On 16 September 1977, Bernhard Meier helped Andreas Grüntzig to perform the world’s first in-human coronary angioplasty procedure. In this commentary, he reviews the peculiarities of that procedure and reports how well the patient, 40 years on, adheres to his medication regimen.
The first odd thing about the first percutaneous coronary intervention (PCI) may be that it was not the first PCI. Norberto Galiano recanalised a right coronary artery in a patient with acute myocardial infarction with a wire in Brazil and published the results in October 1972 in Arq. Brasileiros Cardiologia. Even for Andreas Grüntzig, the September 1977 procedure was not his first PCI attempt. During the two-year search for a suitable first patient, Grüntzig allegedly passed balloon catheters into coronary arteries without using them. Furthermore, on 22 March 1976, he tried to dilate the left main stem of a moribund 73-year-old patient with advanced triple vessel disease, poor left ventricular function, intractable angina, and an occluded descending aorta. The guiding catheter had to be inserted through the arm and never reached the left main stem.
The ideal patient with a documented single significant lesion, normal left ventricular function, and normal access vessels was a rare bird in the 1970s. Bypass surgery had been around for less than a decade and was reserved for patients with advanced disease, still in good general health, and willing to drastically reduce their risk factors. This led to the fact that diagnostic coronary angiography was reserved for patients younger than 65 years who had a long record of therapy-refractory angina, usually including repeat myocardial infarctions. The “search warrant” for the patient that Grüntzig was looking for was not only distributed at his hospital in Zurich (Switzerland) but also at some hospitals of his friends in Germany and in the USA (Grüntzig, himself, spent weeks there without finding a suitable patient).
When insurance salesman Dölf Bachmann—who, like Grüntzig at the time, was aged 38—was identified as a suitable patient, he represented a strange case. A severe bout of angina caught this heavy smoker on one of his early morning fishing sprees. The pain did not relent and the patient drove to his family doctor who performed an ECG. ST-segment elevation was found, the patient received nitroglycerin, and drove, himself, to the nearby city hospital; an ambulance was not involved. There, the ECG had normalised and the pain disappeared. The patient was kept on a ward and a couple of days later, an exercise stress test was performed (today considered poor practice!). This brought about the same excruciating chest pain accompanied by ST-segment elevation and runs of ventricular tachycardia. The tertiary hospital in Zurich was called and subsequently had the patient transferred by ambulance, and he was scheduled to undergo coronary angiography—despite his relatively short history of symptoms, which normally would have meant that he did not qualify for an invasive workup—on 14 September 1977.
I was a young resident who had been helping Grüntzig with his patients with peripheral angioplasty for about two years when this patient was assigned to me. I was not present when the diagnostic study was done but I saw the 35mm cinefilm and realised that it looked exactly like Grüntzig told me it should look for the ideal first patient. All coronary arteries were normal except for the left anterior descending coronary artery, which had a short, tight, and proximal stenosis, not involving the nearby large diagonal branch. The radiologist who had done the angiogram enumerated about five other lesions which were not there then and are still not there now.
The next peculiarity was that the exercise stress test was repeated the day after the coronary angiogram and again produced ST-segment elevation, ventricular tachycardia, and chest pain (on left). That day (15 September), I shared the good news with Grüntzig—just back from yet another unsuccessful trip abroad to find a first patient. He took one glance at the film and immediately took me to Bachmann, with whom I was to grow a solid friendship over the past 40 years. He remembers Grüntzig as an exceptionally good-looking young white-coated fellow “with an aura of competence and conviviality”. Bachmann was upset by stories of his roommates who were recovering from coronary artery bypass grafting (CABG) about how “pitiful” the first days after surgery were and how much their “chests and the legs hurt”. Therefore, he eagerly jumped on Grüntzig’s offer to try to do something much lighter.
I can testify that Grüntzig mentioned that the procedure had never been done before. Yet, according to Bachmann, the simple sketches Grüntzig made to explain what he was going to do and the reference to the facts that a couple of hundred patients had had similar successful procedures in other arteries of the body and that CABG was going to be on standby were all he needed for a quick positive decision. Bachmann also remembers that he slept well that night and was hardly stressed when being wheeled to the catheterisation laboratory the next day. There, he recalls a calm-faced Grüntzig who meticulously explained to him every step of what he was doing. Bachmann was further reassured by several professors in and out the room.
From what I remember, Bachmann was indeed relaxed and Andreas was nervous but hid it well. The professors included Marko Turina, the cardiac surgeon on standby and senior cardiologists—all of whom likely came to see Grüntzig fail. He did not fail but he did dilate the completely normal diagonal branch after having successfully performed the actual left anterior descending coronary artery PCI when one of these colleagues pointed out that there was an additional stenosis there which neither he nor Grüntzig could possibly see on the dismal fluoroscopy of the time. The roller pump for distal coronary perfusion that Grüntzig had used in his dog experiments to avoid ventricular fibrillation during balloon occlusion of the coronary artery was not used, and Bachmann leisurely chatted throughout his two coronary occlusions of less than one minute each. Grüntzig asked him about chest pain but there was none. The ECG showed ST-segment elevation and during the second inflation a right bundle branch block appeared and persisted for almost 24 hours. During manual compression of the 10Fr femoral puncture site, I had time to ascertain that Bachmann was fine and that he had not suffered at all during the procedure.
A few days after the intervention, the exercise stress test was repeated. It still showed some ST-segment elevation at peak exercise and some thallium perfusion defect but the patient was asymptomatic. Grüntzig’s and the world’s first lesson about PCI—that right bundle branch block develops for a day and that the exercise stress test remains abnormal—was completely misleading.
That patient was discharged on a vitamin K antagonist. Acetylsalicylic acid had no cardiac indication at that time. He quit smoking for good but he also quit all drugs after few weeks. His peculiar conviction that drugs (even preventive ones) lose their effect when taken chronically persists to this date. He has successfully lived with coronary artery disease for 40 years without antiplatelet or cholesterol lowering drugs, defying literature and guidelines. How peculiar is that! The last time we talked about that was at his 40-year ceremony at EuroPCR in Paris (Figure 2). He smilingly admitted that my insisting made him take an occasional Aspirin or statin every once in a while.
Bernhard Meier is senior consultant at the University of Bern, Bern, Switzerland
