Interventional cardiology on a roll Interventionelle Kardiologie in der Schweiz: Wo stehen wir im internationalen Vergleich?

The year 2007 marks the 30th anniversary of percutaneous transluminal coronary angioplasty (PTCA), more recently called percutaneous coronary intervention (PCI). It also marks the 20th anniversary of the annual comprehensive poll of catheter-based cardiac procedures in Switzerland. The analysis of the 18th poll pertaining to 2005 is published in this issue. These yearly registries have the longest history worldwide and still the second-best degree of detail and precision (after Austria). PCI has not initiated interventional cardiology but it is its most prominent representative. In fact, the first interventional therapy of heart disease was carried out by RubioAlvarez in 1951. He was using a crude instrument to crack a congenital pulmonary valve stenosis [1]. Of note, percutaneous closure of an atrial septal defect (ASD) also preceded PCI by a couple of years [2]. These were procedures in the realm of pediatric cardiology. The adult cardiologist woke up to mechanical therapeutic procedures with the first case of PCI performed on September 16th, 1977, at the University Hospital (Kantonsspital at that time) of Zurich, Switzerland. This procedure kicked off an unprecedented success story in modern medicine. PCI is currently the most common medical intervention dealing with a prognostically important disorder. It is a direct descendent of peripheral catheter angioplasty introduced with an article of Dotter and Judkins in 1964 [3]. Their method to improve blood flow through narrowed peripheral arteries by passing the stenosis with catheters of increasingly large diameters was moderately successful and highly impractical. It implied a hole at the puncture site commensurate to the largest catheter used. Porstmann in Germany tried to improve the method by using a Latex balloon confined to a maximal diameter because it was inflated within the longitudinally split plastic catheter [4]. However, the disadvantage of catching plaque material during deflation of the device prevented a wider application of the method. The breakthrough came with the polyvinyl chloride (PVC) balloon of Grüntzig. PVC was suggested to Grüntzig by a retired plastic expert of the Technical University of Zurich (ETH) who continued to occupy a small office just a stone-throw away from Grüntzig’s place of work as a resident in the Angiology Division of the adjacent hospital [5]. The fact that the PVC balloon grew to a certain diameter with a low pressure of 1 bar and then retained a fairly constant shape while increasing the pressure up to about 6 bar (rupture pressure of the PVC balloons of the time) predestined it for the treatment of atherosclerotic cardiovascular disease. After using this type of balloon successfully in several hundred peripheral arteries, Grüntzig managed to miniaturise it for the use in the coronary arteries together with a small local company specialising in medical equipment (Schneider Medintag). In 1976, the balloon was ready for a first attempt but a patient was nowhere to be found. At that time in Switzerland, coronary angiography was restricted for patients refractory to conventional triple anti-anginal therapy. This was imposed by a dearth in facilities for coronary angiography which created a long waiting list. Thus, patients finally undergoing diagnostic cardiac catheterisation were typically found to have advanced triple vessel disease. Grüntzig was looking for a patient with a single stenosis. On March 22nd, 1976, Grüntzig decided against his initial plan to try his method on a patient with terminal triple vessel disease and unstable angina. The patient had been turned down by the cardiac surgeons and was in desolate and moribund condition. Grüntzig was