Episoe 18: FIRST BALOON CATHETER CORONARY ANGIOPLASTY
Images of coronary arteries obtained with coronary angiography have revolutionized the treatment of coronary artery disease.
These led to the birth of bypass surgery, to the emergence of coronary units and to treatment through thrombolysis.
Another accidental discovery
It is quite by accident that the first dilation of the coronary arteries or coronary angioplasty was performed.
Dr. Charles Theodore Dotter
The outburst of coronary angioplasty is due to a radiologist, Dr. Charles T. Dotter. This physician had brought the concept of visualizing images of coronary arteries taken by X-rays by placing a catheter at the base of the aorta and injecting a contrasting product to observe them in a non-selective manner.
We later learned that Dr. Sones analyzed a coronary artery in isolation when his catheter was inadvertently positioned in the right coronary artery, giving rise to the first selective coronary angiography.
However, Dr. Charles Dotter, then 32, is the youngest radiologist to be appointed as the chair of radiology at the University of Oregon and the United States as a whole. Dr. Dotter, totally accidentally, completely reopened a partially occluded artery. The catheter he used to perform the angiography of the right coronary artery engaged deeply in it, thus successfully unblocking the first coronary ever.
Dr. Dotter and his resident, Dr. Melvin Judkins, developed the idea of unblocking coronary arteries with catheters.
The concept, first applied in the arteries of the legs of corpses, was to slide catheters with progressively increased dimensions in the obstructed artery until a satisfactory result was achieved.
Ms. Laura Shaw
The first patient to benefit from this new technique was Laura Shaw. Mrs. Shaw, a 82-year-old diabetic, had poor blood circulation in her legs.
Gangrene ulcerations were present and the only option was amputation, which she refused persistently. His doctor, Dr. William Krippaehne, who knew Dr. Dotter's work, referred his patient to him.
Mrs. Shaw was the first patient to benefit from the successful arterial dilatation of her legs. The blood circulation normalized immediately, and the ulcers healed.
Shaw died 3 years later of heart failure at the age of 85. She took pride in reminding her doctor that she was still able to walk on both her legs.
Dr. Andreas Gruentzig
Dr. Andreas Gruentzig, a young radiologist from Zurich, Switzerland, quite unknown, was inspired by Dr. Dotter's technique at a symposium on radiology. His ambition was to improve Dr. Dotter's technique and apply it to the coronary arteries.
Dr. Gruentzig was born in 1940 in East Germany, in the midst of the bombings of the Second World War. Orphaned because of the war, his studies freed him from poverty. He fled from East Germany at age 17 with his brother to take refuge in Heidelberg, West Germany. He graduated in medicine 7 years later; he chose radiology and practiced this specialty in Zürich.
After spending time abroad to master Dr. Dotter's method, he arranged to transfer to cardiology to be closer to his new goal and interest: coronary artery disease.
Years of work in his kitchen
For several years, in his laboratory with the help of friends and his wife, he tried to develop his idea of crushing a cholesterol plaque in a coronary artery using a balloon.
The goal was to install a balloon at the end of a catheter on the cholesterol plaque, inflate it at high pressure to crush it and, eventually, eliminate the narrowing of the artery.
First prototype failed
The first prototype is was unsuccessful in an artery of a corpse because as soon as it was beginning to blow, the balloon broke. Everything had to be started over!
Finally, a little help
His notes indicate that a retired chemist, Dr. Hopf, helped him out when he presented him with a product: polyvinyl chloride, better known by the abbreviation PVC.
Nobody wanted to invest in this project
He tried, in vain, to get help from manufacturers who could make this balloon catheter. Nobody seemed to share his vision, let alone invest money.
Perseverance while facing adversity
For 3 years, he went from failure to failure until his small group ended up developing a balloon catheter that everyone predicted that he would never make it.
Finally, it worked in dogs
His long years of work were finally rewarded. He demonstrated that coronary dilatation was possible in dogs.
But he was shunned by his colleagues
In the same year, he was invited to the 1976 American Heart Association Annual Meeting in Miami, United States. He displayed the explanations of his method with photos of coronary arteries taken with x-rays, before and after dilatation.
Most participants ignored him. Those who took the time to read and listen to his explanations were very skeptical or mentioned that it would never work in humans.
A glimmer of hope
The good news in all this is that local manufacturers accepted to produce some balloon catheters.
Dr. Richard Myler, of San Francisco and present at this congress, saw some merit. He offered to perform one of these coronary dilatations at his hospital.
In May 1977, the two doctors performed the first human coronary angioplasty on a patient under general anesthesia for coronary bypass surgery.
Dr. Myler did not have the courage to take the ultimate step, that is, to allow this dilatation in his hemodynamic laboratory. His enthusiasm was held back by the fear of possible negative repercussions.
From failure to failure, he kept his goal in mind!
Nonetheless, Dr. Gruentzig returned to Zürich more determined than ever to treat his first patient in his hemodynamic laboratory. He is more than ever motivated by his failures and uses these to persevere.
Mr Adolph Bachmann
In September 1977, Adolph Bachmann, a 37-year-old businessman who smoked 2 to 3 packs of cigarettes a day, seemed to be the perfect candidate. He had more and more intense chest pains even with the slightest efforts. A coronary angiography showed a short damage at the beginning of the coronary artery called "anterior descendant".
"Let this young man try his technique"
No victory yet! This procedure, a world first, had to be authorized by the higher authorities of the hospital center.
The meeting about the procedure was not going as planned for Dr. Gruentzig. It seemed that the decision would clearly be "no". However, just before the end of this pivotal meeting, Dr. Ake Senning, respected leader and one of the internationally recognized pioneers of cardiac surgery, spoke up: "Let this young man try his technique."
Finally! Permission was granted! But, success wasn’t automatic. Many people remained skeptical, including cardiac surgeons and anesthetists ready to intervene. The tension was palpable in the hemodynamic laboratory. The first 2 balloon catheters did not collaborate and refused to inflate.
The third attempt was the good one. The balloon did indeed crush the lesion. The coloring of the artery after 2 swellings was almost perfect. No complications, no infarction, arrhythmia or death occurred. The electrocardiogram on the monitor remained normal. All they could see was a beautiful artery allowing the passage of all the blood needed by the heart.
A world first that would change everything in the treatments of patients suffering from angina or heart attacks.
From zero to hero
Dr. Gruentzig returned to the annual conference of the American Heart Association in 1977. This time, he presented the images of the first 5 coronary dilatations in the main room. His speech was interrupted by a standing ovation at the presentation of the fifth patient.
He spent many years in his laboratory. He went through all the stages and resisted multiple opposing opinions:
- it’s impossible,
- it will never work,
Then, people started saying: I knew from the beginning that it was a great idea.
Dr. Gruentzig died prematurely in a plane crash with his second wife and their 2 dogs in October 1985. He was 45 years old.