“The Heart Healers: The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives” (St. Martin Press, September, 2015) by James Forrester, MD, is a new non-fiction book that tells the true story of progress in treating heart disease from the 1940’s to today.
During a career spanning from the 1960s to the present, Dr. Forrester lived through and contributed to developments that dramatically altered our understanding and treatment of valve diseases, arrhythmias, congestive heart failure, and coronary artery disease. In this book, he blends the fascinating story of cardiology advances and discoveries with case histories of his own patients, including how their conditions were treated, and how their treatment would have differed as techniques of diagnosis and therapy improved.
After medical school at the University of Pennsylvania, Dr. Forester completed a residency in internal medicine at UCLA-Harbor General Hospital, and a cardiology fellowship at Harvard’s Peter Bent Brigham Hospital (now Brigham and Women’s). In 1970, he joined the cardiology group at Cedars-Sinai Medical Center. In the ensuing years, he contributed to the development of bedside hemodynamic monitoring with the Swan-Ganz catheter, and co-invented the Diamond-Forrester method of probability analysis in coronary disease. He led the team that developed coronary angioscopy, among many other research projects, and served as Chief of the Division of Cardiology at Cedars-Sinai, where he continues today as Professor Emeritus.
Heart surgery? Too dangerous
Operating on the heart was considered too dangerous to attempt in the early 1940s, expected to produce massive bleeding and instant death. Then, a U.S. military surgeon stationed in a battlefield hospital in London during World War II confronted the challenge posed by shrapnel wounds in the hearts of young soldiers. Rather than accepting inevitable death from those injuries, he decided to remove the shrapnel and designed a technique to close the hole. Dramatically, his first success occurred on a date now celebrated in history — as D-Day, June 6, 1944.
Willingness to challenge preexisting consensus, coupled with creativity, soon led to more complex cardiac surgeries. An operation to correct mitral valve stenosis came first, even before the invention of the heart-lung machine. That technological wonder enabled longer and more complicated operations — to correct congenital abnormalities, repair and replace heart valves, and finally to deal with the biggest killer of all, coronary artery disease (CAD).
Dr. Forrester has a great story to tell, and he does it very well. It helps that his subjects include misfits and rebels like the resident who passed a urinary catheter from his own left antecubital vein to his heart, to test his hypothesis that cardiac catheterization could be done safely. His hospital’s head physician had forbidden the procedure, but the chief’s rage at the resident’s defiance was muted by the procedure’s success.
By the 1950s, cardiologists were able to visualize the chambers of the heart by injecting contrast dye, but had no way to obtain images of the entire length of coronary arteries. Experts agreed that inserting a catheter into one of those vessels could completely obstruct it and lead to an infarct. Even if that didn’t happen, injecting dye into a coronary artery would deprive the heart of oxygenated blood, they believed, and lead to sudden death.
Serendipity stepped in when an attempt to visualize an aortic valve went awry at the Cleveland Clinic in 1958. The catheter accidentally lodged in the patient’s right coronary artery. He suffered no lasting problems, but the procedure produced a clear image of the entire length of his coronary artery. That observation led to the development of coronary angiography, better diagnosis of coronary artery disease, and later to coronary artery bypass surgery.
CAD: from death sentence to successful treatment
In the mid-1960’s, when Dr. Forrester was a medical student, he recalled treating a patient who was admitted to a regular hospital bed with unstable angina. The symptoms inexorably progressed to myocardial infarction, hypotension, ventricular tachycardia, and ventricular fibrillation. The ensuing CPR ended in the patient’s demise.
Only a few years later, Dr. Forrester notes, a patient like that would have been admitted to a coronary care unit with a bedside monitor to promptly detect arrhythmias, and treated with medicines to prevent the sequence of events that ensued. If the patient did go into v-fib, resuscitation would have been more prompt and his chances for survival would have been much better. By the 1980’s, the sudden onset of ECG changes of a heart attack on a bedside monitor would have led to treatment with an intravenous clot buster. Later, coronary angioplasty improved on those results. Along the way, cardiologists also made progress in lowering the risk of CAD with statins and other drugs.
The Heart Healers covers the period of greatest progress in the history of heart medicine through the stories of clinicians, scientists and patients who contributed to and benefited from these developments. Dr. Forester writes clearly enough to be understood by lay readers, but relates enough fascinating anecdotes and historical vignettes to entertain and inform experienced physicians as well.