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Development of Interventional Cardiology
Cardiology has a long and strong history at the Royal Adelaide Hospital. Eric Gartrell brought back the first ECG machine and started the Cardiac Clinic. The Cardiac Ward was developed in the 1950's. Right heart catheterisation began with Hugh Gilmore in 1954. He was joined by John Waddy and later Elton Goldblatt who did the paediatric work. Left heart catheterisation (using arterial cut down) was introduced by Peter Hetzel in 1959, and coronary angiography was brought to the hospital by Robert Craig in 1968.
Initially, some cardiac patients were managed by Cardiologists in ward A4 along with the Cardiothoracic Surgical patients. There was no dedicated Coronary Care Unit until 1969. I can remember looking after some myocardial infarction patients in one of the long wards, as portrayed above, until 1969. In that year, a new Intensive Care and Coronary Care Unit was established in the newly opened North Wing Ward – Q4.
Intervention is defined in the Oxford English Dictionary as "to take a course of action to change an outcome or result". Initially, Cardiologists used cardiac catheterisation to make diagnoses of anatomy and physiology, and therefore the appropriate diagnosis that was necessary for the proper surgical procedure to follow.
Rashkind Balloon Septostomy
The first procedure done by Cardiologists to change physiology and anatomy was undertaken for the transposition of the great arteries. This was first done by paediatric cardiologist Rashkind in the Philadelphia Children's Hospital in 1966.
This is a diagram of the transposition of the great arteries. In this, the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. When the patent ductus arteriosus closes, there are two completely separate parallel circulations not consistent with life. To enable mixing of the circulations, a balloon was pulled through the inter-atrial septum, thus mixing the venous and arterial blood to keep the child alive and allow growth. A more definitive operation could be undertaken later.
After this palliative procedure of atrial septostomy, and the child had grown and was stable, the definitive palliative procedure of excision of the inter-atrial septum and reconstruction using pericardium to create baffles to redirect the venous return was undertaken. Then the pulmonary venous return was directed through the tricuspid valve into the right ventricle, and pumped out through the aorta into the systemic circulation. The systemic venous return was directed through the mitral valve into the left ventricle, and pumped out through the pulmonary artery to be oxygenated in the lungs. This procedure could keep a child alive and be able to grow normally. I have known many people to survive into their fourth decade before the right ventricle starts to fail because of having to maintain a systemic load. Then they are referred for heart transplantation.
Dr Andreas Grüntzig
Coronary angioplasty is a very significant development in the management of angina, and now acute myocardial infarction.
Initially some arterial angioplasty was undertaken using stiff catheters, usually in the femoral artery for femoral occlusions. This work was done by Dotter in California. Andreas Grüntzig (pictured above) was the one who developed balloon catheters and appropriate guide wires to enable coronary balloon angioplasty. Andreas Grüntzig was an amazing man. He was born in the former East Germany, and along with his family, escaped into West Germany during the time of the Cold War. He migrated to Argentina where he undertook medical training and also training in radiology. He was very interested in angioplasty. He returned to Germany and started to work there, but met considerable resistance, so he transferred to Zurich. His initial attempts at angioplasty (not on live people) were unsuccessful because he was unable to get a balloon to a high enough pressure to crack the often very hard plaque. Initial balloons were silastic, the same sort of material as in a Foley (urinary) catheter. After collaboration with materials engineers, he changed to polyvinyl chloride (PVC) and was then able to get the pressure up to 8 – 10 atmospheres, which was enough to crack hard plaque (the usual pressure in a car tyre is 2 atmospheres). There are now balloons that are able to go up to 20 atmospheres which can be used after stenting.
Andreas did his first presentation of this technique in 1976, and his first patient in 1977. That patient, as far as I know, is still alive. He worked for a while in Zurich and was enticed to go to Emory University Hospital in Atlanta, Georgia, USA. He presided over the education and training of many people, developed the technique, and may well have been in line for a Nobel Prize, but he was killed while flying his plane in the mid-1980's.
He had come to Australia in 1983 (Melbourne) and 1984 (Sydney) to teach the local cardiologists how to select cases and perform the procedure. It looked like the procedure was going to be successful and spread and around the world. The first case in Australia was done at the Royal Melbourne Hospital in 1980, and we started performing the procedure at the Royal Adelaide Hospital in 1982.
Initially the balloons were very crude, with just a stiff wire at the end of a catheter and some side holes to measure pressure. The guiding catheter was very large (9F) and in itself caused some problems. Initial equipment for angioplasty cost in the order of $5,000 in today's money.
The procedure was done under sedation and local anaesthesia in the cardiac catheterisation laboratory, as pictured above.
Because of the equipment, the initial lesions were quite proximal. This is a good example of the sort of lesion in the left anterior descending, which had a successful balloon angioplasty in the early 1980's.
Balloon angioplasty is an uncontrolled procedure, so there was a risk of getting significant intimal tears, which can cause abrupt closures. Abrupt closures occurred in 3% - 5% of patients. We had to rush the patient back to the catheter laboratory and repeat the angioplasty, or, very occasionally, they had to go to surgery. Initially all of the patients were prepared for surgery. There was a 20% - 30% restenosis rate, which meant that the procedure had to be repeated in 3 – 6 months. A lot of devices were invented (now abandoned) to try to solve this problem. Coronary stents were introduced in 1989, initially for "bail out" of acute dissections, but they have improved enormously and now are almost routine in use in angioplasty.
Equipment improved dramatically, allowing a rapid expansion in the use of the procedures and indications, and stents are now almost routine. To prevent restenosis we now have drug eluting stents which reduces restenosis to less than 2% or 3%, which leads to a widening indication for the use of angioplasty.
There were many developments, including "over the wire" balloons, where a wire is put down to the distal part of the coronary artery, and then a balloon is slid over it. This enables a guiding track for balloon angioplasty, followed by stents, etc.
There are a number of clever devices involved, including atherectomy catheters, to carve out the atheromatous plaque which led to larger lumens, and a phase of laser catheters (now abandoned).
The introduction of stents has enabled the procedure to be much safer and more robust. On the top of the slide below you can see the thrombus in a dissected artery; and below, a cross-section of a stent, which shows how the artery is propped open giving a wide lumen.
As more was done, more problems were encountered. This one patient came having had multiple stents put into his right coronary following an acute dissection. He had a long narrowing. We were able to get the result below by passing a wire down, then a rotoblator catheter (like a small dental drill) was used to drill out the core, and then we gave 18 gray of intra-luminal radiotherapy to stop restenosis. These techniques are not frequently used, but they are available.