The military heart hospitals

This is the first in a series of four papers that Dr. Wooley wrote exclusively for The American Heart Hospital Journal based on his book, The Irritable Heart of Soldiers and the Origins of Anglo-American Cardiology, published by Ashgate Publishing in 2002.1 Dr. Wooley's book also casts light on the origins of the specialty heart hospital.

History of cardiac rhythm disorders

The history of cardiac rhythm disorders including antiarrhythmic drugs and electrotherapeutical tools is long and fascinating. In the beginning, there was not simply the anatomy and physiology of the heart, but also analysis of the pulse, which indicates the activity of the heart. Thus, like any other field of medicine, the study of arrhythmias has a distinctive past. Our current level of knowledge is not the result of a straight, linear progression any more than there is a static, established, monolithic body of thought dominating this field. Instead, our knowledge of arrhythmias today is the result of many competitive, sometimes serendipitous, scientific realizations, of which a few proved useful enough to pursue and eventually led to real advancements. Looking at the worldwide development of rhythmology it can be said that considerable contributions came from Germany in the last few centuries. Arrhythmology--past, present and future--includes clearly German investigators as pioneers of the field. The growing clinical importance of electric cardiac stimulation has been recognized and renewed as Zoll in 1952 described a successful resuscitation in cardiac standstill by external stimulation. The concept of a fully automatic implantable cardioverter-defibrillator system for recognition and treatment of ventricular flutter/fibrillation was first suggested in 1970. The first implantation of the device in a human being was performed in February 1980. By early 1997, 17 years after the first human implantation more than 100,000 ICD systems had been implanted worldwide. Further developments concern new pharmacological compounds, modern cardioverter-defibrillators, radiofrequency ablation, particularly pulmonary vein ablation in atrial fibrillation, innovative pacemakers including preventive pacing techniques, probably laser therapy and perhaps the automatic implantable pharmacological defibrillator. The advances in the field of therapeutic application of pharmacologic and electrical means as well as alternative methods will continue as rapidly as before in order to give us further significant aid in taking care of the patient.

The Chicago School of Arrhythmology: revisited

The Chicago School of Arrhythmology (Katz, Langendorf and Pick) dominated the field of arrhythmias for at least 20 years until the advent of intracardiac electrophysiology in the late sixties. Thereafter they still played a fundamental role. Whereas other arrhythmologists also made contributions, they did not develop "schools" in the classical Platonic sense. The Chicago School's intuitive, deductive and inductive contributions to the understanding of multiple electrophysiological mechanisms were well appreciated, recognized and corroborated by basic and clinical electrophysiologists. Less known was their ability to propagate this knowledge in semi-tutorial courses which were so unique in explaining complex arrhythmic concepts that it is still used today by those who inherited their prominent position in the ever expanding world of invasive electrophysiology.

[100 years' of ECG or 100 years' of excellence in recording the electrical activity of the human heart]

The authors present a brief history of high-standard records of the electric activity of the human heart. Its beginnings date back to 1892 when Willem Einthoven recorded the first electrocardiogram.

[History of development of manufacture of implanted pacemakers: plans and reality]

The paper deals with the history of design and development of implanted pacemakers, emphasis is also laid on electric neuromyostimulators. Present-day problems and prospects in this area are touched upon.

We have come a long way with device therapy: historical perspectives on antiarrhythmic electrotherapy

The history of device therapies is long and fascinating. In the beginning, there is not simply the anatomy and physiology of the heart, but also analysis of the pulse, which indicates the activity of the heart. The analysis of the (peripheral) pulse as a mechanical expression of heart activity goes back several millennia. In China, in 280 BC, Wang Shu He wrote 10 books about the pulse. The Greeks called the pulse "sphygmos"; thus, sphygmology deals with a theory of this natural occurrence. In Roman times, Galen interpreted the various types of pulse according to the widespread presumption of the time that each organ in every disease has its own form of pulse. The growing clinical importance of electrical cardiac stimulation was recognized and renewed as Zoll in 1952 described a successful resuscitation in cardiac standstill by external stimulation. Meanwhile, millions of patients with cardiac arrhythmias worldwide have been treated with pacemakers in the last 40 years. The concept of a fully automatic implantable cardioverter defibrillator system for recognition and treatment of ventricular tachyarrhythmias was first suggested in 1970. The first implantation of the device in a human being was performed in February 1980. Further developments involved atrial and atrioventricular defibrillators, radiofrequency ablation, laser therapy, and advanced antiarrhythmic surgery. Since 1990, there has been a growing interest in using cardiac pacing as additional treatment in severe cardiac failure. Recent reports have suggested that intervention with left ventricular or biventricular pacing may be helpful for a subgroup of patients with congestive heart failure. Despite encouraging (preliminary) acute and short-term results, pacing strategies for heart failure still are limited and currently regarded as investigational. Advances in the field of therapeutic application of pharmacologic and electrical tools as well as alternative methods will continue as rapidly as before and provide us further significant aid in taking care of patients.

The evolution of internal defibrillators

ICDs have reduced mortality from SCD to 2% per year, which is a record unmatched by any other form of therapy. With continued evolution, ICD systems should become easier to implant, smaller, more effective in managing a variety of abnormal rhythms, and more comfortable for the patient. Implementation of technological innovations in future-generation devices should continue to extend the frontiers as clinicians consider ICDs for an expanding range of therapeutic applications.

Pacing and ICD therapy in Germany (West and East) before and after reunification in 1989

In 1989 the two German countries, FRG and GDR, were reunited after 50 years of political separation. During this time, these countries underwent independent, and in parts quite different, developments. While the reunification has had less effect on the overall situation in the Western part of the country, the Eastern part has experienced considerable changes, including the health service. In the field of pacing and ICD therapy, this study finds that 8 years after the reunification, the German federal states of both parts of the country have converged in the field of pacing and ICD therapy.

Evolution and revolution in drug labeling: regulation of antiarrhythmic drugs by the Food and Drug Administration 1962-1996

Between 1962, when the Kefauver-Harris Drug Amendments were passed, and 1996, 20 pharmaceutical compounds were approved and labeled by the FDA as effective antiarrhythmic drugs for some specified cardiac arrhythmia. Drug research and development in the 1970s and 1980s were focused on treatment of premature ventricular beats as a marker for sudden cardiac death and ventricular tachycardia. The Cardiac Arrhythmia Suppression Trial in 1989 irrevocably altered this approach. Recent drug development programs have targeted atrial fibrillation (AF) as epidemiologic data have predicted an increase in the incidence of AF as the United States population ages, and as treating premature ventricular beats has fallen from favor. The FDA, the scientific community, and the pharmaceutical industry have all participated in and been affected by this evolution in drug development.

[Discovery of the pacemaker and heart conduction system in mammals. Fantasy and truth]

The first report about experimental investigations on the origin of the rhythms in the mammalian heart were published in 1888 by McWilliam. Similar experiments were described by Hering in several publications starting from 1900. The results led to the hypothesis of the myogenic genesis of the rhythms. However, in 1907, Hering stated that the origin of the stimulus in the mammal heart was probably a nervous function. In 1898, 1903, and 1906 Wenckebach described the function and the functional localization of the pacemaker in the heart of the intact man, and in 1906, he described the morphology of the pacemaker and its blood supply in the post mortem human heart. In the same year, Adam analyzed the localization of the "natural" pacemaker and the regions of the secondary pacemakers in the mammal heart. In 1907, Keith and Flack introduced the term "sino-auricular node". They quoted the findings of Wenckebach and Hering, and they mentioned McWilliam. A muscular connection between the right atrium and both ventricles of the mammal heart was found by Kent and by His in 1893. In 1907, Tawara called the structure of the origin of the a-v connection "atrio-ventricular node". It was, however, the scientific discovery of Tawara that the a-v pathway was connected with the muscles of the ventricles by the Purkinje fibers. He discovered that the pathway consists of muscles which are histologically divided and functionally different from the other heart muscles. It is a system of specialized muscles which conduct the stimulus for the contraction without contracting themselves.

Will C. Sealy, MD: the father of arrhythmia surgery--the story of the fisherman with a fast pulse

The development of clinical electrophysiology and arrhythmia surgery has a long and interesting history. On May 2, 1968, Dr. Will C. Sealy, with the electrophysiologists at Duke University, performed the first successful ablation of a pathway in a patient with Wolff-Parkinson-White syndrome using an epicardial approach. Thereafter, he and his colleagues developed improved endocardial techniques to ensure ablation of even multiple and complex anatomic pathways. From this work the impulse to perform these procedures spread worldwide, and a school of arrhythmia surgeons sprouted. For these and other accomplishments, Dr. Sealy clearly became the Father of Arrhythmia Surgery. The story is told herein.

From rebellious palpitations to the discovery of auricular fibrillation: contributions of Mackenzie, Lewis and Einthoven

An irregular pulse, referred to as rebellious palpitations, delirium cordis and pulsus irregularis perpetuus, was a cause of speculation by physicians since early times. It was James Mackenzie, a Scottish general practitioner in Burnley, England, utilizing an ink-writing polygraph to record and label jugular venous pulses, who would pioneer in deciphering normal and abnormal cardiac rhythms. His key observation that the jugular "A wave" was lost in a patient who went from a normal to an irregular rhythm provided the first insight into the mechanism of auricular fibrillation. Similar jugular venous and arterial pulse findings were discovered by Cushny, Edmunds and Lewis in directly observed experimental auricular fibrillation. In 1909 Lewis in England and Rothberger and Winterberg in Vienna, taking advantage of Einthoven's newly developed string galvanometer, were the first to establish electrocardiographically that auricular fibrillation was the cause of pulsus irregularis perpetuus.

Three decades of antiarrhythmic therapy

Over the last several decades there has been an impressive expansion in the study and management of cardiac arrhythmias. New developments in diagnostic and interventional clinical electrophysiology as well as research at the cellular tissue and whole heart levels have improved our understanding of the mechanisms of arrhythmias and have allowed the development of new and effective treatment modalities. During the 1960s (Early Decade-Enabling) the first lifesaving measures such as cardiac resuscitation, external defibrillation, and temporary pacing were introduced in the new coronary care units. Cardiac catheterization and reproducible techniques for recording of intracardiac potentials were developed. The decade of 1970 to 1980 (Middle Decade-Diagnosis) was characterized by the development of programmed stimulation for initiation and termination of arrhythmias. This represented a real revolution in clinical cardiology that led to the understanding of the nature of several tachyarrhythmias and related them to experimental mechanisms of arrhythmogenesis. In the same decade, two other diagnostic tools emerged for assessing cardiac arrhythmias and monitoring the efficacy of antiarrhythmic drug therapy: ambulatory ECG monitoring and exercise testing. In addition, the impact of antiarrhythmic drugs on ionic currents was studied and drug classifications based on these properties appeared. The decade 1980-1990 (Recent Decade-Therapy), witnessed the development of interventional electrophysiology techniques such as transcatheter ablation, and the use of cardiac surgery for the ablation of arrhythmogenic substrates. Another major advance was the design of implantable devices capable of recognizing tachyarrhythmias and treating them by programmed stimulation or defibrillation shocks. In parallel, the efficacy and safety of antiarrhythmic drugs has been reassessed and new compounds are being developed.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical cure of cardiac arrhythmia. 1969

The first surgical procedure undertaken for the intended purpose of curing a patient with recurrent tachycardia was performed by Sealy in 1968, and the report of that operation was published in The Annals of Thoracic Surgery in 1969. The first attempted accessory bundle ablation was successful, marked the beginning of cardiac arrhythmia surgery, and has set the standard against which other methods of arrhythmia control must be measured.

Surgery for ventricular arrhythmia

Years of frustration of cardiac surgeons attempting to control intractable ventricular arrhythmia finally ended when the team of Harken, Josephson, and Horowitz performed electrophysiologically directed left ventricular endocardial resection and reported their early results 10 years ago. The scientific background for this breakthrough is reviewed and some subsequent modifications of their procedure are described. The current status of arrhythmia surgery since the advent of the automatic internal cardioverter-defibrillator is described: the two methodologies are complementary, not competitive.

John Hunter: on heart disease

Images

Digitalis cardiotoxicity

Clinical manifestations of digitalis toxicity were clearly described by Withering in 1785. One hundred years later, certain digitalis-induced arrhythmias were inscribed on the smoked drum, and shortly thereafter with the introduction of the electrocardiograph, manifestations of digitalis toxicity as recognized today were recorded in animals and human beings. With popularization of the direct-writing electrocardiograph in the late 1940s and the introduction of digitoxin in recommended doses (that in retrospect appear inappropriately high), the documented prevalence of digitalis toxicity increased rapidly. With increased understanding of the interaction of electrolytes and digitalis and perhaps, and more importantly, the widespread use of digoxin in doses derived largely from its inotropic action and, thus, inappropriately low for the management of many of the arrhythmias, the prevalence of digitalis toxicity began to decline again. In addition, the advent of serum level determinations and the widespread acceptance of the concept of "therapeutic" levels which, although frequently falling short of the desired clinical end point, served to preclude digitalis toxicity. With the decline in the incidence of digitalis toxicity consequent to these factors, some of the digitalis-related arrhythmias that were common are now rarely observed. This report focuses on arrhythmias that are highly specific for digitalis toxicity and on those that now are less commonly encountered. The discussion and classification of the arrhythmias are based on their most probable electrophysiologic mechanism.

Anxiety and the heart--a historical review

A review is presented of literature describing cardiovascular manifestations of anxiety until the end of the second World War. Clear observations of this important group of somatic anxiety symptoms have been made throughout history, although then, as now, the interpretation of these observations has varied according to the point of view and orientation of the writer. An understanding of the interrelationships between somatic and psychic symptoms of anxiety is particularly necessary now that certain specific symptomatic treatments are available.