The Masters of Medicine with Dr. Andrew Lam - Heart Disease: The Mavericks (Show Notes)

Cardiac procedures we take for granted had to be developed by somebody, somewhere.  I don’t know how many times Mike or I have had a patient come to the ER having chest pain, diagnosed a “heart attack” knowing that some part of the heart needed more blood flow, called a cardiologist and had that patient whisked out of our department and onto a cath lab table within literal minutes, to have their heart plumbing fixed without surgery.  It can certainly be more complicated than that depending on the scenario, but it was not always this way.

One of the interesting things that is discussed early in this chapter, is the fact that the heart was something of an afterthought or organ that was of less scientific interest in the 19th century, and it wasn’t until the 20th century that we made significant developments here.  It wasn’t until 1912 until an internist named James Horrick even speculated to an assembly of physicians that blockage of the coronary arteries was probably a thing explaining sudden apparent death.  Why did it take so long to figure this out and how was his theory received? (We can discuss some basic cardiac circulation and physiology here).

“Myocardial infarction,” the medical term for heart attack, was not really coined until 1918.

1929 - Werner Forssman boldly plays with catheters.  Can you tell us a bit about this story and what the concerns of his colleagues at the time were?

1958 - Dr. Mason Sones at the Cleveland Clinic decides the venous system is too easy to put a catheter into.  Can you tell us how his first foray into the world of sticking catheters into the arterial side of circulation went?  Would you say swimmingly or no?

• Mortality of standard of care prior to 1960 was 30-40% with ASA, morphine, NTG, and thrombolytics

Once the ability to get catheters into arteries was established, how did we figure out how to fix the problems that were found?  This could include a thrombus or blood clot, or a narrowing of the artery due to fat and calcium deposits in the walls (called plaques).  I think this involves explaining what the verb “Dottering” is because, whether I was supposed to or not, this part of the book made me laugh.

I’m not a fan of balloons–too whimsical and noisy for my taste–but they are quite important to the history of cardiac intervention–fixing problems within the plumbing of the heart, especially.  Can you explain what balloons have to do with saving lives?

• Dr. Andreas Grutzig - the developer of the balloon
  • 1974 balloon angioplasty of the femoral artery
  • 1976 AHA poster presentation - meh response
  • 1977 Grutzig does angio with balloon during an open heart surgery
  • Later in 1977 - Standing ovation at the AHA.  Had to feel good.

Any time medicine can fix a life threatening problem without sawing through a ribcage under anesthesia, I’m all for it, but before balloons and catheters were used, one of the only options for fixing artery flow problems to the heart was surgical.  Still in use in the right circumstances, “open heart surgery” is the term for going into the thoracic cavity and literally tying in new pipelines to the arteries of the heart, now typically using a big vein taken from the leg, the saphenous vein, to make nice new piping.  It took a lot of steps to get to this point because, well, it’s hard to do surgery on a moving organ, especially when it’s kind of important to one’s life.  What were the baby steps into cardiac surgery, so-to-speak?

• Dr. Ludwig Rehn - cardiac tamponade, 1896
• Drs. Harken and Bailey try to fix mitral stenosis (rheumatic heart disease)

Under ideal pre modern circumstances, I believe I read it’s about a 4 minute window to do procedures on the heart.  Maybe 12 minutes with hypothermia. Now we can open a heart, replace a valve, ask poor medical students a bunch of questions until they sweat through surgical smocks while observing, and then have plenty of time to close.  What made this possible and how was it discovered?

• Dr. John Gibbon 1953, ASD repair with early verison of ECMO thanks to IBM engineers.

The last frontier of this chapter, fittingly, is heart transplantation.  We can now take a heart from one person and give it to another in need.  Can you talk about the first surgeons to figure out the steps necessary to do this, Drs. Christian Barnard and Dr. Norman Shumway?

Max

Doctor with a mustache.