The First Cardiac Catheter

HISTORICAL VIGNETTES IN VASCULAR SURGERY Norman M. Rich, MD, Section Editor

The first cardiac catheter

Sheldon Marvin Levin, MD, San Francisco, Calif

Alfred Nobel discovered dynamite and became one of the richest men in the world by manufacturing armaments. When a younger brother died in France in 1888, French newspapers mistakenly thought it was Alfred. Their head- lines read “The Merchant of Death is Dead.” The papers declared that Alfred’s powerful explosives killed more peo- ple, more efficiently, than ever before. The incident had a profound effect on him. He began thinking how he could leave a positive legacy. He was a complex person, who spoke six languages, wrote poetry, and was dismayed by the horror of war. After his death in 1896, his will created a foundation from his enormous estate that would bestow prizes to individuals who had achieved significant benefits for mankind. The fields of Medicine, Physics, Chemistry, Literature, and Peace were singled out. The Nobel Prize has become identified as the most coveted in the world. Fig 1. André Cournand. In 1956, the Prize in Medicine was awarded to the developers of cardiac catheterization, Drs André Cournand and Dickinson Richards from America and Dr Werner Forssmann from Germany. Who were these men, and what was their accomplishment? André Cournand (Fig 1) was born in Paris in 1895. From 1915 to 1918, he served in the French army during World War I. Resuming his studies, he graduated from medical school in 1925 and then spent 6 years working in pulmonary disease clinics. In 1931, he migrated to New York, having received an appointment as a resident in the Columbia’s Chest Service at Bellevue Hospital. He was short, jovial, outgoing, and reminded me of a character in Agatha Christy’s novels, Hercule Poirot. He made friends quickly; one was a senior fellow on his service, Dickinson Richards (Fig 2). Fig 2. Dickinson Richards. From the Department of Surgery, University of California School of Medicine. Author conflict of interest: none. Dickinson Richards was born in New Jersey in 1895. Reprint requests: Sheldon Marvin Levin, MD, University of California He graduated from Yale, and when the United States School of Medicine, Department of Surgery, 3838 California St, San Francisco, CA 94118 (e-mail: [email protected]). entered World War I, he volunteered in the army. He The editors and reviewers of this article have no relevant financial relation- served as an artillery officer in France during 1917-1918. ships to disclose per the JVS policy that requires reviewers to decline Returning from the war, resuming his studies, he graduated review of any manuscript for which they may have a conflict of interest. from Columbia’s medical school in 1923. After several J Vasc Surg 2014;59:1744-6 years of training on the Chest service at Bellevue he met 0741-5214/$36.00 Copyright © 2014 by the Society for Vascular Surgery. André Cournand. Athletically built, he stood 6 feet 2 http://dx.doi.org/10.1016/j.jvs.2012.06.086 inches. His manner was quiet and introspective. Though 1744 JOURNAL OF VASCULAR SURGERY Volume 59, Number 6 Levin 1745

In 1945, they confirmed Forssmann’s experiment and opened a cardiac catheterization laboratory at Bellevue Hos- pital. It was an immediate success. Details of heart and lung dysfunction were disclosed and many publications were writ- ten.7-10 In 1948, Dr John R. West became an invaluable member of the team. A brilliant researcher, he designed and constructed most of the recording equipment in the labora- tory. In 1951, a second laboratory was opened at Presbyterian Hospital, directed by Dr West. In 1951, I was in the second year of a 5-year appoint- ment as a surgical resident at Columbia-Presbyterian Hospi- tal. It was a period designated for research. Afternoons were spent in the experimental surgical area testing a plastic replace- ment for the aorta.11 I was interviewed by Dr West and gained the assign- Fig 3. Werner Forssmann. ment to work mornings in his laboratory. My time in the laboratory was a marvelous learning experience with Dr West, who was charismatic and passion- ate about his work. I learned to use the catheters, perform different in appearance and personality from Cournand, arterial punctures, use a fluoroscope, and analyze pulmo- they bonded immediately as close friends and worked pro- nary function data. 1-5 ductively as a team. In 1938, Cournand became an I co-wrote a paper with him,12 my first. Biweekly cath American citizen. laboratory rounds were conducted by Drs Cournand, Rich- In 1940, they read an intriguing article in an obscure ards, and West in the large medical school auditorium. German medical journal written 11 years previously by They were very popular with students, house staff, and 6 Werner Forssmann. The subject was catheterization of the attending staff. These sessions were standing room only. human heart. They realized the enormous potential of Early in 1954, we were devastated to learn that Dr John cardiac catheterization. Reading the paper changed their West was diagnosed with leukemia. In June, at age 37, he lives. died of a cerebral hemorrhage. Dr Richards wrote a touch- In 1929, Werner Forssmann (Fig 3) was a general ing obituary, stressing a great scientific potential that would practitioner in a small town near Berlin. He was interested never be fully realized. in the problems of heart diseases and speculated on the The great contribution to humanity made by the “cath effectiveness of administering digitalis directly into the lab” was recognized in 1956 when the Nobel Prize in medi- heart. Operating on a dog, he inserted a urological catheter cine was awarded to Drs Cournand, Richards, and Forss- through a leg vein into the right atrium. The dog survived. mann. I was in Scandinavia on a surgical fellowship when I He became obsessed with the idea of doing the same thing learned of the award. I wrote a letter of congratulations to on a human, but his colleagues at his hospital thought his them and received a cordial letter from Dr Richards. Through idea was insane. They forbade him to do the experiment on a remarkable chain of events, my wife and I were able to attend a person. He determined to perform heart catheterization the awards ceremony in Stockholm and to cheer loudly for on himself and convinced the operating room nurse at the them. It was an unforgettable evening. White tie, tails, rib- hospital to cooperate with him. She agreed, but with the bons for the men, evening gowns, and jewels for the stipulation that he would catheterize her, not himself. One women. The walls of the opera house were covered with Sunday, he went through the motions of starting the pro- blue and yellow flowers, colors of the Swedish flag. The cedure on her. Instead, he isolated his own left antecubital king of Sweden spoke to each recipient in French and vein and threaded the catheter into his upper chest. He English. After each presentation, the full orchestra played a then told the nurse what he had done and asked her to call short piece. It was a spectacular production, an once-in-a- an X-ray technician to the X-ray room. They walked down lifetime occasion. two flights of stairs to the X-ray department, and, once The following day, the three medalists in medicine gave there, he advanced the catheter a total of 65 cm from the talks at the Carolinske Institute. It was marvelous to greet elbow. An X-ray showed the catheter well into his heart. Drs Cournand and Richards. They were surprised and There were no ill effects, and the catheter was removed. A happy to see me. The joy of the occasion was dampened by short report was made.6 Forssmann did not follow up on the absence of Dr West. his experiment. In 1932, he joined the Nazi party and All of the Nobel Prizes in Medicine recognized gifts to remained a member until 1945. mankind. No contribution has been greater than the devel- Cournand and Richards planned to follow-up on Forss- opment of the “cath labs.” Catheterization of the right mann’s idea but our entry into World War II made them heart led to study of the left heart and to coronary arteriog- postpone their plans. They worked on the problem of trau- raphy. Disclosure of threatening foci of narrowed arteries matic shock4 with relevance to the war effort. led to coronary artery dilatations and stenting and to cor- JOURNAL OF VASCULAR SURGERY 1746 Levin June 2014

onary artery bypass grafting. Millions of lives have been normal and emphysematous lungs, analyzed by means of breathing pure saved and extended worldwide by these therapies, made oxygen. J Clin Invest 1944;23:55-67. possible by cardiac catheterization. It was a privilege to 6. Forssmann W. [Probing of the right heart.] Klin Wochsenschr 1929;8: 2085-7. have known Drs Cournand, Richards, and West personally 7. Richards DW. Cardiac output by the catheterization technique in and to have been taught by these remarkable men. It is various clinical conditions. Fed Proc 1945;4:215-20. fitting to recall the contribution of Dr John Robert West III 8. Baldwin ED, Moore LV, Noble RP. The demonstration of ventricular to cardiac catheterization.13 septal defect by means of right heart catheterization. Am Heart J 1946;32:152-62. 9. Dexter L, Haynes FW, Burwell CS, Eppinger EC, Sosman MC, Evans REFERENCES JM. Studies of congenital heart disease. II. Venous catheterization as a diagnostic aid in patent ductus arteriosus, tetralogy of Fallot, ventricular 1. Richards DW, Cournand A, Bryan NA. Applicability of the rebreathing septal defect, and auricular septal defect. J Clin Invest 1947;26:561-76. method for determining of mixed venous CO in cases of chronic 2 10. Cournand A, Baldwin JS, Himmelstein A. Cardiac catheterization in pulmonary disease. J Clin Invest 1935;14:173-80. congenital heart disease. New York: Commonwealth Fund; 1949. 2. Cournand A, Baldwin ED, Darling RC, Richards DW. Studies on the 11. Levin SM. Breakthrough: Arthur Blakemore and Arthur Voorhees, Jr. J intrapulmonary mixture of gasses. IV. The significance of the pulmo- Vasc Surg 2012;55:1829-31. nary emptying rate and a simplified open-circuit measurement of resid- 12. West JR, Levin SM, Di Sant’Agnese PA. Pulmonary function in cystic ual air. J Clin Invest 1941;20:681-9. fibrosis of the pancreas. Pediatrics 1954;13:155-64. 3. Cournand A, Richards DW Jr. Pulmonary insufficiency 1. Discussion of 13. Richards DW. In Memoriam, John Roberts West III. Yearbook a physiological classification and presentation of clinical tests. Am Rev Archives College of Physicians & Surgeons. New York: Columbia Uni- Tuberc 1941;44:26-41. versity; 1955. Available at: http://www.archive.org/stream/ 4. Cournand A, Riley RL, Bradley SE, Breed ES, Noble RP, Lauson HD, psyearbookofcoll1955colu/psyearbookofcoll1955colu_djvu.txt.Ac- et al. Studies of the clinical circulation in clinical shock. Surgery 1943; cessed June 17, 2012. 13:964-95. 5. Darling RC, Cournand A, Richards DW, Domanski B. Studies on the intrapulmonary mixture of gases. V. Forms of inadequate ventilation in Submitted May 17, 2012; accepted Jun 12, 2012.