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EDITORIAL

State of the art: 40 years of percutaneous cardiac intervention

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There are few areas in medicine where the development of an entire field is perceived to be so closely associated with one individual. Andreas Roland Grüntzig (Figure 1) was born in Dresden, Germany, ten weeks before the outbreak of the Second World War on 25 June 193911. Gaspard P. The History of Coronary Angioplasty. Toulouse, France: Europa Digital and Publishing; 2017. ,22. Monaghan D. Journey into the Heart. New York, NY, USA: Gotham Books/Penguin; 2007. . After graduating from medical school in Heidelberg in 1969, he took a career-defining step by moving to the University Hospital in Zürich to take up a position in the Department of Angiology, which was chaired by Alfred Bollinger. In August 1971, after establishing himself in Zürich and inspired by an earlier lecture given by Eberhard Zeitler33. Zeitler E, Schoop W, Zahnow W. The treatment of occlusive arterial disease by transluminal catheter angioplasty. Radiology. 1971;99:19-26. on the dilatation of peripheral arterial stenosis with rigid tubes pioneered by Charles Dotter44. Dotter CT. Transluminally-placed coilspring endarterial tube grafts. Long-term patency in canine popliteal artery. Invest Radiol. 1969;4:329-32. , he set off for a small town near Cologne to meet Zeitler and gain some hands-on experience with the technique. The two became friends, and subsequently together they performed the first “Dottering” case at the University Hospital in Zürich in late 1971. Grüntzig continued to accumulate experience with “Dottering” procedures over the coming years. Under the guiding influence of Wilhelm Rutishauser he became a cardiology fellow in 1973 and was appointed as a cardiologist in 1974.

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Figure 1. Andreas Roland Grüntzig (1939-1985). Reproduced with permission from https://www.pcronline.com

At the same time, Grüntzig and others were well aware of the limitations of the rigid “Dottering” devices – including damage to the treated segment and distal embolisation – and their particular unsuitability in smaller vessels. With the help of Bollinger’s assistant, Maria Schlumpf, and her engineer husband, the three set about developing balloon angioplasty catheters over the course of the next three years. Working with polyvinyl chloride on Grüntzig’s kitchen table, initially they developed a single and then a double lumen balloon catheter, which allowed balloon inflation through one lumen and perfusion of the occluded artery through the other. The double lumen catheter was ultimately used for the first time to treat an iliac artery stenosis on 23 January 1975. Modifying the technique for use in coronary arteries began with the first dilatations of ligated canine coronary arteries on 22 October 1975. These initial cases were reported in the now famous abstract presentation at the American Heart Association meeting in Miami in November 197655. Grüntzig AR, Turina MI, Schneider JA. Experimental percutaneous dilatation of coronary artery stenosis (abstract). Circulation. 1976;54(Suppl):81. . Also in the second half of 1976, the company subsequently known as Schneider Medintag began the commercial manufacture of the prototype balloon catheters. The final preparation for the first percutaneous coronary intervention was the proof of principle performance of the first dilatation of a coronary artery in a patient undergoing bypass surgery. This was performed through collaboration with Richard Myler in San Francisco on 9 May 1977.

Meanwhile, the search continued for the first patient with a suitable lesion who was willing to undergo angioplasty. Back in Zürich, Bernhard Meier introduced Grüntzig to Adolf Bachmann – a 38-year-old man with debilitating angina and an accessible, focal proximal stenosis of the left anterior descending artery66. Meier B. His master’s art, Andreas Gruntzig’s approach to performing and teaching coronary angioplasty. EuroIntervention. 2017;13:15-27. . The patient had been scheduled for conventional revascularisation with bypass surgery but, after meeting Grüntzig, he agreed to be the first patient to undergo angioplasty77. Serruys PW, Onuma Y. What is it to become an octogenarian 40 years after the first angioplasty? EuroIntervention. 2017;13:11-3. . On 16 September 1977, the patient underwent successful dilatation of his coronary stenosis by Grüntzig (Figure 2)88. Grüntzig A. Transluminal dilatation of coronary-artery stenosis. Lancet. 1978;311:263. . A critical role was played by the renowned pioneering surgeon Ake Senning, who agreed to provide surgical back-up in case something went awry. The story of this remarkable case is now well known and was extensively documented in a recent article in these pages by Meier66. Meier B. His master’s art, Andreas Gruntzig’s approach to performing and teaching coronary angioplasty. EuroIntervention. 2017;13:15-27. along with a video recording of a case demonstration by Grüntzig (Moving image 1). The rest of course is history, and developments over the intervening decades have seen percutaneous intervention become a cornerstone of the treatment of obstructive coronary artery disease. Bachmann remains alive and well 40 years later and you can watch a remarkable recording with him on the EuroIntervention website, in which he recounts his initial meeting with Grüntzig on the day before his bypass surgery was scheduled (Moving image 2).

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Figure 2. Documentation of pressures during the world’s first coronary angioplasty on 16 September 1977 at the University Hospital of Zürich in Switzerland. The top curve represents the aortic pressure (AoP) at the tip of the guiding catheter in the coronary cusp. The bottom curve represents the pressure at the tip of the balloon catheter while in the coronary artery (CoP), damped because of the tiny lumen transmitting the pressure. The very low distal pressure during balloon occlusion (centre) documents the absence of collaterals. The distal pressure stayed practically level with the aortic pressure during balloon pullback at the end of the tracing. This testifies to a good haemodynamic result of angioplasty. The resolution of the cine frames depicted at the bottom is good, as these are pictures of the processed cine film not available during the intervention. The initials and year of birth of the patient are depicted at centre right. Reproduced with permission from Meier et al66. Meier B. His master’s art, Andreas Gruntzig’s approach to performing and teaching coronary angioplasty. EuroIntervention. 2017;13:15-27. . CM: contrast medium; ECG: electrocardiogram

In commemoration of the 40 anniversary of this first percutaneous coronary intervention, the current edition of EuroIntervention is devoted in its entirety to a review of the field. A series of eleven review articles focuses on the different aspects of percutaneous coronary intervention, showing how it has become one of the most frequently performed medical procedures in the world. This issue is released to coincide with the annual congress of the European Society of Cardiology (ESC) in Barcelona – which also has this anniversary as its central theme – and we are very pleased to include an interview with Stephan Achenbach, the chair of the ESC Congress Committee, as a foreword99. Achenbach S. An interview with Stephan Achenbach, Chairperson 2016-2018 of the ESC Congress Programme Committee. EuroIntervention. 2017;13:631-2. . Those attending the congress in Barcelona will be able to visit a dedicated museum celebrating “40 years of angioplasty” organised by PCR located in Village 3. This museum already proved very popular with participants at EuroPCR 2017 in Paris earlier this year.

In the first three review papers in this issue, Carlos Collet and colleagues reflect on the equally remarkable story of the development of diagnostic coronary angiography1010. Collet C, Grundeken MJ, Asano T, Onuma Y, Wijns W, Serruys PW. State of the art: coronary angiography. EuroIntervention. 2017;13:634-43. , Christos Bourantas and colleagues report on the development and progress in intravascular coronary imaging1111. Bourantas CV, Tenekecioglu E, Radu M, Räber L, Serruys PW. State of the art: role of intravascular imaging in the evolution of percutaneous coronary intervention – a 30-year review. EuroIntervention. 2017;13:644-53. , and Gianluca Pontone et al provide an overview of the state of the art in non-invasive imaging1212. Pontone G, Guaricci AI, Neglia D, Andreini D. State of the art: non-invasive imaging in ischaemic heart disease. EuroIntervention. 2017;13:654-65. . Invasive assessment of haemodynamic lesion severity is now an important part of routine clinical practice in patients with multivessel disease and lesions with unclear functional significance. Mauro Echavarria-Pinto provides a timely overview of this field in the light of recent important randomised clinical trials1313. Echavarria-Pinto M, Collet C, Escaned J, Piek J, Serruys PW. State of the art: pressure wire and coronary functional assessment. EuroIntervention. 2017;13:666-79. .

The initial balloon angioplasty catheters of Grüntzig were rudimentary devices difficult to manoeuvre, placing all but the most proximal of lesions out of the reach of this pioneering intervention. Progress in balloon catheter technology was rapid with, amongst others, important advances by John Simpson, who developed a balloon catheter system allowing independent manipulation of the balloon catheter and guidewire1414. Simpson JB, Baim DS, Robert EW, Harrison DC. A new catheter system for coronary angioplasty. Am J Cardiol. 1982;49:1216-22. , and Tassilo Bonzel, who developed the monorail system for facilitating balloon catheter exchange1515. Bonzel T, Wollschlager H, Just H. [A new catheter system for the mechanical dilatation of coronary stenoses with exchangeable intracoronary catheters, fast flow of the contrast agent and improved control]. Biomed Tech (Berl). 1986;31:195-200. . Developments and the state of the art in balloon catheter technology are extensively reviewed by Fernando Alfonso and Bruno Scheller in a comprehensive article1616. Alfonso F, Scheller B. State of the art: balloon catheter technologies – drug-coated balloon. EuroIntervention. 2017;13:680-95. . Emanuele Barbato et al review evolving concepts in plaque modification, particularly as it applies to the treatment of heavily calcified lesions1717. Barbato E, Shlofmitz E, Milkas A, Shlofmitz R, Azzalini L, Colombo A. State of the art: evolving concepts in the treatment of heavily calcified and undilatable coronary stenoses – from debulking to plaque modification, a 40-year-long journey. EuroIntervention. 2017;13:696-705. , and Giulio Stefanini and colleagues provide a comprehensive review of bare metal and drug-eluting stent technology1818. Stefanini GG, Byrne RA, Windecker S, Kastrati A. State of the art: coronary artery stents – past, present and future. EuroIntervention. 2017;13:706-16. , the latter of which was a critical development in facilitating the expansion of percutaneous intervention to patients with complex disease patterns such as left main stem stenosis, coronary bifurcations, and multivessel disease. The widespread adoption of angioplasty and stenting was crucially dependent on the development of effective antithrombotic therapy following intervention. Indeed, the intensity and duration of dual antiplatelet therapy has been the subject of considerable controversy and of a large number of randomised clinical trials over the last decade in particular. An ESC Focused Update on Dual Antiplatelet Therapy will be presented for the first time by Marco Valgimigli at the ESC meeting in Barcelona. In a timely review in EuroIntervention, he and his colleagues provide an overview of trials on dual antiplatelet therapy, incorporating an updated meta-analysis in a document which may serve as a useful companion to the guidelines document1919. Gargiulo G, Valgimigli M, Capodanno D, Bittl JA. State of the art: duration of dual antiplatelet therapy after percutaneous coronary intervention and coronary stent implantation - past, present and future perspectives. EuroIntervention. 2017;13:717-33. .

Bioresorable scaffolds is another area which has attracted considerable debate and many studies in recent years2020. Cassese S, Byrne RA, Jüni P, Wykrzykowska J, Puricel S, Ndrepepa G, Schunkert H, Fusaro M, Cook S, Kimura T, Henriques JP, Serruys PW, Windecker S, Kastrati A. Mid-term clinical outcomes with everolimus-eluting bioresorbable scaffolds versus everolimus-eluting metallic stents for percutaneous coronary interventions: a meta-analysis of randomized trials. EuroIntervention. 2017 Jul 4. [Epub ahead of print]. . Yuki Katagiri, Gregg Stone and Yoshi Onuma provide an overview of the inception and current status of these devices as well as a perspective on future developments2121. Katigiri Y, Stone GW, Onuma Y. State of the art: the inception, advent and future of fully bioresorbable scaffolds. EuroIntervention. 2017;13:734-50. . In spite of the considerable progress in catheter-based treatment of coronary stenosis, future events continue to be determined to a large extent by disease progression in non-intervened segments2222. Stone GW, Maehara A, Lansky AJ, de Bruyne B, Cristea E, Mintz GS, Mehran R, McPherson J, Farhat N, Marso SP, Parise H, Templin B, White R, Zhang Z, Serruys PW; PROSPECT Investigators. A prospective natural-history study of coronary atherosclerosis. N Engl J Med. 2011;364:226-35. . Javaid Iqbal, Robert Widmer and Bernie Gersch provide a review of medical therapy and highlight the importance of optimal therapy in revascularised patients2323. Iqbal J, Widmer R, Gersh BJ. State of the art: optimal medical therapy – competing with or complementary to revascularisation in patients with coronary artery disease? EuroIntervention. 2017;13:751-9. . In the final paper, as we look to the future, Werner Mohl et al provide an interesting overview of developments in cell therapy and its potential for translation to endogenous repair2424. Mohl W, Henry TD, Milasinovic D, Nguemo F, Hescheler J, Perin EC. From state-of-the-art cell therapy to endogenous cardiac repair. EuroIntervention. 2017;13:760-72. .

Of course, progress in percutaneous coronary intervention has also spawned innovation in the transcatheter treatment of valvular heart disease. With this in mind, a second dedicated issue of EuroIntervention will be published to coincide with PCR London Valves in late September, highlighting progress and the state of the art in the field of structural interventions. We hope that you will find both series of papers a valuable resource and a fitting way to commemorate 40 years of percutaneous cardiac intervention.

Supplementary data

Moving image 1. Andreas Grüntzig explaining the bimanual technique. It is particularly helpful even today when it is necessary to intubate the coronary artery deeply with the guiding catheter to pass a tight lesion with the balloon. The voice in the background is that of Spencer King. The case was performed in Atlanta, GA, USA, in 1983.

Moving image 2. Interview with the first PTCA patient, Mr Bachmann. A video from the DVD “PTCA: a history”. Reproduced with permission from angioplasty.org. The full interview is available at the following link: http://www.ptca.org/voice/2012/09/16/35th

Media

Andreas Grüntzig explaining the bimanual technique. It is particularly helpful even today when it is necessary to intubate the coronary artery deeply with the guiding catheter to pass a tight lesion with the balloon. The voice in the background is that of Spencer King. The case was performed in Atlanta, GA, USA, in 1983.

Interview with the first PTCA patient, Mr Bachmann. A video from the DVD “PTCA: a history”. Reproduced with permission from angioplasty.org. The full interview is availabe at the following link: http://www.ptca.org/voice/2012/09/16/35th

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References

  • 1. Gaspard P. The History of Coronary Angioplasty. Toulouse, France: Europa Digital and Publishing; 2017.
  • 2. Monaghan D. Journey into the Heart. New York, NY, USA: Gotham Books/Penguin; 2007.
  • 3. Zeitler E, Schoop W, Zahnow W. The treatment of occlusive arterial disease by transluminal catheter angioplasty. Radiology. 1971;99:19-26.
  • 4. Dotter CT. Transluminally-placed coilspring endarterial tube grafts. Long-term patency in canine popliteal artery. Invest Radiol. 1969;4:329-32.
  • 5. Grüntzig AR, Turina MI, Schneider JA. Experimental percutaneous dilatation of coronary artery stenosis (abstract). Circulation. 1976;54(Suppl):81.
  • 6. Meier B. His master’s art, Andreas Gruntzig’s approach to performing and teaching coronary angioplasty. EuroIntervention. 2017;13:15-27.
  • 7. Serruys PW, Onuma Y. What is it to become an octogenarian 40 years after the first angioplasty? EuroIntervention. 2017;13:11-3.
  • 8. Grüntzig A. Transluminal dilatation of coronary-artery stenosis. Lancet. 1978;311:263.
  • 9. Achenbach S. An interview with Stephan Achenbach, Chairperson 2016-2018 of the ESC Congress Programme Committee. EuroIntervention. 2017;13:631-2.
  • 10. Collet C, Grundeken MJ, Asano T, Onuma Y, Wijns W, Serruys PW. State of the art: coronary angiography. EuroIntervention. 2017;13:634-43.
  • 11. Bourantas CV, Tenekecioglu E, Radu M, Räber L, Serruys PW. State of the art: role of intravascular imaging in the evolution of percutaneous coronary intervention – a 30-year review. EuroIntervention. 2017;13:644-53.
  • 12. Pontone G, Guaricci AI, Neglia D, Andreini D. State of the art: non-invasive imaging in ischaemic heart disease. EuroIntervention. 2017;13:654-65.
  • 13. Echavarria-Pinto M, Collet C, Escaned J, Piek J, Serruys PW. State of the art: pressure wire and coronary functional assessment. EuroIntervention. 2017;13:666-79.
  • 14. Simpson JB, Baim DS, Robert EW, Harrison DC. A new catheter system for coronary angioplasty. Am J Cardiol. 1982;49:1216-22.
  • 15. Bonzel T, Wollschlager H, Just H. [A new catheter system for the mechanical dilatation of coronary stenoses with exchangeable intracoronary catheters, fast flow of the contrast agent and improved control]. Biomed Tech (Berl). 1986;31:195-200.
  • 16. Alfonso F, Scheller B. State of the art: balloon catheter technologies – drug-coated balloon. EuroIntervention. 2017;13:680-95.
  • 17. Barbato E, Shlofmitz E, Milkas A, Shlofmitz R, Azzalini L, Colombo A. State of the art: evolving concepts in the treatment of heavily calcified and undilatable coronary stenoses – from debulking to plaque modification, a 40-year-long journey. EuroIntervention. 2017;13:696-705.
  • 18. Stefanini GG, Byrne RA, Windecker S, Kastrati A. State of the art: coronary artery stents – past, present and future. EuroIntervention. 2017;13:706-16.
  • 19. Gargiulo G, Valgimigli M, Capodanno D, Bittl JA. State of the art: duration of dual antiplatelet therapy after percutaneous coronary intervention and coronary stent implantation - past, present and future perspectives. EuroIntervention. 2017;13:717-33.
  • 20. Cassese S, Byrne RA, Jüni P, Wykrzykowska J, Puricel S, Ndrepepa G, Schunkert H, Fusaro M, Cook S, Kimura T, Henriques JP, Serruys PW, Windecker S, Kastrati A. Mid-term clinical outcomes with everolimus-eluting bioresorbable scaffolds versus everolimus-eluting metallic stents for percutaneous coronary interventions: a meta-analysis of randomized trials. EuroIntervention. 2017 Jul 4. [Epub ahead of print].
  • 21. Katigiri Y, Stone GW, Onuma Y. State of the art: the inception, advent and future of fully bioresorbable scaffolds. EuroIntervention. 2017;13:734-50.
  • 22. Stone GW, Maehara A, Lansky AJ, de Bruyne B, Cristea E, Mintz GS, Mehran R, McPherson J, Farhat N, Marso SP, Parise H, Templin B, White R, Zhang Z, Serruys PW; PROSPECT Investigators. A prospective natural-history study of coronary atherosclerosis. N Engl J Med. 2011;364:226-35.
  • 23. Iqbal J, Widmer R, Gersh BJ. State of the art: optimal medical therapy – competing with or complementary to revascularisation in patients with coronary artery disease? EuroIntervention. 2017;13:751-9.
  • 24. Mohl W, Henry TD, Milasinovic D, Nguemo F, Hescheler J, Perin EC. From state-of-the-art cell therapy to endogenous cardiac repair. EuroIntervention. 2017;13:760-72.