Coronary Artery Bypass Surgery

Coronary artery bypass surgery, was a game changer in the treatment of heart disease and a major  positive disruptive technology which improved, preserved and lengthened the lives of patients with coronary artery disease,

I first learnt about coronary angiography at the Karolinska hospital in Stockholm in 1968. I had been invited by the Elema company to study their angiographic techniques using a large film changer to obtain exquisite and precise high definition images of the heart and its chambers. The radiologists were using an interesting technique of non-selective injections of contrast medium into the root of the aorta. The patient was anaesthetized, and a coiled catheter placed in the aortic root. Ventilation was interrupted, the cardiac output fell as did the blood pressure and then a large injection of contrast medium was made into the aorta. The contrast medium filled the coronary arteries, ventilation and the normal circulation were resumed, and excellent X-ray images were obtained of the coronary arteries.

Mason Sones at the Cleveland Clinic made the first direct coronary angiogram by accident. A cardiac catheter slipped into the coronary artery, contrast material was injected, the coronary arteries were opacified and the patient recovered. He refined his technique and soon was undertaking routine coronary angiography. Floyd Loop, the surgeon, was performing many Vineberg procedures, where the internal mammary artery was implanted into an ischaemic region of the heart muscle, which was not receiving sufficient blood because of a coronary artery obstruction. Mason Sones would then perform selective angiography and show that the internal mammary artery branches had connected to the branches of the obstructed coronary arteries. He had acquired a series of more than 2000 patients and had a vast experience in understanding the anatomy and disease in the coronary arteries.

Coronary artery surgery for atherosclerotic disease has undergone many changes.  First, the pericardium was opened and abraded (roughened) so that on healing small anastomoses were created between the parietal and visceral layers to improve coronary blood flow (Claude Beck). Vineberg in Toronto took down the internal mammary artery and implanted it into a tunnel in the ischaemic myocardium where it generated its own collaterals and this had been proven to be very effective at the Cleveland clinic by Donald Effler and then subsequently proven by angiography by Mason Sones

The coronary arteries were very small – 2 to 4 mm in diameter, but at first the surgeons tried to put patches across the  the narrowing to widen the arteries. This was only moderately successful.

The next step was to use open heart surgery  and support the heart using a heart-lung machine. A large superficial vein from the leg was harvested and used to bypasss the narrowing. The first anastomosis (connection) was to the aorta and the second to the narrowed or obstructed artery beyond the narrowing. Blood flowed through the bypass vein to supply the artery beyond the narrowing. The patient recovered, and his angina disappeared. A man who was unable to walk up a hill was restored to a normal lifestyle. Unfortunately, only very sick patients were selected for the operation. They had very diffuse disease with multiple narrowing’s in several arteries. They had also experienced several heart attacks so that the muscle of the heart had been replaced by a large scar. The post operative recovery was slow and the initial mortality was high. The cardiologists were not keen on sending their patients to an operation with a high mortality and a long recovery period. However Favaloro and Floyd Loop at the Cleveland Clinic, and Dudley Johnson in Milwaukee persisted, and gradually the results improved. They had excellent documentation and followup of their patients but showed that avanced age, multiple lesions and poor ventricular function carried a poorer prognosis.

I faced a different problem. I had learned how to do high quality coronary angiography but my surgeon, Chris Barnard in Cape Town was unhappy to with this microscopic surgical technique, so that I used my first coronary angiograms to exclude coronary disease in older  patients with valve disease before surgery.

I moved to Durban and was joined by Basil Lewis and Avi Bakst. We built a new catheter lab which had a 9 inch image intensifier that gave us a large field ventriculogram, and a second 5 inch intensifier which had greater magnification and produced beautiful cine pictures of the coronary arteries, its branches and the disease processes. Ben le Roux, an excellent surgeon was unwilling to tackle the microsurgery of the coronary arteries and we had to wait until we were joined by Mike Rogers, who had trained with Donald Ross at the National Heart Hospital in London, where he had undertaken the first coronary artery bypass grafts in England. Mike Rogers introduced the bypass graft operation in Durban and with his usual enthusiasm and surgical ability our program took off and flourished.

Basil and I travelled to the United States once a year, and would stop over at the Cleveland Clinic, and in Milwaukee. We continued to learn all the tips and tricks for improving the quality of our angiography and spent hours in the operating room watching the details of coronary artery bypass grafting and then following the patients after surgery in the clinic. Their angina pectoris had disappeared, and they returned to normal life. Their post operative coronary angiograms showed a normal graft filling a diseased artery with contrast medium. The operative problem was being solved.

In Durban our program flourished We now undertook more coronary artery bypass grafting on less severely diseased patients. The South African cardiologists were very impressed and excited by this impressive and revolutionary operation. They followed their patients in the clinic after coronary artery bypass surgery: their angina pectoris had disappeared, and they were living a normal life. The cardiologists started referring patients, but unfortunately most of them had very severe advanced disease.

We changed our research program to study the different patterns of coronary artery disease, their infarcts, their electrocardiograms, their clinical status and we built up a new classification of localized and diffuse disease and its syndromes that appeared after narrowing or obstruction of the left anterior descending, circumflex and right coronary arteries. We became more selective in  our patients, operative mortality fell, the clinical improvement was more marked after surgery and the results outstanding. Patients were referred from all parts of South Africa and now we had a problem with the Provincial Administration about the payment of fees since we were a free government hospital. Later  Rob Kinsley returned from the Mayo Clinic and started bypass surgery in Johannesburg, and a new generation of cardiac surgeons emerged in South Africa, but mostly in the private sector.

When I came to Jerusalem in 1973, coronary artery bypass surgery, was in its infancy, the coronary angiography was of poor quality and the surgeons had little experience.

I drove the program forward with my usual high energy enthusiasm.and soon we became the most active unit in the country and together with good surgery by Joe Borman and his younger colleagues we built up a large reservoir of patients with excellent short and long term surgical and clinical results.

Initially, Joe was a little conservative so that some of our very difficult and complicated  patients were sent to Floyd Loop in Cleveland, Johnson in Milwaukee, and to Green at NYU.  This was a tricky time as the internal medicine physicians were unwilling to submit their patients to surgery. The morbidity and mortality rates continued to fall and we had a flood of patients from all corners of Israel.  The sluice gates had opened.

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After 20 years coronary artery surgery had become the major full-time occupation of the cardiac surgeons. All the major hospitals in Israel followed suite and now have flourishing and  successful coronary artery bypass surgery programs.

 The next development was to protect the myocardium and provide a quiet operative field during the operative procedure. The heart was stopped, and we used hypothermia and direct coronary perfusion to preserve coronary blood flow and oxygenation. Myocardial preservation became a major goal. This was achieved by using potassium infusions into the coronary arteries, that would stop the heart and provide a quiet field for anastomosing the tiny arteries and then use other drugs and electrolyte solutions during the  preservation period. Reperfusion of the coronary arteries with warm blood and then defibrillation restored a beating heart. We restarted the heart but in a few patients there was myocardial damage. Joe Borman undertook extensive investigation of the preservation solutions in his animal laboratory.

We also discovered that the venous grafts had a finite lifespan. About 20% closed shortly after the operation, because of a poor anastomosis, a poor run off causing  low flow with clotting, or the grafts twisted in the pericardial space.

Some of the veins were not healthy or could not withstand the high arterial pressure and developed a reactive fibrosis and closed within the first year. In a third group, the risk factors for atherosclerosis continued to affect the native arteries, the atherosclerotic process developed in the grafts, and we learned that management of risk factors for atherosclerosis was a lifelong intervention and that patients with high blood levels of LDL soon developed graft atherosclerosis. Floyd Loop preferred to use bilateral internal mammary artery implants, the grafts remained patent: the long term results after 10-20 years were excellent. The other arterial grafts from the arm or abdomen were less successful, but as the implant technology improved, so did the long term outcomes.

The next stage was operating  on the beating heart without using the heart-lung machine: “off bypass surgery”. The chest was opened, and all the the anastomoses were undertaken on the beating heart, often at a reduced heart rate using short-term beta blockers. This was more difficult. The left anterior descending artery, on the anterior surface of the heart was easy to anastomose, the circumflex artery was located on the side of the heart, and to expose it, it had to be brought out of the chest and the heart rotated and brought forward. The right coronary artery was more difficult. It was located at the back of the heart and the heart had to be bent and  lifted forward for exposure. We overcame all these problems, but myocardial protection remained the simplest procedure.

Then came minimal invasive surgery using mini thoracotomies and working under telescopic vision. Recovery was rapid causing less discomfort to the patient.

I immersed myself and all my younger colleagues in coronary artery disease, studied all the  techniques at meetings in the US and Europe and spent many hours  in the operating room observing the leading surgeons in Europe and the USA. We also invited them to join us in Jerusalem and operate in Hadassah.

Initially the CABG procedures were treated with skepticism but as the results improved, major multicenter double-blind controlled trials were undertaken to compare medical and surgical treatments. The surgical group had better symptomatic and quality of life outcomes.

Percutaneous coronary angioplasty entered our repertoire in the early 1980’s: a simple technique of improving coronary artery blood flow and  myocardial perfusion without opening the chest and performing a major operation. We again led the way. Most centres would undertake a coronary arteriogram in patients with symptomatic coronary artery disease, return them to the ward, discuss the outcome and then decide whether the patient should be treated with conservative medical treatment or undergo PTCA or CABG. We decided to make the diagnosis at the time of catheterization and then continue to PTCA if indicated. When in doubt we would  consult with the duty cardiac surgeon and have a detailed discussion. If the PTCA was complicated we would consult with another senior interventional cardiologist and decide on the details of proposed interventions. The only problem was that the cardiologist was the gatekeeper in making the decisions. The entire department soon developed an intimate knowledge of the pathophysiology of the disease and became experts in the research literature and guidelines of treatment. The patients from the other major centers  in Israel, underwent an initial  diagnostic test and while waiting for a delayed clinical decision would consult with me and often ask me to undertake the interventional procedure in Jerusalem. This added a major workload but provided my group with extensive practical interventional experience.

Some patients deteriorated after about 10  years because of further progression of the underlying disease or development of graft atherosclerosis. We undertook the follow-up of these patients and became experts in understanding and prediction of the danger signs and introducing an early second round of interventions. Our program of careful clinical follow, liberal use of non-invasive tests to detect early signs of disease progression and then not delaying a second procedure to keep the patients in fine fettle. We relieved suffering and prolonged life. As the medical management and drug intervention  improved fewer and fewer patients needed reintervention and life was prolonged almost indefinitely. This placed a heavy clinical burden on myself and my staff.

The hospital administration  did not or would not recognize this revolution. I moved my own clinic outside the hospital where I could extend my day and see patients until 10 or 11PM in the evening. Unfortunately, this impinged on my research times and writing was often deferred to the early hours of the morning.

Joe Borman was a tireless surgeon and undertook meticulate anastomoses so that his grafts remained open for many years. His operating times were prolonged, but this was reflected in the long term symptom free survival of his patients. When he retired and Gideon Merin took over from him, the surgical wards were expanded and we doubled our patient throughput, but many of the patients needed a second operation after about ten years due to graft degeneration or progression of the underlying disease.

There was gentle competition between the cardiologists and the surgeons about who should intervene, and whether surgery was preferable to PCI and many trials were undertaken to compare the outcomes of the two competing procedures and frequent new modified guidelines were published. We maintained a friendly and congenial coexistence, as major clinical trials tried to determine which procedure was superior in the different patient subsets Earlier interventions and vigorous secondary prevention of disease progression also improved the long-term outcomes.

Robotic surgery entered the playing field and although some of the American and European surgeons have excellent results, we never entered the arena.

The hospital administration failed to understand the importance of our cardiological program and long-term rehabilitation, and we lagged in providing appropriate facilities.  My own relationships with the hospital administration became strained and I became known as the “octopus” who thought  that he owned the hospital. It is sad that we moved into adequate new facilities only when a new hospital director was appointed 17 years after my retirement as the Head of the unit. The Director, Prof Zeev Rotstein together with the Hadassah ladies and the Irma and Paul Milstein foundation have now provided adequate space and excellent facilities for the expanding service but unfortunately  most of the my fiery enthusiasm has abated.

Primary and secondary prevention programs are essential to limit the development of atherosclerosis. They have slowed the development of the disease so that severe atherosclerotic disease is disappearing, the disease has become less common and with almost universal opening of obstructed coronary arteries during acute infarction, there are less total obstructions and the patients have more suitable anatomy for later PCI or CABG.

The cardiac surgeons have played a lifesaving role in the management of coronary artery disease and have been my closest partners. Now we are taking over their function with simpler percutaneous techniques.Nonetheless there remain many patients with severe disease who need surgery.

I am very proud of catalyzing coronary artery bypass surgery and the overall management of coronary artery disease in South Africa and Israel.

It has been a  lifelong project of persistence and perservation and over last 15 years we have reduced the mortality of Cardiovascular Disease in Israel by 63 %.

Learning Hebrew 

I learnt “synagogue Hebrew” for my Bar Mitzvah from Rabbi Falkow in Hermanus, in South Africa and continued learning with him in order to deliver the prayers, but my understanding of the language was very poor. A few years later, in high school, my father brought home some rudimentary books on translation and grammar of Modern Hebrew, and we would sit and learn together.

The learning stopped because I was too occupied with studying medicine, until I moved to Durban, where my interest was rekindled by Rabbi AbnerWeiss. He was a young rabbi with great personal enthusiasm . He had studied in Johannesburg and came to Jerusalem as the young Rabbi in Durban North. The local congregation soon appreciated his ability and sent him  abroad to improve his Rabbinical training.He spent two years at the prestigious Kerem B'Yavneh where he studied Gemara and Shulchan Aruch(Jewish Law. He then contued to Yesiva University where he studied Psychology and took a Ph D in Philosophy and then returned to beome the senior Rabbi in Durban. He returned to imbibe his enthusiasm in Durban and looked for young congregants to share his enthusism. whereunderstanding of JudaismIt became important to understand the content of the prayers and the Bible. When I started traveling to Israel, the language became a living medium of communication, and I joined the local Ulpan in Durban. When the appointment in Jerusalem started to materialize, it was important that I take the language seriously. Avi Bakst and I started extra lessons with the local Hebrew teacher at the university. I also used a tape recorder to record the news broadcast in simple Hebrew and would listen to the tapes in the car. The language learning was auditory rather than visual, and I supplemented it with the language laboratory at the university.

Hebrew is an interesting language. Children learn automaticall from their parents and simply copy the the inflections of the nouns and verbs. It is very similar to Latin with a very precise grammar that has changed over the years from the original Mishnaic Hebrew, to the poetic language of the Middle Ages, the Enlightenment in Poland in the 19^th-century and then the neo-Hebrew, where many new words were created to cover the new concepts, ideas and inventions of the 20^th century. It also has different letters and is read from right to left so that the transition from the European the Hebrew language was difficult.

When I arrived in Jerusalem in 1973, my first priority was to polish my rudimentary Hebrew, and it was decided that I should attend an Ulpan. I registered at the Etzion ulpan at the southern end of Derech Beit Lechem. It was housed in an old building but had an exciting group of enthusiastic new olim, who were filled with energy and tasting their first experiences of Israel.

I was placed in the third class with a non-religious teacher. The learning was a little tedious after the excellent Hebrew teachers in Durban, where I had learned the lilt and poetry of the language and the rhythm of the verbal conjugations. My previous teachers in Durban had created an exciting environment and taught us the music of the language, the way it was learnt by little children. The teacher in Jerusalem was good but was anti-religious. This disturbed me when she taught us about Joseph and his narcissism and began to scoff at the stories of the Bible.

I persisted for four weeks, but the pace of learning was too slow. I had a very busy timetable ahead and felt the urgency to move back into medicine. Despite my enthusiasm to learn good Hebrew, I was impatient and wanted to start work at the hospital, so I left the Ulpan.

After the experience at Etzion, I joined the summer school afternoon ulpan at the Hebrew University, which was more academic and successful. There were many young foreign students, who were learning the language professionally to use as part of their studies and not only as part of the daily vernacular. Their youthful enthusiasm was unbounded, and the spirit in the classroom was uplifting. We sat at desks, and the teachers used the blackboards, rather than sitting around in a circle and singing songs as was done in Ulpan Etzion.

When I started working at Hadassah, I would spend hours with Miriam, my new Hebrew secretary, and we would translate the most complicated modern Hebrew medical files. We took the patients’ folders and translated the summaries. We found some textbooks for nurses in Hebrew, which we would read aloud. Joe Borman sent Aryeh Shaeffer, a 5^th year student, to teach me supplementary medical terminology, and I was soon fluent in Hebrew. So fluent, that many of the students did not recognize the words as they had become accustomed to the assimilated Latin terms.

I started interviewing the patients, and this was possible with a very small, rudimentary vocabulary. Determined not to use a translator from Hebrew. I wrote down all the new words with the English translation and would walk around with the written note in my pocket until each word was imprinted in my memory. I soon found that when cross-examining a patient, I was becoming more and more fluent in the use of the language with its particular inflections

My first excursions into teaching students were in English, but with Aryeh’s help, I acquired a good technical vocabulary and was able to teach small groups of students quite comfortably. They became a willing audience, and would correct any of my mistakes or omissions.

My first major effort was teaching the “Introduction to Cardiology" course to the fourth year students in September 1973. Here, I was faced with a class of 100, who were more critical. I started in English, but after the third or fourth lecture, I was able to slip into “pigeon” Hebrew.

By the end of the year, I was relatively fluent in the language, and I continued to read, to write a little, but to maintain a very fluent conversational language. Soon, I was thinking in Hebrew, and over the next 40 years, have continued to read books in Hebrew, enrich the vocabulary, jotting down all the new words on a slip of paper, which I kept in my shirt pocket. Unfortunately, I used my Hebrew secretary to write reports and correct my language but did not put pen to paper, nor did I read sufficiently so that the language has been an oral experience. I still have difficulty with spelling in Hebrew.

The language changes your personality, and although English will always be my first language, I love the lilt of Hebrew, its inflections, and it’s thought processes. This is real integration into the country, and I have always expected my new young doctors who come on Aliyah to become fluent in the language.

Coronary Angioplasty

Coronary angioplasty

1980 was a turning point in the management of coronary artery disease. The introduction of interventional cardiology (percutaneous coronary interventions – PCI)  was a major disruptive process and changed the trajectory of the development and expansion of cardiology in general and of the department in Jerusalem in particular.

Interventional cardiology has been one of the most dramatic revolutions in cardiology and medicine. The cardiologist had been a diagnostician, and suddenly, the volcano erupted and his therapeutic armamentarium changed from simple conventional pharmacological and medical therapy to a para surgical discipline. The cardiologist changed his coat and became the gatekeeper and was able to provide real curative interventional therapy.

It is interesting to review the milestones in the development of these innovative interventional procedures. Charles Dotter, a radiologist involved in the dilatation of narrowed and obstructed arteries in the legs. was the first radiologist to open a peripheral artery with a balloon. Andreas Gruentzig working in Zurich studied his technique and suggested opening a narrowed coronary artery with a balloon. Gruentzig set about developing and perfecting a suitable balloon catheter and worked in the evenings with his wife and his assistant Maria Schlumf and her husband. They ingeniously developed an inflatable balloon at the end of a diagnostic cardiac catheter by taking a hollow catheter and at its distal end, glued a balloon and tied two sutures to keep it in place. They cut longitudinal slits in the catheter inside the balloon and occluded the catheter at its tip. This made it possible to inject fluid or contrast material into the catheter and inflate the balloon. The development was a long and tedious process, but he perfected a double lumen catheter, with a balloon at the end. One lumen was to measure pressures and the 2^nd to inject contrast material to inflate the balloon. In Zurich he undertook his first six human cases. The results exceeded all expectations with excellent improvement of the angina pectoris. Re-angiography showed that the vessels had improved and were patent.

This seemed a simple method to dilate narrowed, diseased peripheral and coronary arteries. He used a preformed guiding catheter in the aorta, placing the tip in the orifice of the coronary artery and dilated his first patients. He progressed and made a special double lumen catheter. At the tip, he attached a flexible wire, which could be molded according to the curvature of the coronary artery. The distal tip could then be guided into the appropriate branch and slid through the atheromatous narrowing. The distal wire was often bent out of shape while the thickness of the catheter created friction with the arterial wall. We ordered the first balloons from the Schneider Company in Zurich. They were thick, difficult to manipulate, and had a fixed flexible guiding wire at the tip. Each tip had to be modeled, and if it was deformed by the pushing and rotation, the expensive balloon became ineffective and was ruined.

Gruentzig was an unusual physician. He was a kind and thoughtful personal doctor, but, consumed by an internal fire, perfected the technology that would change the face of the treatment of coronary disease. Later he moved to Atlanta and unfortunately at the age of 46, lost his life when a storm downed his plane that he was flying

Richard Myler in San Francisco suggested making the first dilatations during open heart surgery for coronary artery bypass surgery and invited Gruentzig to come to St Mary’s Hospital in San Francisco where the procedure was undertaken by Elias Hana, his cardiac surgeon.  The patient was prepared for surgery, the artery opened distal to the narrowing and the balloon catheter threaded through the narrowing and dilated.  There were no emboli and the vessel successfully dilated.     The results were dramatic:  the narrow coronary artery was enlarged and a near normal blood flow was restored. 

            Gruentzig continued experimenting and was active in his kitchen where he introduced new improvements in balloon manufacture together with his technician and her husband.

The manufacturing process was now taken over by Schneider—Medintag who made the first commercially available balloons.  Kaltenbach from Frankfurt joined the group but he preferred the Sones’ technique, using an arterial cut down in the elbow to introduce the guiding catheter.  

Several American cardiologists were excited by this new technological innovation. Simon Stertzer from the Lennox Hill Hospital in New York in1979, sent me the first samples of the balloons they were using during open heart surgery. Ed Koch, the Mayor of New York, invited  Mr. Begin and his party for the weekend to Gracie Mansion and while I was there received the first balloons. He sent them in a small sealed envelope. I was surprised and a little shaken and not sure that the balloons would be effective. They proved themselves and opened a new era in our approach to the treatment of coronary artery disease. Stertzer wrote last year. “Intuitive belief that new therapy should not be frustrated by negativity from bureaucracy or less courageous investigators”.

Richard Myler, from San Francisco, whose mother lived in Jerusalem and was under my care, had also started interventional procedures. When he came for a family visit, persuaded me about the value of the procedure for selected patients. We became good friends, and together with Basil Lewis, I visited him in St. Mary’s Hospital in San Francisco to learn the new technology. This was a great experience to see him pass the balloon at the end of the catheter through the narrowing, inflate the balloon precisely within the narrowed segment, and lo and behold, when he deflated the balloon, the narrowing had disappeared.

The interventional group at the National Institutes of Health in Washington, D.C., guided by Kenny Kent, together with Marty Leon who later moved to the Washington Hospital Cente, continued to treat the patients with this novel technology  and led a major coronary interventional industry.

Initially, I was a little skeptical about the effectiveness of the procedure but in 1982 we invited Doug Rosing from the National Institutes of Health to set up our system. Doug moved in for a few months. He was an excellent mentor and taught Basil Lewis and me the tips and tricks  of the new  procedure. In 1983 we published the results of our first 16 patients in the Israel Journal of Medical Sciences. Successful dilatation was accompanied by a significant improvement in symptoms and in myocardial performance, as judged by atrial pacing MUGA (multigated) radionuclide ventriculography. The ischemic response of the ventricle to stress was significantly reduced or abolished. I undertook every dilatation slowly and deliberately. Gentle initial dilatation to avoid cracking and tearing the plaque, and then using more prolonged inflations to remodel the artery.

PTCA was a revolutionary, nonoperative method for dilating obstructed coronary arteries and improving myocardial blood flow!

The initial guiding catheters had a high profile, with a large 9 French outer diameter.  They were made of poor material, had low torque ability, with poor push ability and steer ability.  The first balloons had a 6F shaft and a fixed wire at the end.  The wire had to be bent to follow the curve of the artery and was very difficult to manipulate. The balloon was thick, and friction made it difficult to pass through tight obstructions.  The guiding catheters were soft like macaroni and would crack as they were rotated.  Each procedure was a major physical undertaking for the operator and stretched my nerves and patience.  The balloon catheter tip wire folded and bent and lost its shape and it was very hard to recreate a new curve.  The hardware cost $1,500 per patient and the administration accused me of exceeding my budget.  My first action was to clean and resterilize the equipment.  A few patients had pyrogenic reactions to the foreign proteins.  I became known as the cardiologist who reused balloons until they burst.

I was still a little uncertain about the outcomes and would measure pressure gradients across the lesion before and after the dilatation and after the procedure would study stress testing and nuclear ventricular function to determine whether we really had abolished the ischemia.  We now learned the relationship between diameter and length of the stenosis in determining a decrease in blood flow and inducible ischemia and became experts in understanding the pathology and hydrodynamics of blood flow in the coronary arteries. 

We were limited by our budget since the catheters and balloons were very expensive. This was a brand new expensive medical expedition. The initial results were very encouraging. It was clear that we had a successful new modality for treating the patients with localized atherosclerotic disease. Nonetheless, the initial experience was frightening. Inflation of the balloon caused severe chest pain to the patient, the ST segment was elevated on the ECG, and when the balloon was deflated and removed, it often took time for the ECG to return to normal.

The next development came from John Simpson at Stanford in Palo Alto. He introduced the “over the wire” and then the “parallel wire” technique. The angioplasty guiding catheter was introduced from the femoral artery and placed in the orifice of the coronary artery. Next, a special guide wire was threaded through the guiding catheter and then guided into the culprit artery, passed through the lesion and then anchored distally in the artery. The guide wire had a firm body, which provided good torque ability and a malleable tip, which could be adjusted according to the shape of the artery and would not damage the intima. The balloon was threaded over the guide wire and advanced until it was seated within the narrowing in the artery. The balloon was then inflated with contrast medium so that it was clearly visible on fluoroscopy. The balloon was then deflated and partially withdrawn and further angiography showed the precise dilatation and remodeling of the lesion. The balloons were thin and had greater malleability. The second system was even better-the parallel wire technique. The balloon catheter was guided over the wire in its distal 10 cms so that the system occupied less space in the artery and was simpler to exchange.

The first procedures were tough on my nerves. Initially, the technology was difficult to master, since the balloons were not ideal and the “learning curve” prolonged. Occasionally, one could not cross the lesion, or the lesion would rupture, the artery would close, the patient would have severe angina, and after the procedure, the anti-coagulants caused bleeding in the groin. I persisted as I really believed in the technique, and my persistence was rewarded.

The major problem was collapse of the artery after the dilatation.  The expansion of the balloon with sudden dilation cracked and tore the internal layers of the artery and this was followed by obstruction and subsequent thrombosis. We tried prolonging inflations of the balloon to glue and reattach the fragments of the fractured artery and administered more anticoagulants but to no avail.  We even used a special perfusion balloons to prolong dilatation and maintain flow through another channel in the dilated balloon and maintain flow through the obstructed artery. The patient had severe chest pain, frightening changes on the ECG, often collapsed and his blood pressure fell  and often progressed to a cardiac arrest.  It was clear that the only satisfactory treatment was an emergency coronary artery bypass grafting operation where the graft would bypass the new obstruction and restore coronary blood flow. We had to find a vacant operating room, transport the patient, down eight floors to the operating room floor and undertake general anesthesia on an almost pulseless patient with an anxious family blocking the entrance to the operating room.  My surgical colleagues were upset by this disturbance of their daily routine, particularly as some patients would have a small heart attack and a stormy post-operative course. We learned the value of the intra-aortic balloon pump which acted like an auxiliary heart to help the ischemic and failing left ventricle.  

All the patients required anticoagulation to prevent clotting on the balloon which was a foreign body, and on the damaged inner lining of the artery.  We continued the anticoagulation after the procedure until we felt that the artery had healed. Also, we had to remove the catheter and compress the artery in the groin until the bleeding stopped. We used large doses of Heparin and then Coumadin but, with more careful understanding of platelet physiology, introduced a new generation of platelet IIb-IIIa receptor i and ADP inhibitors. We had converted the patient into a "bleeding machine" which required hours of firm pressure to prevent bleeding from the groin where the catheter had been inserted.  Continuous oozing produced a large blood clot in the groin which often communicated with the artery causing an aneurysm.  This then needed surgical correction or an injection of Thrombin into the aneurysm to cause clotting.  We now became partners with the vascular surgeons. Fortunately, they were excellent, willing colleagues, ready to come out at night and suture the hole in the artery.

We were thrilled by our initial results, until it became clear that about 10% of the arteries recoiled within 24 to 48 hours and another 30% healed because of fresh fibrosis and new atheroma in the damaged artery and the artery restenosed. The anginal syndrome recurred, and the new angiogram showed recurrence with an endoluminal picture, which was no different from the predilatation angiogram. We learned to treat restenosis by repeat angiography and a second angioplasty. We researched the restenosis patterns by studying three-dimensional mathematical reconstructions of the angiogram before and after dilatation. I had now become the doyen of interventional cardiology in Israel and as the reputation spread, patients from other hospitals who had developed restenosis streamed to Hadassah

By 1982, the catheterization suite had changed its coat. Coronary angiography had been a diagnostic procedure where we assessed the severity of coronary artery disease, triaging the patients into three groups: patients with mild disease best treated medically, moderately severe disease which needed coronary bypass surgery, and very severe disease which was not amenable to operation. The paradigm had shifted, and we had become interventionalists, treating the patients ourselves, rather than being purely diagnosticians and sending the patients for a bypass procedure. We now had a fourth group of patients: an intermediate group with localized disease in the larger coronary arteries, which was amenable to balloon dilatation. Three dimensional viewing in multiple planes was essential as most of the lesions were asymmetrical and since the X-ray angiographic picture is a 2-D shadow of a 3-dimentional tube we needed multiple pictures  to build at truly 3-dimensional picture of the anatomy of the coronary artery tree and it’s disease. Serruys studied quantitative coronary arteriography in detail while we were interested in the sites of the lesions at bifurcations and bends in the arteries.

We entered a new phase of exponential growth in our cardiological practice.  Patients with angina pectoris (chest pain on exertion) and objective evidence of ischemia (decreased oxygenation of the heart muscle) on exercise as shown by a positive stress test on a heart scan were candidates for angiography and if they had simple significant lesions were suitable for angioplasty.  Patients, who formerly needed coronary artery bypass grafting could now avoid the operation and instead of a major procedure with 7 – 10 days hospitalization were sent home after 24 to 48 hours  after a simple puncture to the groin.  The initial results were excellent but - 20% of the patients returned within three months with recurrent angina pectoris.

In the beginning, we had a limited financial budget, no extra staff, and we spent more hours on longer, more complex and often nerve-wracking procedures. We had no nursing staff in the catheterization theater, and the patients waited in the busy corridor after the interventional procedure before they were taken from the cath lab in the basement of the hospital to the cardiology department on the eighth floor.

Every member of the staff should have received a medal for voluntary after-hour work. The three technicians were heroic work horses, caring for the patients, monitoring them during the procedure, maintaining sterility, clearing the dirty linen and preparing the equipment for the next case.

The younger cardiologists, Yonatan Hasin, Basil Lewis, and David Halon were like fish in a new fish tank.

The interventional cardiology  physicians introduced a new method of communication and teaching. Gruentzig held his first teaching course in Zurich, and he was joined by Bernie Meyer, who had moved from Zurich to Geneva and Martin Kaltenbach in Frankfurt. They held their large public courses using a new system of teaching. The images from the television screen in the cath lab were projected onto large screens in a big auditorium, while a second or third image showed the operator, a close-up of his hands and the entire cath lab. It was possible to show how the operator manipulated the wires and the balloon in the patient's heart. A panel of moderators in the lecture theater would maintain a dialogue with the operator in the cath lab and include the audience in the discussion. These essential interactive sessions became very popular and were soon extended to include John Marco and Jean Fajadet's group in Toulouse, King in Atlanta, Hartzler in Kansas City, Marty Leon in Washington, D.C. and Patrick Serruys in Rotterdam. As satellite communication improved, the demonstrations were streamed from one continent to the other.

The junior staff at Hadassah now entered the fray.  Basil Lewis plunged into angioplasty like a fish takes to water.  David Halon traveled to the Geneva courses.  I traveled around the world to learn the "tips and tricks" from the masters.  Hartzler in Kansas City was the "master."  He had unique eye—brain—finger coordination and was an expert on virtual 3-dimension reconstruction in his mind of the coronary arteries and their narrowing’s.  He was more adventurous and would dilate several lesions in a patient and many of these were long or complicated.    Dick Myler from Seton Medical Center in San Francisco and and I became firm friends.  He, too, had skillful finger control, but kept good records and understood the outcomes in his patients.  King and Douglas at Emory in Atlanta had a large volume of patients and excellent statistical control of the results.  We soon became experts but when Yonatan Hasin entered the arena it was clear that he, too, had superb eye –brain—finger control, navigated the arteries with great manual skill and dexterity and had nerves of steel.  He was patient, fearless, and untiring, His  enthusiasm and creativity spearheaded our activities.  He was a natural, adventurous operator initiating many new manipulative techniques.

This was a unusual opportunity for us to travel, interact, and learn. I would take my audio tape recorder to the meetings to record the cases and discussions, and when I came home, listen to the discussions several times until I understood the intimate details and finesse of the procedures. I acquired a small, lightweight video recorder to record the proceedings and spent many interesting evenings rerunning the tapes with my junior staff. I would always spend an additional fortnight in the local lab learning and reinforcing my concepts of the new manipulative techniques.

We, too, introduced the live teaching seminars.  We placed video cameras in the catheter theater, wired the ceilings and mounted slave monitors in the recovery room.  We removed the patient’s beds, brought in chairs and projection screens and this was converted into a lecture theater for 50 visitors.  We invited Rutherford from Kansas City and Jean Fajadet from Toulouse and many other US and European experts.

We now entered the era of restenosis. Pathological and functional studies showed that some were due to elastic recoil of the artery while others were due to over--vigorous healing with the formation of a fibrous scar which narrowed the artery anew.  After the dilatation, the angina would return after a week if there was recoil or after a few months because of fibrous healing.    Nonetheless we persisted, redilating the restenosed arteries. Renu Virmani from the Armed Force Institute of Pathology  in Washington and Valentin Fuster from Mt Sinai in New York  led the field in understanding the pathology of the atherosclerotic process, the effects of balloon dilatation and the cellular basis of restenosis.

After five years, research moved in a new direction. Was it possible to remove the atheroma? New technologies appeared.  Maurice Buchbinder from San Diego introduced Rotational Atherectomy, the rotablator, a high speed, oval, rotating burr studded with diamond chips to drill through, and pulverize heavily calcified, nonmalleable plaques. This reamed out the atheromatous tissue. The tiny fragments would embolise downstream and pass into the distal coronary circulation. We treated some patients with long, heavily calcified LADs with excellent 10 – 15-year results. It was also good for cleaning out orifical lesions. We use this in a limited number of patients and the results were excellent for heavily calcified lesions in the arteries. The other useful instrument was the Directional atherectomy catheter which had a hollow cylindrical distal body with a rotating knife in the lumen and which would shave off and excise the plaque. The fragments would be caught in a hollow chamber and were removed. It needed a large 9-F guiding catheter, and one felt that you were manipulating an elephant's trunk. We treated some very interesting patients. It was very good for removing the atheroma from the LAD at the first bifurcation. It was very good for eccentric lesions. The process was completed by supplementary balloon angioplasty.  These devices were expensive, but they had the advantage of removing the offending plaque. 

A new cutting balloon had foldable blades attached to the balloon. These would open and cut the dense, fibrous or calcified atheromatous plaques, followed by balloon inflation and  dilatation. Both techniques had a good future, but another innovation, laser angioplasty which cut and cauterized the diseased areas of the arteries but damaged the inner layers of the artery. We had our own laser system, this damaged the inner layer of the artery causing early restenosis and after 6 months the unused equipment blocked a corner of the lab, and we asked the supplier to remove the equipment.

The introduction of the coronary stent by Ulrich Sigwart from Lausanne in 1992 changed PTCA to PCI (percutaneous coronary intervention) and led to another complete revolution and paradigm shift. The first Palmaz-Schatz stent was a tiny, expandable, stainless steel tube with slots so that it could be crimped on a balloon, dilated as the balloon was expanded in the narrowed artery, and then, did not recoil when the balloon was deflated and removed. It maintained patency of the artery. The stent changed the face of interventional cardiology and prevented the need for a surgical intervention if the artery collapsed after balloon dilatation. It provided sterling service, but it was plagued by intra-stent thrombosis, since it was a foreign body, and later stimulated neointimal proliferation, fibrous tissue overgrowth with scarring and restenosis. The excessive use of anticoagulants caused bleeding from the groin and femoral artery aneurysms. The stent industry has been one of the great advances in interventional PCI. New materials, stent shapes and coatings and the use of impregnated antirejection drugs have changed the face of restenosis.

Over the next 15 years we treated 1000 patients a year with excellent results, and there was progressive research and development in this dynamic field. I trained a new generation of interventionalists: Chaim Lotan, Yossie Rosenman, Morris Mosseri, Ron Waxsman, Hisham Nassar, Chaim Dannenberg, Boris Warshitsky and many foreign trainees from Poland, Roumania and Bulgaria, all of whom rose to important positions in their countries and led the younger generation in Europe.

New anticoagulants included low molecular heparin and recombinant hirudin. Hirudin is a natural anticoagulant and anti-thrombin produced by leeches and an integral part of their therapeutic use. The drug companies were able to manufacture a synthetic hirudin, which is now in daily use. New anticoagulants appeared every few months, and they made the anticoagulation program much simpler and caused less bleeding. We became experts in the biochemistry and physiology of clotting and platelet function and antithrombotic and platelet drugs.

New families of stents were developed with different shapes, flexibility and tensile strength. In-stent restenosis was the biggest problem and occurred in more than 30% of the patients. This was treated by re-dilatation and intra-stent radiation. Ron Waxman, one of my fellows, who had migrated to Atlanta to study the mechanisms of restenosis and then to the George Washington Medical Center, became one of the most important researchers in radiation therapy, and we learnt how to use gamma radiation with great success This killed the exuberant overgrowth of the healing cells.. The manufacturer later removed it from production since it competed with their new drug-eluting stents. Morris Mosseri was responsible for our radiation program. Each treatment was a major procedure. Radiation screens were placed in the cath lab. A senior oncology radiation technician brought the radioactive ribbon in a protective case. A special catheter was placed within the lesion and a ribbon containing a train of iridium-192 seeds place inside the catheter (Best Medical International).

Drug-eluting stents were introduced and promised to prevent restenosis. The metallic stent was covered with a thin polymer coating impregnated with an anti- cell-rejection drug. This was liberated to prevent endothelial overgrowth.  I listened to Patrick Serruys describe the results of his first controlled trials. The lecture theatre was packed. The results were exciting and positive “We have conquered the problem” he announced proudly.

Many different drugs which blocked cell proliferation were introduced, and a large commercial industry developed around the different drug eluting stents. Unfortunately, the drugs were so effective that they prevented endothelial regrowth and repair so that the new inner layer of the artery did not re-form and heal. The metal stent struts remained bare, and were not covered by endothelium, a fresh clot formed, and this caused sudden, delayed obstruction, often with serious fatal side effects.

There were many large, randomized, clinical trials with multi-million-dollar budgets, heavy competition between the companies, and pressure on the cardiologists to use a particular stent. The companies were very liberal and provided extensive travel for the investigators. I felt sorry for the control subjects in the clinical studies. In stent restenosis is now uncommon, but sometimes causes trouble.

Chaim Lotan developed our databases so that it became possible to compare stents and their effectiveness.

Ron Waxman, one of my trainees, who continued his research under  Spencer King in Atlanta and who is now the Cardiology director  of the Medstar Washington  Heart Institute and a leader in Education in Interventional Cardiology together with his colleagues are now investigating bio-absorbable stents. These provide a framework and support for the artery after dilatation, the stent material is then absorbed and disappears leaving a nearly normal arterial wall. Restenosis and fracture were problems but new generations of bioabsorbable materials have improved the outcomes.

We used the femoral artery for access, soon but turned to the radial artery in the forearm. It was easy to cannulate but had a smaller lumen, which made manipulation of the catheter more difficult. A variety of closure devices were developed to close the arterial access sites in the leg and prevent excessive bleeding. We published one of the first studies recommending its use.

The introduction of percutaneous coronary interventions (PCI) and the phenomenal speed of development and improvement of the equipment introduced a new world of medical progress: innovation and research, new ideas, large scale clinical trials, multicenter research projects, all funded by the device and drug companies or by the NIH itself, when there was an important conflict of interest.

Certain pathological syndromes are still difficult to treat. Diffuse, disseminated atherosclerosis is not ideal and  amenable to balloon dilatation, and these patients are probably best treated by bypass surgery. Unfortunately, one cannot place enough grafts to bypass all the lesions. Small arteries are difficult to dilate, and minor restenosis causes recurrence of symptoms. Many lesions occur at bifurcations in the arteries, and we used double balloon techniques with two separate balloons inflated at the same time but this was not was not always successful. Chronic total obstructions are related to acute occlusions, which later organized and became dense fibrotic scars. The long lesions can be difficult to cross, and often, a stiff guide wire would perforate the artery and could cause fatal bleeding. Nonetheless, with patience and stiff wires, it is possible to re-enter the distal artery, gradually dilate the obstruction, create a new lumen, and implant a stent to prevent recoil and collapse of the lumen. One could pass the wire into a second artery, retrogradely through a collateral and then thread it into the first artery beyond the obstruction. We became experts in these complex situations, and gradually PCI started replacing coronary artery bypass surgery. The competition between the surgeons and cardiologists increased, but we were the gatekeepers, and most patients preferred a simpler PCI, which allowed them to return home the next day without the extensive convalescence. All the younger cardiologists became interventional experts, and I believed that the department needed a large volume of patients to provide sufficient experience for all the operators.

I personally trained all the young trainees by an apprenticeship system where the assistant progresses to take over parts, and then all the procedure. Later I would continue to help him for at least another year until he was completely independent. He would undertake the diagnostic catheterization, together we would decide on the correct interventional procedure, select the appropriate equipment and I would either scrub in or and remain in the cath lab vicinity to observe the progress and if needed come to his help until the intervention was complete. Mentoring would continue for  several years and I would be called when the diagnostic procedure was complete.

If the patient had simple localized lesions we made it a custom to consult with a second interventionalist, but if it was more complex we would call for an immediate consultation with an available cardiac surgeon and if there remained further indecision, the patient would be taken off the table and the management algorithm planned at our combined Medico-Surgical Cardiac Meeting. We had precise decision-making algorithms and based these on the International Guidelines, modified by personal preferences based on our collective experience. The level of discussion was unbelievable and the personal academic reactions of the highest standard. The cath lab generated a continuous buzz of discussion: every patient provoked intense interest.

The technical innovations paralleled the clinical progress. The X-ray equipment improved, more advanced X-ray tubes and image intensifiers to reduce radiation dosage and improve picture quality, and new table designs. The greatest quantum leap was the introduction of digital imaging. Initially we used 35mm. film recording but this delayed the procedure time while we waited until the film was processed and developed, but the exponential advances in computer memory and speed allowed immediate replay, retrieval and storage of the angiograms and improvement in image quality so that we had immediate diagnostic imaging.

The rapid expansion of the variety of different interventional techniques and the number of patients who were referred for treatment needed a new financial approach to cardiology. The disposable equipment costs wee exorbitant. I was appointed to the Ministry of Health as head of the advisory body to suggest changes in the system. Most important was the introduction of the Diagnosis-related group (DRG)method of remuneration. Previously, the hospitals were recompensed from the sick funds based on the number of days of hospitalization so that expensive procedures with short periods of hospitalization were financially counterproductive to the hospital. The Ministry of Health introduced a DRG for 12 important procedures, which included cardiac catheterization, balloon angioplasty, stent implantation, and open heart surgery procedures. This made the catheterization and angioplasty profitable but carried financial losses for stent implantation. Cardiology, which had been a financial burden on the hospital, suddenly became a semi-profitable department. We reused and re-sterilized our equipment and made the department even more profitable. The hospital realized we now needed more staff, beds, and catheterization space.

The service expanded rapidly, and as the reputation grew, more and more patients came to Hadassah. The out-patient clinic was flooded with old and new patients. Many patients from the Tel Aviv area and the remainder of the country, who had re-stenosis of their previous lesions, turned to us for help. The hours in the cath lab were prolonged, and we introduced a second shift, which rewarded the technicians and the physicians and provided spare income to hire more staff. The results were excellent.

The hospital administration suddenly awoke to the importance of our work. They increased our floor space and staff but never shared the passion and dream of our group. We always had an overflow of additional patients. Somehow, we managed to treat them all without delay.

In the 1990’s Bill O’Neill and Cindy Grines from Beaumont Hospital in Oak Ridge Michigan showed that acute PCI could open the artery immediately and shorten the period of ischaemia in Acute Myocardial Infarction. The Ministry of Health introduced a new DRG which allowed us to maintain an emergency staff 24/7 to perform immediate PCI in acute myocardial infarction. We provided this 24/7 service which completely altered our treatment of myocardial infarction. Today 90% of the patents in Israel with an acute myocardial infarction undergo primary PCI within 4 hours after the onset of chest pain.

Percutaneous coronary interventions have proven to be very effective. They have prolonged life and reduced suffering. Patients return to work and continue to live productive lives This has been the greatest success of my life and my enthusiasm has never faded.

Some examples illustrate the successes and difficulties.

Mr. Y.E. is now 76 years old. He is a patent lawyer, who at the age of 55 was unable to walk up a steep slope in Jerusalem. Angiography 25 years previously showed a single lesion of his proximal left anterior descending coronary artery, and this underwent simple balloon dilatation. He has been free of symptoms for 21 years. His first wife passed away after a prolonged illness, and he is courting a young lady.

Mrs. A.B. was a 50-year-old university lecturer in English. She had a severe lesion of her LAD and circumflex arteries, which were dilated by plain balloon angioplasty. I saw her every year for at least 30 years, and I believe that she is still symptom free.

Mr. J.C. was a 70-year-old, religious gentleman, who wrote many classical interpretations of Jewish law. He had severe triple vessel disease and underwent a triple vessel coronary artery bypass graft, including a left internal mammary anastomosed to the LAD. His angina returned after seven years, and the venous grafts had obstructed. He underwent a second operation, which improved his angina for about eight years. Re-catheterization showed severe obstructions in the venous grafts, even though he had received intensive statin therapy. The grafts were dilated and stented, and his angina improved. The disease returned three times, and each time, there were fresh lesions in the grafts. He underwent another three angioplasties, and at the age of 96, developed severe pneumonia with a resistant organism, and passed on. The procedures had prolonged his life by 26 years and allowed him to produce another 10 volumes of his legal masterpiece.

Mrs. A.P. was a 62-year-old lady, whose husband had died from ventricular fibrillation in his sleep. She developed severe angina pectoris with extensive diffuse disease in her LAD and circumflex arteries. The LAD was unsuitable for plain old balloon angioplasty, and we performed rotational angioplasty of the LAD, reaming out atherosclerosis involving two thirds of the artery. She was fine for a year, the angina recurred, and she had a single re-stenosis in the middle of the LAD. This was dilated and a stent inserted. After 25 years, she is symptom free with a negative exercise test.

Mr. J.G. was a 45-year-old teacher with sudden onset angina pectoris. Angiography showed an isolated lesion of the LAD, probably an acute rupture of the plaque. I dilated the LAD, and the region of the lesion promptly collapsed. He started sweating with severe chest pain, the ST segment elevated 5mm, and his blood pressure fell to 50/30. This was during the pre-stent period, and after three further dilatations, the artery refused to remain patent. I sweated more than the patient, and we rushed him to the operating room, where Joe Borman implanted a venous graft to the distal obstructed artery. He had a small anterior infarct, but recovered, and I followed him anxiously for the next 25 years. He is still alive and symptom free and teaching.

Mr. E.X. was a 120kg shopkeeper from the Old City of Jerusalem. He had severe triple vessel disease. I dilated two arteries, but as I passed the wire down the LAD, it must have entered the arterial wall under a plaque, perforated the artery and the distal end of the wire waved around freely in the pericardium. I replaced it with a balloon and tried to block and stem the little leak in the artery by inflating the balloon, but to no avail. He continued to bleed into the pericardium, so I placed a drain to remove the accumulating blood. We took him down to the operating room and sutured the perforation in the artery. He has lost 30kgs, and his shop is still a stop for many tourists.

These visits to the operating room always created “action stations” and caused a great commotion. The entire medical, nursing, and technical team were mobilized. The patient would have to be connected to mobile monitoring equipment, moved onto a trolley, wheeled out into the corridor into a waiting elevator, taken down eight floors to the operating room, and then, surrounded by a flurry of nervous anesthetists and anxious surgeons and cardiologists. We were fortunate as nearly all the patients survived these nerve-wracking episodes.

The catheter lab was always on full alert for sudden emergencies and possible complications during procedures.

The equipment has been improved, and new materials used for balloons, their diameter has decreased, and the use of stents has changed the picture. PCI is a simple and relatively safe procedure, and often the patients can be discharged home on the day of the intervention. The young doctors are well trained and make intelligent decisions and have safe hands. The cardiac surgeons are our closest friends. Although the volume of their work has decreased, the overall patient population remains constant. Primary and secondary prevention has decreased the number of patients with severe atherosclerotic coronary disease and life is being prolonged.

New technologies such as intracoronary ultrasound and optical coherence tomography have given us a new approach to understanding the pathology of the atheromatous lesions in the coronary arteries in the living patient. We can identify the precise 3-dimensional nature of the lesion, remodeling of the artery,  and the composition of the plaque: soft, fatty atheroma, fibrous scar or heavy calcification together with the nature of the cap covering the plaque. One can then predict the natural history (future) of the plaque and more rational treatment. Unfortunately these  additions have two disadvantages; they need a separate wire with the transducer at the tip, so that the artery requires further intubation and also the cost of the disposable equipment. It is still reserved for research projects but if it becomes universal, we will have large  accessible databases to improve patient care in the individual patient.

Another important advance is the use of the fractional flow reserve to measure flow through the artery and the narrowingwhen flow is increased. The greatest improvement is the use of Computed tomography angiography with FFR. The process is noninvasive with a little extra X-ray radiation, so that it can be performed  as an initial outpatient test. Tthe cardiologist can assess the extent and severity of the atherosclerotic lesions and their physiological importance on outpatients with suspected disease  and plan the need for an interventional procedure and the kind of intervention.

Percutaneous coronary interventions has revolutionised our approach to the diagnosis, management and prognosis of patients with coronary artery disease. The cardiologist graduated from simple pharmacological management with bedrest to allow the overworked heart to recover to an activist who can mend diseased coronary arteries.

The use of intensive prophylactic programs to prevent atherosclerosis and the statin drugs and the PCSK 9 inhibitors are reducing the prevalence and progression of atherosclerosis. Unfortunately, the patients often neglect their drug regimens and disappear from the rehabilitation programs, recurrent myocardial infarction nibbles away at the myocardium and this has generated a new population of patients with heart failure.

The mortality of cardiovascular disease in Israel has decreased by 60% in the last 15 years. My work has been successful, I have now trained generations of interventional cardiologists and the message has been disseminated throughout all the cardiac units in Israel.

The modern interventional cardiologist is a new breed of cardiologist where high incomes are the key factors in a few of their lives. I have earned a good income with interventional cardiology, but my main interest has been helping patients and using new technologies to improve their outcomes. 90% of my patients were simple sick fund patients and were covered by my hospital salary and it’s to this population that I devoted the latter years of my work in the hospital. I have always regarded myself as the compleat cardiologist who treats the patient as a holistic human being and in which the intervention was only part of his management. The patient has 4 components – the heart, the comorbidities, his psychology and the improvement in his sociological environment and most of all to maintain him as a healthy carer for his family. Many of the patients remained under my care for 20-30 years and I was able to follow and understand the natural history and the fascinating development and  secondary prevention of this previously fatal disease.

Chaim Lotan and Chaim Dannenberg have continued to carry on the good work.

Nonetheless the essential approach is not to wait until the patient needs an intervention but to broadcast and teach the need for primary prevention!  Education should start in the schools and continue in the newspapers, radio and television.