The Heart Healers (53 page)

18. A Balloon in Zürich

The life and times of Charles Dotter, the pioneer of interventional radiology.
Payne MM. Charles Theodore Dotter: The father of intervention.
Tex Heart Inst J.
2001;28(1):28–38.

Andreas Gruentzig recalls the development of his original coronary angioplasty device.
Gruentzig’s notes were published by his friend and professional colleague Spencer King. In the years after Gruentzig’s recruitment to Atlanta, King became a world leader in interventional cardiology. King SB. Angioplasty from bench to bedside to bench.
Circulation.
1996;93:1621–1629.

Andreas Gruentzig’s breakthrough human coronary angioplasty procedure in Zürich.
Adolph Bachmann’s name is recognized by every interventional cardiologist in the world. So I have not given him a pseudonym nor altered any details of his history.

Origin of “grabbing the brass ring.”
Years ago there were thousands of merry-go-rounds in the United States; only hundreds remain. A few of these are “brass ring” carousels. Riders can reach up once a rotation to grab a ring above them. The rider who grasps a brass ring gets a free ride.

The drama of the first successful angioplasty recalled by its participants.
Doctor Bernhard Meier, who assisted Gruentzig, and the patient Adolph Bachmann discuss the event in a two-minute video clip at
www.ptca.org/videos.html
.

A view of Gruentzig written by his boss.
Hurst JW. Andreas Roland Gruentzig, M.D.: The teaching genius.
Clin Cardiol.
January 1986;9(1):35–37. Hurst, author of the era’s principal textbook in cardiology, was chief of cardiology at Emory University.

A view of Gruentzig by his biographers David Monagan and David Williams
. Monagan D, Williams DO.
Journey into the Heart: A Tale of Pioneering Doctors and Their Race to Transform Cardiovascular Medicine.
New York: Gotham Books; 2007. Williams is an internationally acclaimed interventional cardiologist now practicing at Harvard’s Brigham and Women’s Hospital after many years on the staff of Brown University.

19. Conquering Atlanta

“
Goyishe kopf.
”
In my years at Cedars Medical Center, I have learned a lot of Yiddish words.
Goyishe kopf,
is a humorous term for “dumb non-Jew,” of which I am one.

Aaron Stein’s doctor.
I chose not to use Aaron’s doctor’s real name because of the circumstances preceding my referral of Aaron to his care.

Gruentzig considers leaving Atlanta
. In
Journey into the Heart,
Gruentzig’s biographers David D. Monagan and David O. Williams suggest that he considered leaving Atlanta to move to California. I can confirm this speculation, based on conversation with those who discussed the option with him.

The crash of the Beechcraft Bonanza.
The most comprehensive description of the last minutes of Gruentzig’s flight that I have seen appears in the book by Monagan and Williams referenced in the previous note. Although the cause of the crash was not definitively established, a reasonable speculation is that Gruentzig became confused about his true direction. Confronted with a disparity between his own instincts and information from his instruments in an atmosphere in which he could see neither the ground nor the horizon, he incorrectly believed he had an instrument malfunction.

Gruentzig discusses his approach to patient care.
An interview of Gruentzig made a month before his death appears at
www.ptca.org/archive/bios/gruentzig.html
.

20. Pricking Andreas’s Balloon

ST segment elevation prior to an exercise stress test.
After our Myocardial Infarction Research Unit segued into the NIH-sponsored Specialized Centers of Research (SCOR), for many years my clinical job was to direct the cardiac stress laboratory. Having conducted many hundreds of stress lab tests, I never allow a test to begin without prior evaluation, and am present throughout the test. None of my patients had a heart attack or cardiac arrest.

The changing mortality rate from CAD in the modern era.
Dudas K, Lappas G, Stewart S, Rosengren A. Trends in out-of-hospital deaths due to coronary heart disease in Sweden (1991 to 2006).
Circulation.
January 4, 2011;123(1):46–52.

Geoffrey Hartzler’s colorful life within and outside cardiology
. Hartzler’s career is engagingly portrayed in Kahn JK. Profiles in cardiology: Geoffrey O. Hartzler.
Clin Cardiol.
2004;27:58–59. A section edited by Drs. J. Willis Hurst and W. Bruce Fye.

Time to treatment is crucial in acute myocardial infarction.
Rathore SS, Curtis JP, Chen J, Wang Y, Nallamothu BK, Epstein AJ, Krumholz HM; National Cardiovascular Data Registry. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: National cohort study.
BMJ.
May 19, 2009;338:b1807.

Why restenosis occurs following angioplasty.
Forrester JS, Fishbein M, Helfant R, Fagin J. A paradigm for restenosis based on cell biology: Clues for the development of new preventive therapies.
J Am Coll Cardiol.
1991;17:758–769.

The origin of stents.
Roguin, A. Stent: The man and word behind the coronary metal prosthesis.
Circ Cardiovasc Interv.
2011;4:206–209.

21: Why Do Atheromas Form in Blood Vessels?

The limitations of bypass surgery.
Preston TA. Marketing an operation: Coronary artery bypass surgery.
J Holistic Med.
1985;7(1):8–15.

When bypass surgery clearly saves lives.
To be cardiologically correct, revascularization by PCI or CABG clearly reduces mortality in acute coronary syndromes (unstable angina and acute myocardial infarction) and probably does so in two specific coronary anatomic conditions, left main coronary artery stenosis and selected patients with disease in all three coronary arteries.

The familial component of risk for CAD.
Ranthe MF.
J Am Coll Cardiol.
2012;60(9):814–821.

Separating diet from genetics in CAD risk.
Yano K, Reed DM, McGee DL. 1984. Ten-year incidence of coronary heart disease in the Honolulu Heart Program: Relationship to biologic and lifestyle characteristics.
Am J Epidemiol.
1984;119(5):653–666.

The half-century confrontation over the role of cholesterol.
San Diego lipidologist Dr. Daniel Steinberg, one of the leading combatants, recounts the fascinating battle in his book: Steinberg D.
The Cholesterol Wars: The Cholesterol Skeptics vs the Preponderance of Evidence.
New York: Academic Press/Elsevier, Inc.; 2007.

22. Plaque Rupture, Heart Attack, and Sudden Death

The life and influence of Russell Ross.
An affectionate portrait of Ross is provided by his biographer and fellow dentist Dr. Henry Slavkin in: Slavkin HC. Atherosclerosis, Russell Ross and the passion of science.
J Am Dent Assoc.
August 1999; 130(8):1219–1222. An excellent account of the impact of his iconoclastic thinking in cardiology is given by a leader in atherosclerosis research in the next generation, Dr. Peter Libby of Harvard in: Libby P. Russell Ross, PhD. Visionary basic scientist in cardiovascular medicine.
Nature Medicine.
1999;5:475.

Ross sends atherosclerosis research in a new direction.
Ross R, Glomset JA.

Atherosclerosis and the arterial smooth muscle cell: Proliferation of smooth muscle is a key event in the genesis of the lesions of atherosclerosis.
Science.
1973;180(4093):1332–1339.

The discovery of ruptured plaque in unstable angina.
In the mid-1980s my team developed a new technique, which used flexible fiberoptics to provide images of the surface of coronary arteries in the catheterization laboratory. We discovered that patients with unstable angina “always” had a damaged blood vessel surface with a small nonocclusive clot. The report appeared in: Forrester JS, Litvack F, Grundfest W, Hickey A. A perspective of coronary disease seen through the arteries of living man.
Circulation.
March 1987;75(3):505–513.

The modern understanding of plaque rupture.
One of cardiology’s hottest topics in the 1990s was the mechanisms responsible for plaque rupture. Forrester JS. Role of plaque rupture in acute coronary syndromes.
Am J Cardiol.
October 19, 2000;86(8B):15J–23J. Falk E, Shah PK, Fuster V. Coronary plaque disruption
. Circulation.
August 1, 1995;92(3):657–671.

23. A Moldy Gift

The scientific and corporate issues in the evolution of statins.
Jie JL.
Triumph of the Heart: The Story of Statins
. New York: Oxford University Press; 2009.

Akira Endo’s recollection of his discovery of statins.
Endo A. The origin of the statins.
Atheroscler Suppl
. October 2004;5(3):125–130.

The cost effectiveness of widespread use of statins in prevention of CAD.
Grabowski DC, Lakdawalla DN, Goldman DP, Eber M, Liu LZ, Abdelgawad T, Kuznik A, Chernew ME, Philipson T. The large social value resulting from use of statins warrants steps to improve adherence and broaden treatment.
Health Aff.
October 2012;31(10):2276–2285.

An objective analysis of the components of diet in promoting or inhibiting the development of CAD.
Hu FB, Willett WC. Optimal diets for prevention of coronary heart disease.
JAMA.
November 27, 2002;288(20):2569–2578.

The Mediterranean diet vs. the low fat diet.
The trial, called the PREDIMED trial, has an appendix with 14 points by which you can rate your own diet. It seems to me to be extremely difficult to score 14, but it may be possible to raise your score by several points. Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet.
N Engl J Med.
2013; at
www.nejm.org
.

24. Yosemite

The chest thump.
Tragically, there is also a tiny millisecond “vulnerable window” in the cardiac cycle during which a thump on the chest can induce an electric shock that induces ventricular fibrillation. The condition is called commotio cordis, the cause of the rare sudden death in young athletes struck by a baseball, or a chest blow in martial arts (for a tragic video example see
www.youtube.com/watch?v=LLtzT2bXVGI
).

Electrical energy delivered over time.
Although some of us understand volts and amps, few of us recognize joules. A joule is a measure of electrical energy over time: 1 volt × 1 amp for 1 second = 1 joule.

The duration of successful and failed CPR.
Goldberger ZD, Chan PS, Berg RA, et al. American Heart Association Get With The Guidelines-Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: An observational study.
Lancet.
October 27, 2012;380(9852):1473–1481. In children, CPR longer than twenty minutes is not necessarily futile: Matos RI, Watson RS, Nadkarni VM, et al. Duration of CPR and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests.
Circulation.
2013;127(4):442–451.

Factors influencing when to terminate resuscitation.
The issues in termination of CPR are discussed in: Nolan JP, Soar J. Duration of in-hospital resuscitation: When to call time?
Lancet.
2012; 380(9852):1451–1453.

Probability of successful CPR when it occurs in the hospital.
An analysis of 64,000 in-hospital cardiac arrests in 435 U.S. hospitals between 2000 to 2008 found that in about half (31,000) of the patients CPR resulted in return of the patient’s spontaneous circulation. Only 10,000, however, survived to discharge. For the patients whose independent circulation was restored, the average duration of the CPR was twelve minutes, whereas for nonsurvivors, the average CPR lasted twenty minutes.