner Forssmann is certainly our boldest winner.

*   *   *

IN JUST A
decade, Dwight Harken’s challenge to conventional wisdom when he clamped a hemostat onto a shard of shrapnel on D-day had precipitated the evolution of closed heart surgery, open heart surgery, and the development of the heart-lung machine. The complications of open heart surgery led to the invention of pacemakers and defibrillators, and to the development of the catheterization laboratory. For the first time we could see the heart’s secrets during life. We could see malformed structures, analyze their effect on the heart, and see how surgery restored heart function. And yet the greatest prize remained beyond our reach. We could not see the disease that caused most cardiac death and disability, the disease that lurked in the coronary arteries. We could not see CAD until our patient was on the autopsy table. We were like jewelers trying to fix a watch wearing a blindfold. And so the proscenium was set for our emergence to today’s modern era.

PART III

THE PAST CREATES THE PRESENT

11

ONE MAN’S DISASTER IS ANOTHER MAN’S BREAKTHROUGH

Serendipity is the faculty of finding things we did not know we were looking for.

—GLAUCO ORTOLANO, BRAZILIAN-AMERICAN WRITER

TO DIAGNOSE AND
evaluate CAD, we needed to see the coronary arteries. X-ray dye injected into the heart itself outlined the chambers, but the dye was far too diluted by the time it reached its coronary arteries. Everyone knew that a catheter could not be inserted directly into a human coronary artery because it might completely obstruct the small vessel, depriving the heart of blood and causing sudden death. Even if the catheter allowed some blood to flow past, the nonoxygenated angiographic dye would fill the coronary arteries, obstruct oxygen delivery, and end in fatal ventricular fibrillation. There was no solution. Cardiologists were stumped.