Thread by @sjauhar

In honor of #HeartMonth, I’ve been posting threads on the rich history of the human heart. This one is on the development of angioplasty, and the brilliant innovator at the center of it. (1/)

If, as Osler said, the tragedies of life are mostly arterial, then the source of most of mankind’s misery is the fatty plaque. By cutting off blood flow, obstructive arterial plaque is responsible for heart attacks and strokes, the most common ways we die. (2/)

By the early 1960s, cardiologists could image coronary plaque. But how to fix it? Surgeons were already bypassing obstructions in the legs and in the heart using vein grafts harvested from various sites in the body. (3/)

However, mortality and morbidity rates in these bypass operations were unacceptably high. So a cadre of zealots began to try to figure out ways to create new channels of blood flow, not around a blocked artery but through it. (4/)

The most critical contributions to this procedure, angioplasty, were made by a German physician, Andreas Gruentzig, who began toying with catheters in the late 1960s. Like so many of the great cardiac innovators, Gruentzig was an engineer at heart. (5/)

His two-bedroom flat in Zurich was across the street from where James Joyce wrote much of Ulysses, and his kitchen table, laid out with drawings, knives, plastic tubing, air compressors, and epoxy glue, was in fact a portrait of an artist’s workspace. (6/)

Gruentzig often worked all night fashioning prototype catheters. When colleagues would visit—at all hours, to the chagrin of Gruentzig’s long-suffering wife—he would lead them to his kitchen and put them to work. (7/)

With a mane of black hair and a burly mustache, Gruentzig was handsome and charismatic. Like Werner Forssmann, his legendary predecessor, he was a risk taker, winging his single-engine plane low over the Swiss Alps on weekend getaways. (8/)

But unlike Forssmann, he worked systematically and inspired followers. (9/)

Gruentzig set as his task adding an inflatable balloon to the end of his catheters that was thin but strong enough not to compress or burst when encountering arterial walls studded with plaque. He first tested these balloon catheters on anesthetized dogs that he smuggled... (10/)

into the hospital on gurneys under drapes.The dogs’ arteries were stitched half closed to mimic an atherosclerotic blockage. When those experiments proved successful, Gruentzig went to work on human cadavers. (11/)

On February 12, 1974, Gruentzig used one of his catheters to perform the first human balloon angioplasty on a 67yo patient with a severe stricture of the iliac artery, a major vessel in the leg. (12/)

After the balloon was inflated, relieving the blockage, an ultrasound showed free-flowing circulation, and the patient’s incapacitating leg pain vanished. (13/)

Following this triumph, Gruentzig began to perform angioplasty on a regular basis, handcrafting catheters for every new pt and tracking his results to deny voice to his critics. It was painstaking work. “If I had an enemy, I would teach him angioplasty,” he once said. (14/)

However, the ultimate goal for Gruentzig and others was the coronary artery, whose disease was responsible for so much death around the world. “The legs were only my testing ground,” Gruentzig said. “From the beginning I had the heart in mind.” (15/)

However, the idea of coronary angioplasty was heretical in the extreme. There were so many potential pitfalls. The balloon could puncture the artery, causing hemorrhage. The vessel could close, causing a massive heart attack. The heart could develop fibrillation and stop. (16/)

For years, Gruentzig’s ideas were met with disdain, motivated by fear and perhaps not a small amount of jealousy. But he was a man of conviction, and there was nothing Gruentzig believed in more than himself. (17/)

Gruentzig meticulously pursued his vision. He forged collaborations on steerable catheters with American manufacturers, including the company that would eventually become the multibillion- dollar conglomerate Boston Scientific. (18/)

He practiced on the coronary arteries of cadavers, then later on living patients undergoing bypass surgery, but only in vessels that were already bypassed or about to be bypassed, or were small and inconsequential. (19/)

Gruentzig presented his results at cardiology meetings but, like Werner Forssmann, encountered skepticism and derision. Nevertheless, he bided his time, waiting for the right opportunity to present itself, a living person on whom to demonstrate his technique. (20/)

He finally got his chance on 9/16/1977, when Adolph Bachmann, a 37yo insurance salesman, was transferred to the Univ Hospital in Zurich with chest pain. A coronary angiogram revealed a short obstructive plaque in the beginning portion of the left anterior descending artery. (21/)

An emergency coronary bypass operation was scheduled for the following day, but Gruentzig persuaded Bachmann, who was afraid of open-heart surgery, and his doctors to allow him to perform balloon coronary angioplasty instead. (22/)

The following morning, as a dozen cardiologists, surgeons, anesthesiologists, and radiologists looked on, Gruentzig threaded one of his balloon- tipped catheters into Bachmann’s femoral artery, up his aorta, and into the opening of his LAD. (23/)

Two out of Gruentzig’s three balloons burst during preparations, but the third one remained intact. Two quick balloon inflations inside the coronary artery and blood began to flow normally down the vessel. The surgeons in the audience stared in disbelief. (24/)

Gruentzig had restored blood flow to heart muscle without scalpel, saw, or heart-lung machine. It seemed impossible. Bachmann’s chest pains immediately subsided. A post-procedure angiogram showed almost complete resolution of the obstruction. (25/)

(Ten years later, the artery remained open.) The only complication was a transient EKG abnormality that cleared up spontaneously. (26/)

At the American Heart Association conference in Miami that year, Gruentzig presented the results of his first 4 coronary angioplasties. True to his iconoclastic form, he presented his data (to raucous applause) wearing sandals. (27/)

After years of working in obscurity, Gruentzig quickly became one of the most famous cardiologists in the world. In 1980, three years after the first coronary angioplasty, he moved his research enterprise to Emory University in Atlanta, Georgia. (28/)

Over the next five years, he helped to popularize angioplasty in the United States by performing approximately 2500 procedures. He had so much faith in his technique that he once had a cardiology fellow perform a coronary angiogram on Gruentzig himself. (29/)

Gruentzig climbed onto the cath table at 5:00 p.m., underwent the procedure, and then went to pick up his wife, arriving at the department’s Christmas party by 7:00. Incidentally, his coronary arteries were normal. (30/)

Gruentzig’s procedure ushered in the field of interventional cardiology. In 2001, when I began my fellowship, coronary angioplasty was already a sprawling business. Today several million angioplasties are performed worldwide every year, one million in the U.S. alone. (31/)

In 1994, the Food and Drug Administration (FDA) approved the release of coronary stents, tiny metallic coils that are used in the clear majority of angioplasties today to keep ballooned arteries open. (32/)

From Forsmann’s self-surgery in a tiny operating room in Eberswalde, Germany, cardiac catheterization has been transformed into a hugely profitable, multibillion- dollar industry. Unfortunately, Gruentzig never got a chance to witness this revolution. (33/)

He and his second wife, a medical resident, died on October 27, 1985, when the private plane he was piloting crashed in a storm in rural Georgia. He was 46 years old. (FIN)