The Heart Healers (35 page)
Authors: James Forrester
The screaming crash of the Beechcraft Baron in a rural Georgia field shook the world of cardiology to its roots. Our generation’s supernova had been suddenly extinguished. But Andreas left a legacy. He had worked with the National Heart, Lung, and Blood Institute to establish a multicenter registry of treated patients whose response to angioplasty could be followed over time. The results of the registry suggested that angioplasty was comparable to surgery for relief of angina. We estimate that today, about 600,000 angioplasty procedures are performed each year in the United States.
Today we have no hard-and-fast rule for choosing bypass surgery or angioplasty for relief of stable angina that is not controlled by nitroglycerin. My thinking for an individual patient is based largely on the severity of disease we see on the angiogram. If all the vessels have CAD, or if there is significant heart failure, I may favor surgery. For the rest, I often favor angioplasty because the recovery period is so much shorter.
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ANDREAS GRUENTZIG’S STORY
has a bizarre epilogue. In September of 1985 Andreas put on his last teaching course at Emory. He gave special tribute to the three great “fathers” of interventional cardiology: Charles Dotter, Mason Sones, and Melvin Judkins. He pondered the strange irony that the three great pioneers had all passed away within months of each other that year. Andreas was to join them in just a few weeks. Andreas’s early tragic death levitated him from the king of angioplasty to cardiologic sainthood. He was just forty-six-years old and yet was already, and remains, the most memorable cardiologist of our times.
Andreas Gruentzig had persisted through years of isolated frustration in his kitchen by using failure as fuel, advancing rather than retreating from errors. Years later a series of Apple advertisements reminded me of Andreas. A large photo of one of the century’s brilliant innovators—Albert Einstein, Bob Dylan, Martin Luther King, John Lennon, Muhammad Ali, Mahatma Gandhi, or Pablo Picasso—was shown with a small Apple logo beneath and just two words: Think Different. The ad was brilliant in its simplicity. I thought if a cardiologist had been selected, Andreas would be the first, glancing up from a glass of red wine at his Zürich kitchen table. Andreas Thought Different.
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ANDREAS GRUENTZIG HAD
proven that it was possible to crush an obstruction in the coronary artery that caused angina and heart attacks, restoring the coronary angiographic image to normal. But as groundbreaking as his idea was, an even grander idea lay inherent in his breakthrough: heart disease does not require the doctor to crack open the chest, touch the offending organ under direct vision. We can treat congenital heart disease, valvular disease, and electrical disorders of the heart with devices inserted through the skin. As he basked in deserved glory, however, Andreas Gruentzig’s ideas were about to be challenged by the most unlikely of any of the characters in our story.
Every really new idea looks crazy at first.
—ALFRED NORTH WHITEHEAD
ENGLISH MATHEMATICIAN AND PHILOSOPHER
We know that the nature of genius is to provide idiots with ideas twenty years later.
—LOUIS ARAGON, FRENCH POET AND NOVELIST
DR. GEOFF HARTZLER
was a quintessential American Midwesterner who dressed like he was the bass guitarist for redneck country singer Johnny Cash. The son of a Mennonite minister, in his rebellious youth Geoffrey Hartzler was consumed by rock ’n’ roll and his bass guitar. His talented high school and college bands had blasted music throughout his home state of Indiana. When I met him as a cardiologist, his big smile framed by his droopy mustache and his cowboy boots suggested he was more ready to perform the Texas two-step than balloon angioplasty. Not that Geoff cared a whit about what I, or anyone else, felt about a doctor who dressed like a cowboy. Geoff’s whole persona said maverick.
Hartzler had first encountered Andreas Gruentzig in Miami at his poster presentation on balloon angioplasty in dogs in 1976. After Gruentzig’s dramatic human results in 1977, the Mayo Clinic catheterization laboratory team planned to test his method in the leg vessels of 100 patients before attempting the procedure in the coronary arteries. Hartzler, a younger member of the group, ignored the plan, performing angioplasty on a lesion similar to Bachmann’s. His aggressive nature did not mesh well with the conservative philosophy of his colleagues, and he soon moved on to St. Luke’s Hospital in Kansas City, Missouri, where he quickly became one of the country’s leading practitioners of coronary angioplasty by performing fifty-five procedures in his first six months.
Geoff shared with Lillehei and Bailey that complete indifference to criticism from others that would have devastated most of us. If he did not fit society’s norms, he did not care. The certainty in the righteousness of his cause spurred Geoff to pursue treatment options that his colleagues scorned. That perspective was essential because his decision to perform angioplasty on multiple atheromas in the same patient brought him into direct and heated conflict with Gruentzig, who feared Hartzler’s complication rate would soar, besmirching the reputation of the method he had pioneered. In an intriguing reversal, iconoclastic Gruentzig assumed the role of conservative establishmentarian in his ballet with Hartzler, the rogue dissenter.
Fearing early adverse outcomes could kill his baby while still in the manger, Gruentzig insisted that angioplasty should be restricted to one simple lesion like that of Adolph Bachmann, in which the probability of success was high. With tongue-in-cheek logic, Hartzler replied that after he had successfully dilated one lesion, if he saw another he did that one, too, since he was only treating one lesion. Hartzler’s insouciance outraged Gruentzig. He countered Hartzler’s cavalier attitude by refusing to be in the same room with him. Most of us sided with the charismatic German who urged us to build our wall carefully, brick by brick. True, the mustachioed Midwesterner’s magical skills in catheter manipulation matched his dexterity with the guitar, but still he was a cowboy, a guy playing it too fast and loose. So that’s what we called him, Cowboy Geoff.
Hartzler went completely off the reservation in 1980. Like so many of cardiology’s breakthroughs, it happened because of a wildly fortuitous convergence of person, place, circumstance, and time. Geoff had a stable angina patient in the hospital scheduled for angioplasty, when the laboratory called to say that the procedure had to be canceled because the man was having an acute myocardial infarction (a heart attack).
“That didn’t seem logical to me. It seemed that an hour before he was a candidate for angioplasty,” Geoff said. At that moment, what seemed illogical to everyone else made sense to Geoff. Like Walt Lillehei years earlier, conviction in the rightness of his cause was the only impetus he needed. Geoff Hartzler jumped into the abyss with both boots:
We brought him down to the lab. The right coronary was blocked … we put a catheter in. It went through this occluded vessel right where the stenosis had been shown the day before. I expanded the balloon and it was the most amazing thing I had seen. The ST segments came down to normal (the electrocardiographic signs of heart attack disappeared), the pain went away totally, and he was normal … We had opened this totally blocked artery. It was unheard of at that time. It was amazing. It was fantastic. It changed my thinking.
On that day, Cowboy Geoff revolutionized the treatment of heart attack. He had opened a blood vessel that was obstructed with a blood clot, not with a drug but with a balloon catheter.
The patient was discharged home in a few days, rather than the usual two-week stay. From that moment on, Geoff began using angioplasty as his therapy for acute myocardial infarction. We already had the highly effective clot-dissolving therapy for myocardial infarction, but that made no difference to Geoff. Conventional wisdom, and Andreas Gruentzig, held that putting a balloon catheter into the coronary artery of a patient dying from acute myocardial infarction was unacceptable, even crazy, yet Hartzler was doing it anyway.
Soon after he began his angioplasty program in acute myocardial infarction, Geoff invited me to be a visiting professor in Kansas City, making hospital rounds and lecturing. In a packed auditorium, Geoff presented a case of a patient with shock accompanying acute myocardial infarction, and asked me to discuss patient management. After I discussed the patient’s very poor prognosis based on his ECG, chest X-ray, and hemodynamics, Geoff asked me how I would treat the patient.
In medicine our opinions are slaves to our prior experience. Hailing from the home of thrombolytic therapy, I pontificated over the use of intravenous streptokinase to dissolve the clot, while warning the prognosis for such patients in shock was very poor. Geoff countered by showing a film of his dramatic opening of the obstructed culprit vessel by coronary angioplasty. In case anyone doubted what he had done, Geoff topped off his visual tour de force by adding that the patient had walked out of the hospital in good shape a week later.
Even though I had been played as Stump the Chump, I refused to concede to my younger colleague. “That’s terrific, Geoff,” I said. “But here in the USA, we say ‘In God We Trust, all others must have data.’ I have data, and all you have is a case.” Geoff heard my admonition and by 1983, he published his data on angioplasty in forty-one heart attack patients who were treated within an hour of hospitalization. Only one patient, who arrived in shock, died. The paper concluded, “All remaining patients had prompt pain relief, subsequent stable clinical courses, and no clinical or late angiographic evidence of coronary reocclusion … At follow-up, 94% of patients remained free of angina.”
Although Geoff’s results proved both the feasibility and safety of angioplasty during a heart attack, I, along with other thought leaders, insisted on randomized trials to determine if it was really a better therapy than thrombolysis, as he claimed. Three years later, a slew of trials established that angioplasty outcomes indeed were superior to thrombolytic therapy, provided the procedure is performed within less than two hours from emergency room arrival. And with that, the stampede to angioplasty as a treatment of heart attack began.
So despite his laid-back persona, his droopy mustache, and high-heeled boots, the Cowboy was right. Twice right. He was correct when he argued with Gruentzig about multivessel angioplasty and right again on that day in Kansas City when he argued with me about angioplasty in acute myocardial infarction.
Over the years that followed, whenever Geoff and I met, he loved to needle me, saying: “Hey, Jim, tell me again about data and “In God We Trust.” My lame repartee to my young friend also was always the same: “Aw, Geoff, medicine is a discipline in which the fool of this generation can go beyond the point reached by the genius of the last.”
Today, immediate angioplasty is the preferred treatment of acute myocardial infarction. This approach has reduced the in-hospital mortality rate to about 5%. That’s a fall from 30% since my encounter with Willie the Phillie. It’s tempting to put that spectacular reduction alongside similar jaw-dropping reductions in mortality from congenital heart disease and valve disease and rest on our laurels. And yet, when I come to talk about the future, you will soon see that another wave of spectacular advances is on the near horizon.
Like Andreas Gruentzig, Geoff Hartzler was an interventional cardiology meteor. At age forty-nine, just fifteen years after he first flashed across angioplasty’s sky, he stepped away from the catheterization laboratory table. His years of wearing heavy lead shielding had compressed his vertebrae, leading to five back surgeries. In retirement he built himself a professional music studio in Kansas City where he played his bass guitar in a band called, what else, Heart Rock. Geoff died prematurely of prostate cancer in early 2012.
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AND SO WE
return to my friend Aaron Stein, whom we met in the last chapter, as his angina was being relieved by balloon angioplasty. After a year or so his angina came back. His cardiologist decided to perform an office treadmill exercise stress test to assess the severity of his CAD. But the doctor made a serious mistake. A few minutes delayed in getting to the office, he told his stress lab technician to begin the test. The doctor did not examine Aaron’s resting ECG before the test, and his technician missed an obvious, admittedly unusual finding. Although Aaron did not mention chest pain, his ECG showed unequivocal evidence of a beginning acute myocardial infarction.
A few minutes into the treadmill exercise, Aaron began to complain of severe substernal chest pain and light-headedness. The technician immediately terminated the test, and instructed Aaron to lie down. When the doctor arrived just a few minutes later, Aaron’s pain had not relented with either rest or nitroglycerin. His ECG screamed the reason: heart attack. But this was a special kind: heart attack with a lawsuit waiting to happen.
Getting to a hospital quickly is the single most important factor in surviving a heart attack. Data from Sweden’s national medical data base, collected over fifteen years, showed that 29% of 385,000 heart attack patients died before reaching a hospital. In comparison, the mortality rate among those who made it to the hospital was less than 10%. Today the vast majority of heart attack deaths, about 90%, occur outside the hospital. The message is clear: for a person with a heart attack, the care we are now able to provide in a hospital is lifesaving.
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ABOUT AN HOUR
and a half later, Aaron had been whisked by ambulance from his doctor’s office, through our emergency room, and into our catheterization laboratory. Our mantra for treating heart attack is, “Time is muscle,” three words that conveyed the message that in the first few hours after onset, the size of the segment of dead heart muscle expands like the ripples from a stone tossed into a quiet lake. In the first few hours, if the occluded coronary artery is opened, cell death stops. So every minute counts. This is the single most important message I can give you readers who have CAD. If you have substantial chest pain that persists after nitroglycerin, go immediately to the emergency room. Angina disappears very quickly. Heart attack pain does not. There are three compelling reasons to move swiftly. The greatest mortality from heart attack is in the first hour after onset, and occurs outside the hospital. You’ll survive if you get to the hospital. Second, the amount of permanent heart muscle damage is markedly reduced by early opening of the coronary artery. Third, our diagnostic skills are now outstanding: if you are not having a heart attack, we will be able to tell you.