Thirty years of interventional cardiology

The first introduction of a catheter to the human heart was performed by Dr. Werner Forsmann in Eberswalde (Germany) in 1929. Dr. Forsmann introduced a catheter to his own heart following a therapeutic idea, that this method would allow intracardiac administration of medications [1]. The world‘s first diagnostic cardiac catheterisation in patients (n = 11) was successfully performed by Dr. Otto Klein in the University Hospital Prague (Czechoslovakia) in 1930 [2].

It took 26 additional years before this diagnostic method became widely recognised thanks to Andre Cournand, who was awarded (along with W. Forsmann and C. Richards) the Nobel Prize in 1956 [3].

The original (Forsmann’s) idea of therapeutic cardiac catheterisation was re-vitalised 48 years later, in 1977, by Dr. Andreas Grüntzig - a young (born in Dresden, June 25, 1939) German physician, working in the Kantonspital Zürich, Switzerland. He modified the angioplasty balloon first developed by W. Portmann in 1973 for peripheral arteries [4]. Andreas Grüntzig (fig. 1) recognised the potential of the balloon catheter and developed the double lumen ("over-the-wire“) angioplasty balloon. He tested this balloon in animal experiments and first applied it to a patient with proximal left anterior descending coronary artery stenosis on September 16, 1977 [5, 6]. This procedure was so successful, that this first angioplasty patient outlived his doctor: while Andreas Grüntzig died with his wife in a private plane crash (in Forsyth, Georgia, October 27, 1985), his first patient remained asymptomatic and was talking about his experience 20 years later – at a special symposium held in 1997 in Zürich celebrating the 20th anniversary of the first angioplasty.

During the initial cca 5 years (1977-82) percutaneous transluminal coronary angioplasty (PTCA, name given to this method by A. Grüntzig) had technical success rates of 50-60% (and this was when only proximal type "A" lesions in stable patients were approached). Simultaneously, complication rates were initially high: mortality 1-2%, non-fatal MI 5%, emergency CABG 6%. These results substantially improved during the subsequent years despite the fact that more complex lesions and more severely ill patients were being treated (table 1).

The two main limitations of “plain old balloon angioplasty“ were restenosis after balloon dilatation (angiographically present in 30-50%) and abrupt vessel closure due to major dissection or thrombus (5-10%). Both these problems have been approached by several methods, but only one of them gained large clinical recognition: coronary stents. The first stent in humans was implanted by Ulrich Sigwart and co-workers [7]. This was a self-expandable "Wallstent", later abandoned due to a high rate of stent thrombosis or restenosis. Instead, balloon-expandable stents have gained wide acceptance in the subsequent years. However, it took almost 10 years before stents could be used for the vast majority of patients treated by angioplasty. The reason was high incidence of acute / subacute stent thrombosis (8%) and of severe bleeding complications (5-10%) with the old antithrombotic regimen (heparin + aspirin + dipyridamol + warfarin + dextran) used before 1994. It was the introduction of high pressure inflation (" stent oversizing" under the guidance of intravascular ultrasound) and of thienopyridines (ticlopidin or later clopidogrel replaced warfarin + dipyridamol + dextran), that changed coronary stents into a  current routine and safe device [8, 9]. The procedure is now called percutaneous coronary intervention (PCI).

Highly flexible, balloon-expandable coronary stents combined with effective and safe antithrombotic therapy made possible the true “invasion” of interventional cardiology to the area, originally considered as contraindication: for the treatment of acute myocardial infarction. After initial attempts with intracoronary thrombolysis [10], angioplasty was proved to be the most effective strategy for ST elevation acute myocardial infarction [11].

While the original indication for PCI (chronic stable angina pectoris) remains even after 30 years only symptomatic indication (PCI was never shown to improve prognosis of these patients – last evidence provided by the COURAGE trial – ref. 12), the original contraindication of PCI (acute coronary syndromes, especially acute myocardial infarction) became today the main indication for PCI (and is a prognostic indication).

Thus, a 30 year-old subspeciality, interventional cardiology is one of the key parts of modern cardiology, saving the many lives of patients with acute myocardial infarction or unstable angina pectoris and improving the quality of life of patients with chronic stable angina pectoris. PTCA / PCI history is a European success story: most of the pioneer work cited above was done in Europe by European cardiologists.

The improving cooperation between the European Society of Cardiology – European Association of PCI (EAPCI, represented by William Wijns) - largest educational meeting in the field (EuroPCR, Jean Marco) - the new journal (EuroIntervention, Patrick Serruys) opens great opportunities for the near future.

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Note: It was the intention of the author not to discuss here the latest achievement in the field – drug eluting stents. It is too early to place this promising and still evolving tool in the history of our subspecialty. Only the future will tell.

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Table 1: Angioplasty indications and success rates evolution over 30 years.

Table 2: Major contributions of European cardiologists to the development of interventional cardiology.

Fig. 1: Dr. Andreas Grüntzig
 

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.