P&S Journal: Fall 1996, Vol.16, No.3
Interventional Cardiology Center Cardiac Catheterization: Yesterday's Groundbreaking Research is Today's Lifesaving Intervention
By Sally R. McLain
Reviewing the films of an interventional procedure
| Tuesday morning: Dr. Kenneth Giedd, instructor in clinical medicine and an interventional cardiology fellow, presents a case at the weekly Interventional Cardiology Center conference. |
See also:The Founding Fathers of Cardiac Catheterization and Their Legacy and Interventional Cardiology Center Research Highlights
Step back in time to a day in 1976. Dr. Andreas R. Gruentzig, a cardiologist, is speaking to a group of physicians at Massachusetts General Hospital about his experimental use of catheters to clear blocked arteries. In the audience is Dr. Allan Schwartz, a young clinical and research cardiology fellow. Like many of his colleagues, Dr. Schwartz is skeptical when he hears of this radical procedure.
Now, fast forward to 1996. Few things have remained the same in cardiac medicine in the 20 years since Dr. Schwartz reacted to that presentation. Today, cardiac catheterization is a commonly used procedure. The thin tubes used to explore the interior structure and function of the heart have become a basic tool for intervening in heart diseases that would otherwise cause disability and death for many. And Dr. Schwartz, who is now the director of Columbia-Presbyterian's Interventional Cardiology Center and the Margaret Milliken Hatch Professor of Clinical Medicine at P&S, calls Dr. Gruentzig a great pioneer in cardiac medicine.
Today, the offspring of the same catheters developed by a West German researcher and two P&S faculty members is used internationally to diagnose, treat, and in some cases all but cure heart disease. Columbia-Presbyterian's Interventional Cardiology Center is now one of the most advanced and well-staffed cardiac catheterization labs in the country.
Being among the best means an early start for those who work in the cath lab. Before the doctors even begin treating patients, a specially trained nursing staff prepares the lab for the day's procedures and welcomes patients, who start arriving as early as 7 a.m.
In the cath lab, from left, Drs. Schwartz, Apfelbaum, and Wasserman prepare for the day's procedures by reviewing patient charts and their schedules.
|While that's going on, a group of 10 or 12 doctors and cardiology fellows start each Tuesday by discussing the previous week's atypical cases. Films of heart catheterizations are flashed on a screen by Dr. Hal Wasserman, assistant professor of clinical medicine, while Dr. Schwartz leads the discussion and the other doctors drill each other on the particulars. Sometimes they listen, other times they give advice or ask questions-but it's always lively. One cardiology fellow, reading his notes from index cards, presents a case: "Ms. M. is a 22-year-old woman who had a heart transplant at the age of 14. She came to the cath lab last week for a diagnostic procedure and heart biopsy following signs of transplant rejection," he says. "It was shown that she also had arterial disease in the grafted heart arteries."|
Ms. M.'s story opens up an ethical discussion. This case raises the issue of whether a patient, in this instance a young one, should have a second transplant when many patients are waiting for a first. "In the setting of our weekly conference, we are able to very frankly discuss real issues," says Dr. Schwartz. "Those discussions help us refine our decision making and ensure that our lab operates as efficiently and as up-to-date as possible."
Dr. Schwartz has been director of the center since 1990, when he took over the reins of a facility in dire need of improvement to its physical plant and equipment. "From 1990 to 1991 we planned and built a new lab in the Milstein Hospital," says Dr. Schwartz. "We picked a site and designed a space from scratch." The team led by Dr. Schwartz had three goals for an interventional cardiology facility heading into the next century: resuscitate the patient care facility...resuscitate research...resuscitate the invasive cardiology training program.
With the opening of the new lab, says Dr. Schwartz, the physician staff has been able to develop to its full potential. "We have good people here who create a very stimulating environment. With the new lab came the initiative to produce clinical and technical research that has gained international respect. I set the goals but didn't achieve them-the people here did."
Dr. Allan Schwartz, director of the Interventional Cardiology Center, leads a Tuesday morning discussion. Dr. Hal Wasserman, associate director, runs the projector.
| The focus of the center is motivated wholly by patient care and quality of life. "Our aim is to diminish symptoms and decrease risk," says Dr. Schwartz. As part of Columbia-Presbyterian's Heart Institute, the cath lab is one component in the extensive pediatric and adult cardiology service that helps patients achieve the best possible outcomes through surgical, catheter, and drug therapies, diet, exercise, and stress management.
Heart disease continues to be the No. 1 cause of death in the United States. The survival rate from heart attack, though, is improving, thanks to early intervention. "Interventional cardiology has come to refer to the use of catheters to repair problems in blood vessels," says Dr. Judah Weinberger, associate professor of clinical medicine (in pharmacology), who is both a researcher and clinician within the Interventional Cardiology Center. "What I do today was not imagined when I graduated from medical school in 1980. When I was trained, you gave patients supportive care, alleviated their pain, and got them through the attack. Now we can usually provide improved survival and ventricle function with treatment."
|Although treatments have improved vastly, Dr. Weinberger continues to search for even better outcomes. After angioplasty, roughly 20 percent of patients experience recurrence of chest pain due to restenosis, or recurrence of blockage, within six months following the procedure. "We came up with the idea to use local radiation, hoping that it might prevent the abnormal proliferation of cells, which is what causes the restenosis. A local therapy would be the most straightforward so that's when we thought of radiation delivered by catheter directly at the problem site in the artery," he says.|
Our plan is to get started with human trials later this year. The goal is to find treatments that are less invasive and more definitive," says Dr. Weinberger. "Hopefully, we'll be able to prevent disease or offer good alternatives." The treatment, on which Dr. Weinberger holds a patent, has been shown to be effective in animal models of restenosis.
Cardiac catheterization allows doctors to visualize the heart and the coronary arteries that supply blood to the heart muscle and helps to determine pressure and flow in the chambers of the heart and across the heart valves and the pulmonary artery. It also can show if the arteries are occluded-a major cause of heart attack and chest pain, or angina-and help doctors determine whether the best option is bypass surgery, catheter-based treatment, or continued drug therapy.
Two Interventional Cardiology Center nurses prepare for a catheterization-one nurse preps the patient in a procedure room while the other begins entering patient data into the computerized log in the observation room.
Dr. Schwartz likes to use what he calls "real-life" analogies when discussing treatment options with his patients: "Dealing with heart disease is like crossing the street," he tells them. "You can wear a blindfold and something will probably happen. But if you take off the blindfold, look both ways, and wait for the light to change, you'll probably make it, although there's still the chance that a drunk driver could pull around the corner and hit you." In other words, Dr. Schwartz says, the goal is to look for the treatment with the best possible outcome, although risks cannot be completely avoided.
Although it may not have the stigma of open-heart surgery, cardiac catheterization is still an invasive procedure that frightens many patients. When a patient comes in for diagnosis or treatment, he or she usually has just learned of a possible heart problem, says Bernadette Miesner, the center's nurse manager. "A lot of patients are frightened. We have a chance to intervene and sensitivity is so important. My main concern is if I don't impact on patient care, nothing else matters."
Dr. Schwartz agrees. "Patient education is critical to taking care of someone and to a good outcome. And comfort starts the minute you meet someone. A good physician or nurse knows that there's a real science to what makes people relax."
Later on Tuesday morning, Room 2 in the Interventional Cardiology Center has been cleaned following the first procedure of the day-an angioplasty. Two nurses begin preparations for the next patient by following what seems to be a protocol as precise as if they were setting a table for a formal banquet. Instead of soup spoons and water glasses, needles, wires, dye mediums, and various sterile tools and towels have been organized in an order as exact this time as the last.
| Metal in a row: Dr. Schwartz puts on protective garments, known as metal, that shield physicians from radiation used during interventional cardiology procedures. || Three individual cath rooms surround a central area where the nursing station and supply areas are located. On the other side of the nursing station are patient prep and recovery areas. |
Once Room 2 is ready, the next patient is wheeled in. After the nurse shaves a small area at the groin, rubs it with a sterile pad, and covers the area with a surgical towel, Dr. Schwartz enters. He and a cardiology fellow will perform this diagnostic procedure. The patient, in his mid-50s, had a small clot pass between the chambers of his heart, causing a few mild strokes. Today, the patient is in the cath lab to be screened before heart surgery.
Over his surgical scrubs Dr. Schwartz puts on a protective vest and skirt that in lab lingo are called metal. The metal protects the clinician from the constant exposure to radiation. In their metal, doctors and nurses look a little like futuristic druids before they cover up with another layer of sterile garb.
Dr. Schwartz numbs the area around the artery and the patient is given Valium and Benadryl as conscious sedation-awake but comfortable. Once the introducer sheath, or needle, is inserted, Dr. Schwartz begins to thread in the catheter. To watch him insert the wire is like watching Houdini-it looks like sleight of hand as the wire seems to disappear effortlessly into the patient's body.
In this case, a dye will be used to identify a blockage. Once the catheter is inserted, Dr. Schwartz injects the dye as the fellow activates the fluoroscope to take an X-ray of the heart.
Later, during a rare moment when Dr. Schwartz is able to sit in his office, he recalls his days at P&S in the early 1970s. "Medicine looks nothing like it did in 1974 when I graduated from medical school. Interventional cardiology-historically cardiac catheterization-started as a diagnostic procedure. Since then, there's been a rapid progression of technology and thanks to some real pioneers in interventional radiology, neurology, and cardiology, we are now moving on to the next level of interventional cardiology in which we will use molecular biologic and genetic treatment techniques going directly to the sites of disease." That's how Dr. Weinberger's studies in site-specific radiation and the work of other modern-day specialists will advance the interventional cardiology field.
Also, there's Dr. LeRoy Rabbani, assistant professor of medicine, who is studying vascular biology under an NIH grant. Dr. Rabbani, a 1984 graduate of P&S, says being a researcher and clinician in interventional cardiology puts him in a position to see mostly positive results. "It's one of the fields where you can get gratification because there's a lot of success." Dr. Rabbani is investigating factors that control smooth muscle cell proliferation and migration as they occur in angioplasty restenosis and atherosclerotic narrowing of coronary arteries.
Dr. Rabbani calls stenting the latest advance in cardiac catheterization. "It's revolutionary. It's a bail-out procedure in an emergency and reduces restenosis when used electively." (See "The Founding Fathers of Cardiac Catheterization and Their Legacy.")
Despite the advances and continuing growth of the field, not all heart questions have ready answers. "It's not always a clear-cut issue," says Dr. Rabbani. "It's a field where you need collaboration."
Visual aids: Interventional cardiologists insert a catheter into a patient's artery and then inject dye to see abnormalities or obstructions in the heart. An internal view of the procedure is visible on a video monitor, which records the catheterization for later review and diagnosis.
|A perfect example was seen the day before: A man in his late 60s came into the cath lab in great discomfort. The patient had undergone heart bypass surgery at another institution 10 days earlier and ended up in the cath lab because of sudden breathing difficulty and low blood pressure. In the course of the angiogram, the patient edged close to death when he could not breathe. At least 10 people were in the lab and observation area-six around the patient-trying to save the man's life. Dr. Mark Apfelbaum, assistant professor of clinical medicine, pointed at an image of the heart on the monitor and said, "There's something very wrong here," indicating an area around the lung that appeared to be full of fluid. While Dr. Schwartz, Dr. Apfelbaum, and Dr. Wasserman looked at the screen, they agreed that an infection likely caused the fluid. "The heart seems to be functioning fine, but there's something creating a lot of pressure, perhaps blood, but we've got to remove whatever it is to buy some time until we can figure out what's causing the pressure," said one of the doctors. Soon, a surgeon was paged, came to the lab, and drained the fluid in the man's chest.|
Once the situation was stabilized, doctors determined the patient had an infection, a rare complication of bypass surgery. After another surgery, the patient recovered.
"These are difficult decisions that must be made quickly," says Dr. Schwartz, "and the information we use to make those decisions is constantly changing. At any given time, we're attempting to choose the treatment with the best possible outcome and least risk."
Pulse point: Bernadette Miesner, the center's nurse manager, makes a quick phone call to one of the cath lab's nurses, who has been at home ill for a couple days. "I hope you're feeling a little better today, Charlie," she says, while Dr. Apfelbaum takes care of paperwork. Behind him on the wall is a list of the day's scheduled procedures.
|But back to a more routine day. Later on this Tuesday, in Room 3, Dr. Schwartz and a cardiology fellow conduct a diagnostic angiogram on a middle-aged male. "We're about to inject the dye so we can get the images recorded, so you may feel a little warmth down your left arm," Dr. Schwartz warns the patient. He then asks the patient to put his arms over his head for one picture. "If you're comfortable like that, we'll be done in just a few minutes. You can daydream you're lying on the beach." |
While Dr. Schwartz and the cardiology fellow view the film on a video monitor in the observation room, the nurses attend to the patient and send him to the recovery area. There he will rest, have the sheath removed, watch a little TV, and talk to Dr. Schwartz about the findings of his test.
"Things happen pretty quickly around here," Dr. Schwartz says after he has explained the angiogram findings to the patient. "This is that same-day surgery kind of thing-I had to tell that patient he needs surgery, call his doctor in New Jersey, and speak with the patient's wife in the waiting room. Then I'm off to talk with the next patient. In this age of technological advances and the movement toward ambulatory procedures and shorter hospital stays it's very challenging to form a therapeutic relationship." That's why Dr. Schwartz makes it part of his routine to speak with each patient by phone the day before the catheterization procedure. "It's better for them because they know what to expect and that I care, and it's better for me because the patient is more calm.
"No matter what, patient care comes first," he says. "That's why it's amazing some of this staff with their heavy clinical responsibilities have been able to do high-quality research and get grants."
That, he believes, is what puts this cath lab in the company of the best.
The Founding Fathers of Cardiac Catheterization and Their Legacy
In 1929, a West German physician named Werner Forssmann tested the first prototype for cardiac catheterization by threading a catheter not through the artery of an animal or even a human volunteer but through a vein in his own arm to reach his own heart.
Dr. Andre Cournand
|Later, Dr. Forssmann studied cardiac catheterization with two researchers from Columbia-Dr. Dickinson W. Richards and Dr. Andre F. Cournand. The three were awarded the Nobel Prize for Medicine and Physiology in 1956 for their tool that penetrates the heart to record blood pressure and other conditions essential to the treatment of cardiovascular and pulmonary disease. |
They were cited for their work using a thin tube to explore the interior of the functioning human heart-the precursor to today's interventional cardiology practices. The Nobel recognized "their discoveries concerning heart catheterization and pathological changes in the circulatory system. These investigations have meant that diagnosis can now be made earlier and with greater certainty than before."
Drs. Richards and Cournand collaborated on their search for practical uses of the cardiac catheter for 40 years, starting in 1932 and ending when Dr. Richards died in 1973. Dr. Cournand died in 1988.
Dr. Dickson Richards
|Today's cardiac catheterization works this way: Once an introducer sheath is inserted into an artery, either in the patient's arm or groin, a guiding wire followed by a catheter is passed through to help a cardiologist diagnose or treat a condition. For diagnostic purposes, the catheter measures pressures or introduces a contrast medium into the heart's arteries and veins to allow the physician to make an angiogram that shows abnormalities or obstructions. More recently, catheters using ultrasound have been used to explore the interior of arteries. |
A similar procedure, called balloon angioplasty, allows physicians to go to the site of the obstruction and press the built-up plaque into the wall of the artery to allow more normal blood flow to return. Two other procedures, rotablation and coronary stenting, employ cardiac catheterization methods to clear blockages by respectively shaving away plaque or inserting special hardware that works as a venous "scaffold." That hardware, called a stent, looks something like the spring in a ball point pen but with a higher price tag-about $1,500. For three years, U.S. cardiologists have successfully used stenting as a bail-out procedure when an artery closes after angioplasty and one year ago the Food and Drug Administration approved stenting as a measure to reduce restenosis.
Interventional Cardiology Center Research Highlights