The Heart Healers (33 page)

His transfer was hardly like being let out of jail. As in radiology, his boss soon told him that his pursuit of his passion would be strictly on his own time, after work hours. So with his loyal assistant Maria Schumpf, her husband, and his wife, Michaela, Andreas set to work at night in his kitchen. Six months became a year. Imagine trying to keep three normal people interested in the task of putting a balloon on the end of a catheter. Night after night Gruentzig mixed boundless enthusiasm with bottles of wine to cajole the little group to play his game of catheters. He and his friends began by affixing small cylinders of latex or rubber to the end of a catheter with thread and epoxy glue. When the little group finally mastered a method for attaching a balloon to a catheter, Gruentzig tested their prototype in cadaver vessels. His balloons burst.

Gruentzig’s friend and colleague Dr. Spencer King published Gruentzig’s notes describing what happened next: “I spent the next two years contacting manufacturing plants in an attempt to solve this problem. It was at that time that I met a retired chemist, Dr. Hopf, a professor emeritus of chemistry of the junior high school of Zürich. He introduced me to polyvinyl chloride (PVC) compounds.… After hundreds of experiments, most of which were performed in my own kitchen, I was able to form a sausage-shaped distensible segment.” What Gruentzig had needed from the start was a bladder, which could withstand great internal pressure, like an auto tire or an inflatable toy. Now he had a distensible PVC bladder, which looked like a miniature football, one that could retain its shape at high pressure without bursting. At the same time it could deliver tremendous force to the vessel wall.

But now a new problem emerged. To negotiate the catheter through the tortuous vessels of the heart, it needed to be passed over a previously placed guidewire. Gruentzig would need two lumens (channels), one for the wire, and a second to deliver air to inflate his balloon. He had no way to construct a double-lumen catheter, and he could find no catheter company that saw any reward from the cost of designing and fabricating such an unproven, untested device.

Working in complete obscurity, Andreas Gruentzig had now spent three years of his life moving from failure to failure. On the brink of defeat, a young friend came up with an ingenious solution. He created a longitudinal groove on the length of catheter’s outer surface, then covered it with a long thin tubing. Voilà, a second lumen to deliver air to inflate the balloon.

He had finally succeeded in constructing a homemade, cockamamie balloon catheter that everyone agreed would never work. But at least he could try his contraption in the coronary arteries of dogs. It worked! Now, armed with X-ray images as proof, he was finally able to convince a local manufacturer to construct a real double-lumen catheter. Elated, Andreas packed his before-and-after images of obstructed coronary arteries in dogs, and headed to the 1976 annual American Heart Association meeting in Miami in the United States. He imagined that he would astound the world of cardiology with the results of his animal research through his poster presentation. Many thousands of cardiologists walked past his poster. Most ignored the enthusiastic bubbling German completely. The ones who stopped were courteously deeply skeptical. His presentation was just a goofy curiosity by a home hobbyist. His technique was irrelevant to humans. World-renowned catheterization specialist Dr. Spencer King told me that when he saw it, he walked away, telling a colleague, “It’ll never work.”

At the meeting, however, one cardiologist saw merit in Gruentzig’s enthusiasm. San Francisco cardiologist Dr. Richard Myler invited him to come to St. Mary’s Hospital in San Francisco to perform the procedure on a patient. Gruentzig and Myler performed the first successful human coronary angioplasty under anesthesia during coronary bypass surgery in May 1977. Although now convinced it would work, Myler lived in a different era than Dwight Harken. He realized that he could not risk his career by using it in the cath lab, cognizant of the condemnation from colleagues and the massive California lawsuit that would follow any complication. Years later Dick Myler described the episode to me as his most bittersweet experience: exhilaration with their technical success, belief that he had a breakthrough technology at his fingertips, yet frustrated by insurmountable barriers to its implementation.

Dusting himself off after being ignored in Miami and stymied in San Francisco, Gruentzig returned to Zürich determined to treat a patient in his laboratory. He struggled for months to find a suitable patient, one in whom he had a high probability of success. He wanted to dilate just one atheroma in a large coronary artery. After months of searching he found his potential candidate in mid-September 1977. Adolph Bachmann was a thirty-seven-year-old Swiss businessman with severe typical angina. A two-to-three-pack-a-day smoker, his angina had progressed to the point that he required up to twenty-five nitroglycerin tablets daily. “I ultimately couldn’t do anything. With the slightest exertion came pain,” Bachmann told later historians. Coronary angiography showed he had a severe stenosis in his left anterior descending coronary artery. He needed surgery. The vessel was large; it would easily accommodate the untried balloon catheter. Bernhard Meier, the resident at the time, notified Gruentzig.

Gruentzig went to see Bachmann. His personal charm, sincerity, and honesty carried the day. As Bachmann recalled, “Gruentzig wasn’t at all overbearing … He made it clear that I would be the first man ever to receive this pioneering procedure … The severe choice between the scheduled bypass operation and the alternative dilatation probe left little doubt in my mind as to which path was preferable … I said ‘What’s the big deal? The difference can’t be so great.’” When Gruentzig scheduled the procedure for the next day in the catheterization lab, however, he ignited a conflagration similar to that faced by surgeon Walt Lillehei a quarter of a century earlier. In a hastily called conference with his hospital leadership, both the hospital’s chief of medicine and chief of cardiology were vehemently opposed to the procedure. Gruentzig watched his dream evaporate as the sacred Hippocratic Oath was added to practical arguments like unknown risk and negative public backlash. As the meeting neared closure, the hospital’s most respected leader, internationally famed pioneering surgeon Dr. Ake Senning, rose to speak.

“Let the young man try it,” Senning said.

When no one deigned to challenge Senning, Gruentzig, against all odds, had carried the day.

At 7 a.m. the following morning Adolph Bachmann, conscious but sedated, was wheeled into the cardiac cath lab. With a dozen doctors watching, the laboratory crackled with tension. “Only those who dare to fail greatly can ever achieve greatly,” Bobby Kennedy had said a decade earlier. This was Andreas Gruentzig’s moment. But he encountered difficulty from the start. Before inserting the catheter, he tested his balloon. It would not inflate. Frustrated, he discarded the defective catheter. He tore open a new sterile package for a second backup catheter. It, too, would not inflate. By now Gruentzig could visualize a story to be told and retold for years in Zürich with just the right amount of schadenfreude. He ripped open a third package, attached a syringe to the end of the catheter, and pressed on the barrel of his syringe. The third balloon inflated. That tiny piece of polyvinyl chloride encircling a catheter tip was his career’s brass ring. Could he grasp it?

Gruentzig poked a needle into a quarter-sized patch of skin above the femoral artery in Bachmann’s groin, to inject a local anesthetic. The first steps were routine: needle into the femoral artery, guidewire passed through the needle, push the wire back up the aorta to the orifice (opening) of the left coronary artery, slither his catheter over the wire. He took his first step into the unknown, the unexplored ominous domain of the atheroma, the land of sudden unexpected death, passing the guidewire into the left coronary artery, sliding silently past the lurking atheroma. He slid his catheter over the wire, puffs of X-ray dye illuminating the landscape beyond, catheter creeping forward, finding the perfect position where the uninflated balloon near the catheter tip completely straddled the obstruction in Bachmann’s coronary artery. Tension in the room escalated, Gruentzig staring at the monitor, surgeons and anesthesiologists poised to rescue Bachmann from his plight with emergency bypass surgery.

Imagine yourself in Gruentzig’s profoundly uncertain moment, not knowing if inflating the balloon would cause a heart attack, precipitate sudden death by ventricular fibrillation, or open the obstruction in Bachmann’s coronary artery. Gruentzig tells what happened next: “The catheter wedged the stenosis so that there was no antegrade flow and the distal coronary pressure was very low” (his catheter completely obstructed the artery, so no blood could flow beyond it, causing pressure to drop). Gruentzig’s catheter was obstructing the most important coronary artery of Adolph Bachmann’s heart. “To the surprise of all of us, no ST elevation, ventricular fibrillation or even extrasystole occurred and the patient had no chest pain.” He inflated the balloon. “After the first balloon deflation, the distal coronary pressure rose nicely [suggesting the vessel was no longer obstructed]. Encouraged by this positive response, I inflated the balloon a second time to relieve the residual gradient.”

Bachmann seemed just fine … at least no harm done. But to what benefit? The proof would lie in a repeat coronary angiogram. As Gruentzig sent a new load of X-ray dye cascading down Bachmann’s coronary artery, onlookers gasped, hands flying to mouths as if to stifle a shriek, silently trying to comprehend the incomprehensible, to believe the unbelievable. It seemed like a magician, scrub suit for cape and catheter for wand had, with a couple of thrusts on the plunger of a syringe made an atheroma vanish completely! But each observer knew that what they had witnessed was no illusion … it was a medical breakthrough. Years later, pathologists would prove that the force exerted by his inflated balloon crushes the atheroma back into the wall of the blood vessel, completely reopening it.

I rank this miraculous, magical, astonishing moment in the history of cardiology in the same pantheon as Claude Beck’s defibrillation of the fourteen-year-old boy. Thirty-seven-year-old Adolph Bachmann was about to become the best-known patient in the history of cardiology. Gruentzig recalled, “Everyone was surprised about the ease of the procedure and I started to realize that my dreams had come true.” A new legend in cardiology had been born. Andreas Gruentzig was poised to be the most famous cardiologist of our time.

After the procedure, Bachmann had no further angina. King recatheterized Bachmann on his tenth anniversary. The vessel continued to look perfect.

Gruentzig returned to the annual American Heart Association meeting in 1977 to describe his first four angioplasty procedures in human beings. But this time he spoke from the podium. His voice washed over the heads of a rapt audience as he showed all-too-familiar angiographic images of coronary arteries obstructed by atheroma. Then came his Big Reveal. After balloon angioplasty, the obstructions simply disappeared. Cardiologists are a visual species: for us, seeing is believing. As each new image flashed across the screen, murmurs rose from the audience as people turned to each other to say, “That’s amazing” and “Did you see that?”

What happened next was a first in my experience of listening to thousands of scientific presentations over forty years. In his words, “I also showed the slide of the fourth patient with the incredible success of main stem dilatation and it was during this case that the audience started applauding in the midst of the lecture. I was so surprised that I almost could not proceed with my ten minute presentation.” When he finished, his audience rose as one, and his ten-minute presentation concluded with a standing ovation.

No one could to fail to grasp that this was a transitional moment in medical history. Moments later, the torch was passed to a new generation. Mason Sones approached him after the lecture and asked to see more than snapshots. He wanted Sonesian proof: the movie films that Gruentzig had recorded during his procedure. Gruentzig said, “I invited him to share with me the cineangiogram [coronary angiogram recorded on movie film] which I had in my suitcase. We went to the exhibition hall and reviewed the film of this patient together at the booth of one of the exhibitors.”

Gruentzig reported his first five cases in a letter to the editor of the prestigious English medical journal
The Lancet
in 1978. In the three years following his first case in Zürich, he performed coronary angioplasties in 169 patients. Ten years later, nearly 90% of his patients were still alive.

*   *   *

I FIRST GOT
to know Gruentzig during his Zürich years when the two of us and our wives had dinner as a foursome in Aspen, Colorado. What a couple! His wife, Michaela, a psychologist, was very bright and very pretty. Andreas was Michaela’s equal in charm and grace. He told wonderful stories and listened with great interest to my banal ones. He spoke with passion about almost everything, was at once ebullient, down-to-earth, and larger than life. I recognized the charisma that I had seen earlier in Dwight Harken and my mentor, Jeremy Swan. I left dinner that night feeling that Andreas had opened my mind to a new world of limitless possibilities I had never before imagined. For the first time we could enter our patients’ coronary arteries; we could touch and manipulate our tiny adversaries that lay within.

In science, failure occurs in isolation, success draws a crowd. Gruentzig’s kitchen receded into distant memory as the world’s cardiologists clamored to be taught his procedure. With thousands of cardiologists wanting to learn, he found a way. He wore a microphone in his cath lab and sent continuous X-ray images from the laboratory to monitors in the hospital’s auditorium as he performed live procedures. Hundreds of cardiologists sat in reverence like parishioners at a Billy Graham sermon. Immediately after each procedure Gruentzig strode from his lab to the auditorium lab to talk about the just-witnessed case. His approach was revolutionary. As his biographers David Monagan and Dr. David Williams concluded, “Almost no modern surgeon back then would have dared televise in real time the unpleasant sights and sounds of his unpredictable trade. But Gruentzig was passionate about holding nothing back, believing that the sheer dint of his scientific honesty would be the key to gaining credibility in the world of skeptics.”