Remembering the Classics: “TripTik” to the Heart
Alan Jay Schwartz, MD, MSEd
It’s the late 1980s. We were planning a family summer trip to explore 9 states in the western US. Remember, I had no cell phone with GPS to guide us. We depended upon a TripTik. What is a TripTik you ask? The AAA (American Automobile Association) TripTik was a loose-leaf paper booklet, custom made to guide arrival to a specified destination. It included a starting and end point with turn page-by-page directions pointing out the landmarks along the way.
At the turn of the 20th century the story was quite similar. Physicians wanted directions, a TripTik if you will, to safely navigate the circulatory system to reach the heart. Let’s recount the steps achieved by the luminaries who crafted the TripTik to the heart.
TripTik to the heart-page 1:
In 1929, a young recently minted Doctor, Werner Forssman, “…became interested in cardiac arrest and was struck by how intracardiac injections of resuscitating medications were avoided, until patients were beyond help, because of well-founded fears of causing pneumothorax, tamponade, or coronary artery laceration. Deciding to research better ways to inject drugs for cardiac resuscitation, he deduced that catheterization of the right heart via the venous system would be a far safer and thus more applicable method of access to the cardiac chambers.”1 Inserting a ureteral catheter into his own basilic vein, Forssman threaded the device into his heart and then pranced to the radiology suite to document his achievement.2
TripTik to the heart-page 2:
In the 1930s and 1940s, “[In 1936] At Bellevue Hospital (New York), [André F] Cournand and [Dickinson W] Richards began their classic studies of right-heart physiology…[In] 1941…this team issued a series of papers on simultaneous right-heart pressure measurements and oximetry-based studies of cardiac output; in 1942 they catheterized the right ventricle and in 1944 the pulmonary artery.”1
Forssman, Cournand and Richards’ “studies…established use of cardiac catheterization, among other things, to introduce contrast fluid for X-ray images and to measure pressure and oxygen content [in the circulatory system] …” earning them the 1956 Nobel Prize in Physiology and Medicine. (https://www.nobelprize.org/prizes/medicine/1956/cournand/facts/ accessed 04/11/2023)
TripTik to the heart-page 3:
In 1953, vascular cutdown was the common technique for introduction of large bore catheters into the central circulation from peripheral insertion sites. Sven Ivar Seldinger, was concerned that, “The artery exposure technique of catheterization [wa]s time-consuming, troublesome and may present certain risks.” To answer these concerns he described, “Catheter Replacement of the Needle in Percutaneous Arteriography-A New Technique”.5 Today, this “guidewire” technique is a staple for radiologists, cardiologists, and anesthesiologists among many other practitioners.
TripTik to the heart-page 4:
In 1970, Swan, Ganz and colleagues introduced another safety advance in mapping the route to the heart. Swan linked his observations of wind catching sails to move boats with the current to blood flow catching a balloon tipped catheter to move it through the circulation.6,7 “Pressures in the right side of the heart and pulmonary capillary wedge can be obtained by cardiac catheterization [at the bedside] without the aid of fluoroscopy…catheterization of the right ventricle and pulmonary artery can be accomplished rapidly and safely without fluoroscopy in seriously ill patients.”6
When you are on route to the heart, depend upon the TripTik described by a few insightful physicians who mapped out a safe and effective route:
Start following Forssman-central vascular cannulation from a peripheral insertion site.
Turn left to follow Cournand and Richards-right heart catheterization.
Turn right to follow Seldinger-percutaneous guidewire cannulation.
Arrive at the heart following-Swan, Ganz, and colleagues balloon flotation bedside cardiac catheterization.
References
1. Mueller RL, MD, Sanborn TA: The history of interventional cardiology: Cardiac catheterization, angioplasty, and related interventions. AM HEART J 1995; 129: 146-72.
2. Forssmann W. The catheterization of the right side of the heart. Klin Wochenschr 1929; 8: 2085-7
3. Cournand A, Ranges HA: Catheterization of the right auricle in man. Proc Soc Exp Biol Med 46, 462 (1941)
4. Richards DW. Cardiac output by the catheterization technique in various clinical conditions. Fed Proc 1945; 4: 215-20
5. Seldinger, SI: Catheter Replacement of the Needle in Percutaneous Arteriography: A new technique. Acta Radiologica 1953; 39 (5) 368 – 376
6. Swan HJC, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D: Catheterization of the Heart in Man with Use of a Flow-Directed Balloon-Tipped Catheter. N Engl J Med 1970; 283: 447-451
7. https://bcmj.org/articles/jeremy-swan-and-pulmonary-artery-catheter-paving-way-effective-hemodynamic-monitoring (accessed 04/11/2023)