Pioneers Who Transformed Coronary Disease: From Eisenhower’s Heart Attack to Clinton’s Coronary Surgery and Stents

By Allyn Mark M.D.

In 1955 at a time when the cold war was tense, President Eisenhower suffered a massive acute myocardial infarction (heart attack) while on vacation in Denver. His primary treatment consisted of six weeks of strict bedrest. Fortunately, Ike recovered his heart attack and served a second term only to succumb to further heart attacks and heart failure after his second term. In retrospect, we now know that at this time, there was virtually nothing of value therapeutically that his physicians had to offer him. In the half century following Ike’s heart attack, innovative doctors led the discovery and development of coronary arteriography, coronary artery bypass surgery, balloon coronary angioplasty and coronary stents, discoveries that dramatically improved the outlook for patients with coronary heart disease. This book tells the personal stories—the biographies--of these physicians—iconoclastic, innovative, charismatic and some tragic—who transformed the treatment of coronary heart disease in the half century after Eisenhower’s heart attack. Former President Bill Clinton is among the millions who have benefited from these discoveries.

• Language: English
• Publisher: AuthorHouse
• Release date: Aug 13, 2020
• ISBN: 9781728369594

Allyn Mark M.D.

Allyn Mark, MD, Professor Emeritus of Cardiology, directed the Cardiology Division of the Department of Internal Medicine at the University of Iowa Carver College of Medicine from 1976 to 1995 and was President of the Association of University Cardiologists from 1994-1995. He is the recipient of the Distinguished Mentor Award of the Carver College of Medicine. He has a long standing interest in the personal stories of pioneering discoveries.

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© 2020 Allyn Mark, M.D. All rights reserved.

No part of this book may be reproduced, stored in a retrieval system, or

transmitted by any means without the written permission of the author.

Published by AuthorHouse  09/04/2020

ISBN: 978-1-7283-6960-0 (sc)

ISBN: 978-1-7283-6958-7 (hc)

ISBN: 978-1-7283-6959-4 (e)

Library of Congress Control Number: 2020915043

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CONTENTS

Foreword

Chapter 1     A Rough Diamond: F. Mason Sones, Jr. And The Discovery Of Selective Coronary Arteriography

Chapter 2     Rene Favaloro: The Father Of Coronary Artery Bypass Surgery

Chapter 3     Time Will Tell: Charles Dotter—The Father Of Interventional Vascular Medicine And Interventional Radiology.

Chapter 4     Andreas Gruentzig : The Father Of Interventional Cardiology

Chapter 5     Geoffrey Hartzler: Angioplasty’s Aggressor

Chapter 6     Pioneers Of Coronary Stenting

Chapter 7     Robert Falotico And The Development Of The Cypher Sirolimus Drug- Eluting Coronary Stent.

Afterword: Clinton’s Coronary Surgery and Stents

References

FOREWORD

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EISENHOWER’S HEART ATTACK

AND CORONARY ARTERY DISEASE.

In September of 1955, at a time when the Cold War was foremost on the country’s mind, President Dwight Eisenhower suffered an acute myocardial infarction (heart attack) while on vacation in Denver where he and Mrs. Eisenhower were staying at the home of her mother. Between 1:30 and 2:30 AM Ike awakened Mamie saying I’ve got pain across the lower part of my chest.¹ Since the president had complained of indigestion the previous evening, Mamie gave him milk of magnesia but soon realized he was seriously ill and placed an alarming phone call to Dr. Howard Snyder, the president’s personal physician and close personal friend. Dr. Snyder, who was sprite at seventy-five, but professionally rusty, arrived within minutes. Dr. Snyder injected morphine for relief of pain, but delayed nine hours before requesting an electrocardiogram that revealed a massive myocardial infarction involving the anterior wall of the heart. Dr. Snyder had Ike transferred to Fitzsimmons Army Hospital in Denver by Secret Service car (not by ambulance) where he was cared for by Drs. Byron Pollock and Thomas Mattingly, two capable military cardiologists, in consultation with Dr. Paul Dudley White of Boston, the world’s leading cardiologist.

The American public was largely unaware of the growing incidence of coronary artery disease and heart attacks in the country and was gripped with anxiety, but on September 26, in what was called the day America learned about coronary artery disease, Dr. White held a masterful press conference in which he explained the disease to the American public and reassured them that the president would recover.²

The president’s care consisted primarily of six weeks of strict bedrest—a treatment for myocardial infarction now known to be ineffective, if not counterproductive. It was not until late October, almost five weeks after his heart attack, that the president was allowed to sit, stand and take even a few steps.

Ike made a joyous return to the White House on Veterans Day, November 11 seven weeks after his attack, and was then driven to his farm home in Gettysburg where he continued to slowly increase his activity. He was not allowed to return to full activity in the White House until January 18, 1956, fifteen weeks after his heart attack. In February, Eisenhower announced his intention to run for reelection which he won in a landslide. Fortunately, his cardiovascular health remained unchanged during the campaign and his entire second term as president with no chest pain even upon exertion, and no symptoms or signs of heart failure.³

Then, in November 1965, five years after his presidency, he sustained a second heart attack involving the inferior wall of his heart. This was followed by congestive heart failure in February 1967, and a third heart attack in April 1968. In May 1968, essentially a cardiac invalid, he was transferred to Walter Reed Army Reed Medical Center where he remained with continuous cardiac monitoring until his death on March 28, 1969 from progressive heart failure and repeated life-threatening heart rhythm disturbances almost fifteen years after his first heart attack.⁴

Although the commentary on Ike’s first heart attack in 1955 has focused on Dr. Howard Snyder’s delay in seeking prompt diagnosis and treatment, we now know that even had there been a prompt electrocardiographic diagnosis and hospitalization, there was nothing that his physicians had to offer in the way of effective treatment that would have minimized damage to his heart. Indeed in 1955 three words were frequently used to characterize coronary thrombosis and heart attacks: unpredictable, unpreventable, and untreatable.⁵ But over the next 45 years, innovative, iconoclastic, and charismatic physicians led the the way to discovery and development of coronary arteriography, coronary artery bypass surgery, peripheral arterial angioplasty, percutaneous balloon coronary angioplasty, and coronary stents.

This book tells the personal stories of the physicians, who made these discoveries and transformed the diagnosis and treatment of coronary artery disease in the second half of the 20th century. As we shall see, fifty years after the onset of Eisenhower’s first untreatable heart attack, former President Bill Clinton was among the millions who benefited from these advances. His story is told in the Afterword.

CHAPTER 1

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A ROUGH DIAMOND: F.

MASON SONES, JR. AND THE

DISCOVERY OF SELECTIVE

CORONARY ARTERIOGRAPHY

As a sophomore medical student at the University of Maryland, F. Mason Sones decided he wanted to be a cardiologist. At the end of his internship in 1944, one of his professors who learned of his intent told him, You can’t do that because there is not enough in cardiology to occupy you for a lifetime. Sones recognized the limitations of cardiology in this era and in the typically blunt style that would become his trademark, he recalled, I was convinced that all the stuff they were teaching us about managing heart disease was a lot of crap, so I decided to dedicate my life to proving those old guys were full of it.¹,²,³ Fourteen years later at age 40, he did just that with his serendipitous discovery of coronary arteriography, the cornerstone in the diagnosis of coronary artery disease and considered by many the most important discovery in 20th century cardiology. It paved the way for the introduction of coronary artery surgery and angioplasty that revolutionized the treatment of coronary artery disease.

Who was this character? Who was Mason Sones? Born in rural Mississippi, his childhood, education, and family were undistinguished. After he moved with his parents to Maryland, Sones attended Western Maryland College, a small, obscure liberal arts college.

After medical school and an internship at the University of Maryland, followed by two years of military service, Sones trained first in pediatrics and then in pediatric cardiology and cardiac catheterization at Henry Ford Hospital in Detroit.

In 1950, Carl Ernstene, Chairman of the Department of Medicine at the Cleveland Clinic, recruited Dr. Sones to establish a cardiac catheterization laboratory at the Clinic, but told him that the laboratory would be primarily for research and said, I doubt that cardiac catheterization will ever amount to anything as a useful clinical tool.⁴ Sones was unconvinced and undeterred. He was now a staff cardiologist, not a trainee, and he had his own laboratory. The catheterization lab became his domain.

He was driven by his work. He allowed nothing to get in its way and his family life suffered because of it. When his wife, Geraldine, called him at his lab in the evening to ask when he was coming home, he would say, Hon, I’ve got my coat and hat on and I’ll be there in twenty minutes, when he had no such intention. A custodian often saw him reviewing films alone in his office at two or three in the morning.⁵

Sones was uncouth and unkempt. He was relentlessly profane, even in the presence of patients. He wore the same T-shirt and trousers for days without cleaning. He ignored standards of sterility in the catheterization (cath) laboratory. He refused to wear a sterile cap and mask and didn’t wash his hands before putting on sterile gloves. He wore a lead apron over a T-shirt with no sterile gown over the apron. During a live demonstration course, Sones was once chastised by a cardiologist in the audience for breaking sterility by wiping the sweat from his forehead with his forearm. Sones countered, I don’t hold the catheter with my arm. I hold it with my fingers! He continued with the catheterization.⁶

He was a chain smoker and smoked during the procedures in the cath lab by holding a cigarette with sterile forceps. He would take a few puffs and park the forceps with the lighted cigarette on the edge of the sterile instrument table while he performed the catheterization. He was so adroit that he could complete a procedure before the cigarette burned out!⁷

Sones drank heavily. He loved to entertain visitors over drinks and dinner at the Theatrical Grill or the Bolton Square Hotel. He would talk and drink into the early morning hours and be late for the cath lab in the morning. He was especially rough on Mondays after drinking heavily over the weekend.⁸ Floyd Loop, a prominent cardiac surgeon and a friend of Sones, told me, Mason spilled more liquor than you and I will ever drink.⁹

Sones had a consuming drive for perfection. It’s not good enough, was his recurrent comment. Almost nothing in the cath lab escaped his improvement. His fame emanated primarily from his discovery of coronary arteriography, but before this discovery his insatiable drive for innovation led Sones to the forefront of new methods for cardiac catheterization, notably cineangiography (motion picture photography of the coronary arteries and heart during catheterization).¹⁰

His colleagues and trainees repeatedly refer to Sones’ obsession with honesty and truth. William Proudfit wrote, Most people who talk about his greatest attributes in medicine cite his intellect and drive. That misses the point. His greatest attribute was his honesty. He was always completely honest about his work.¹¹ He never forgave dishonesty. His long-time secretary, Elaine Clayton, told me that, the only thing he wouldn’t tolerate was lying.¹² Conrad Simpfendorfer, a former trainee, said Sones was brutally honest with patients and referring physicians. If he made a mistake, he would say, I made a mistake. He wouldn’t cover up anything when it came to the care of his patients. ¹³ Despite his colleagues’ emphasis on his honesty, as we shall see, there were a number of occasions when Sones shaded or abandoned the truth when he thought it would hinder the acceptance of coronary arteriogrphy during its development.

Sones was a demanding task master. He had an explosive personality, and often showed anger over trivial annoyances. He did not hesitate under any circumstances to criticize others if he thought they did not meet his standards.¹⁴ When he was invited to speak at panel discussions, he did not hesitate to interrupt and challenge other speakers when he disagreed.. An embarrassing episode occurred at a meeting of the American Heart Association when a young cardiology trainee from Boston was presenting a talk on myocardial infarction (heart attack) with normal coronary arteries.¹⁵-¹⁶ He showed a slide and began to say in this normal arteriogram.. Before he could continue Sones stood up in the back of the room and said, That’s not normal, there is a stenosis in one of the coronary arteries. Although Sones was correct, his rude interruption violated the normal courtesy of scientific meetings.

In today’s medical and scientific world, these traits would likely have doomed his career, but in the less restrained medical and scientific culture of mid-20th century, they did not overshadow and may even have buttressed his resolute development of coronary arteriography.

He was a brilliant thinker with a prepared mind able to grasp the significance of an accidental result that had the promise of a transformational discovery. He was self-believing and canny enough to press forward with that discovery in the face of criticism from leaders in cardiology that would have prompted many to retreat.

Despite his volatile and feisty personality, there was widespread affection and admiration for Sones among his colleagues and trainees. What explained this seeming incongruity? It was his devotion to patients and medicine and his modesty, optimism and persistence in the face of criticism.¹⁷

His devotion to patients, whether factory workers or heads of state, was overriding and obvious. His colleagues understood that his one objective in life was to improve the lives of patients with no need for recognition, prestige or honor.¹⁷ He had a direct and disarming clinical manner. He allowed nothing to interfere with his patient’s best interest. Any physician showing the slightest lack of consideration toward one of his patients was the recipient of Sones’ wrath. He loved his patients and they were fond of him. Rene Favaloro wrote, Those who knew Sones only through his participation in meetings where he was generally aggressive and even disrespectful will never appreciate that he was an extremely sensitive person who suffered with his patients whom he loved deeply.¹⁸

He had a ready laugh, endearing him to friends. Although brilliant and accomplished, he was modest. He treated the cleaning staff with as much respect as members of the Board of Governors at the Cleveland Clinic.

Sones loved to talk, and expressed himself forcefully. But as his colleague, William Proudfit, said, Unlike most talkers, Mason was also a great listener, as long as you had anything to say. If Mason drifted off while you were talking, you knew that you no longer had anything to say. His conversations were never far from medicine. His mind was like a steel trap. He remembered everything you told him.¹⁹

Although a fascinating conversationalist, Sones’ lectures were disorganized. He was always thinking and talking about something new as he was presenting. He could not keep to his outline or train of thought. Ironically, he was a magnificent clinical teacher while at the bedside caring for patients.²⁰

When Sones joined the Cleveland Clinic in mid-century, it was not the medical colossus it is today. But the foundation was being laid for the emergence of the Cleveland Clinic as the house that heart built. In 1948, two years before Sones’ appointment, Donald Effler was appointed Chief of the Department of Cardiothoracic Surgery. Effler was a talented, innovative surgeon, an excellent judge of talent, and an arrogant, domineering leader. In contrast to Sones who was short and feisty, Effler was tall and refined. Whereas Sones scorned the establishment, Effler was an elite, polished medical politician. Both were talkers and liked to dominate. And both were fearless and audacious.²¹,²²

These strengths and styles provided the foundation for the rise of the Cleveland Clinic to international prominence, but they also created conflict.

Effler was soon joined by Willem Kolff from the Netherlands who had developed his own heart-lung machine for open-heart surgery. The first step in the collaboration of Sones, Effler and Kolff was in the care of infants and children. Sones began his career as a pediatric, not an adult,