I DO NOT have a financial conflict of interest in the context of this presentation.

Disclosure Statement of Financial Interest

Mavericks Created Modern Cardiology

Mavericks share 3 characteristics:Outside-the-box thinking, disdain for common wisdom, & persistence.

In a time of widespread challenge to conventional wisdom, One man challenges cardiologic teaching

MI mortality is 30% mostly due to CHFSwan challenges conventional Rx [strict bedrest x 3 weeks]His idea: treat aggressively, using bedside hemodynamicsBut CCU MD Danzig finds it impossible: catheter coils in RA

Our Story Begins With Brilliant IngenuityIn Response to Frustration

Genius is seeing what everyone else has seen and thinking what no one else has thought

Inspiration on Santa Monica Beach: sail a catheter into PACCU and cath lab MD’s ridicule idea of sails & wires

Danzig: Irreversible entanglement in chordaeMarcus: imagines it sailing “like a Mary Poppins umbrella”

Mavericks persist in the face of ridicule

Undaunted, Swan takes his idea to Edwards Laboratories’ engineers.

Edward’s engineers’ response to the idea ofa catheter festooned with sails and wires:

It’s unanimous:

Putting Swan’s imagined catheter is a “logistic impossibility”Swan’s idea is dead.

But then…

Mind–Boggling Serendipity: Two Different Ideas CollideIn the Only Place in the World it Could Happen

Fogarty’s catheterSwan’s sailboat

The incandescent stroke of invention

David ChonetteDirector of Edward’s new product development

“Mostly as a [?face-saving?] favor to Jeremy”Chonette attaches a balloon to an infant feeding tubeSends it up to Willie Ganz in Cedars of Lebanon animal lab

The Instant of Invention is Hardly a Eureka Moment

By Now It’s 1969:Diamond & I Do Our First Animal Catheterization

Fluoroscopy: catheter has weaved thru entire right heart to distal PA!What should we do next?

Inserted thru jugular vein: Stuck in the coronary sinus??

So we sterilize our catheter & go directly to our MIRU patient’s bedside

IRB’s don’t exist

Our First-Ever Catheterization In Man:Horrifying Run of Ventricular Tachycardia

Spectacular good luck allows us to eliminate catheter-tip induced tachycardia

Induced by the catheter tip flailing wildly within the RV

Double-lumen Cath Overturns Conventional ThinkingAnd Reveals Things We Never Knew

•The gold standard, CVP, has little value for assessing left heart failure•PCW changes hours, often a day, before rales or chest xray•We discover new entities like RVMI and silent mitral insufficiency

Swan HJC. Catheterization of the heart in man with use of a balloon-tipped catheter. NEJM 1970Forrester J. Right and left heart filling pressures in acute MI. NEJM 1971Forrester J. Silent mitral insufficiency in MI. Am Heart J. 1971

Yet for CHF management, we also want to measure cardiac output. Now enters the incredible benevolence of chance.

Forrester J. Silent mitral insufficiency in MI. Am Heart J. 1971

We Discover New EntitiesLike RVMI and Silent Mitral Insufficiency

The Incredible Benevolence of Chance: It Comes Not from Medicine, But from Politics

Abandons all his worldly possessions to escape communism49 yo unknown lab researcher [9 ms]; prospects bleakThru Jewish philanthropy he lands at Cedars animal labHe’s penniless, but what he brings is beyond imagining

In Prague Willie has invented thermodilution cardiac output.He injects a cold solution in RA, & records temperature change in the PAWith just 2 thermistor wires, we can add CO measurement to our catheter!

As Swan contemplates sailboats, a world away in Prague, Willie Ganz…

But then…

Disaster! It’s impossible to pass the thermistor wire to the RA

The Impossible ProblemThermistor wire either buckles or obstructs flow to RAInjectate temperature is not knowable; CO cannot be measuredWillie’s dream is shattered

Predict RA injectate temp by measuring: injectate temp outside the bodycatheter length patient’s body temperature

We bench test, then validate vs cardiogreen in cath labEdwards incorporates PA thermistor into body of catheter

George Diamond

Forrester JS: Thermodilution CO with a single flow-directed catheter. AHJ 1972

Ingenuity revisited: an outside-the-box thinker’s idea

+Congestion-Hypoperfusion

+Congestion+Hypoperfusion

-Congestion-Hypoperfusion

-Congestion+Hypoperfusion

Warm, dry

Cold, dry

Warm, wet

The Conceptual Breakthrough: Integrate Basic Science With Both Bedside Hemodynamics & Clinical Symptomatology

Cold, wet

The Forrester Classification

Starling function curve Bedside hemodynamics Clinical symptoms

We Define The Effects Of All Bedside Interventions On Cardiac Fx

Medical Therapy of Acute Myocardial Infarctionby Application of Hemodynamic Subsets

James S. Forrester, M.D., George Diamond, M.D., Kanu Chatterjee M.R.C.P., and HJC Swan M.D., Ph.D.

By the end of the decade. MI mortality is cut in half!

Cedars of Lebanon’s Turning Point: NIH Creates Huge Grant for MI, Swan Decides to Compete With Nation’s Top Programs

JSF creates a 300 page proposal, NIH sends site visitors, and…

We won with outside-the-box ideasDenouementThrombolysis, PTCA & 2DE reduce mortality by half again.

In its era, >25M caths created foundation of hemodynamic bedside Rx

Cedars of Lebanon HospitalDukeHarvard-MGHJohns HopkinsCornellUniversity of AlabamaUCSDUniversity of RochesterUniversity of Chicago

Yesteryear’s insights for today’s cardiologic mavericks: Challenge convention, think outside-the-box, persist, & get lucky.

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CVPWe could diagnose pulmonary embolus, ventricular septal defect and RVMI at the

bedside

Here's to the mavericks,the misfits, the round pegs in the square hollesThey're not fond of rules, and they have no respect for common wisdomYou can glorify or vilify them, but you can't ignore them because they change things. And while some may see them as the crazy ones, we see genius, Because the people who are crazy enough to think that they can change the world…

are the ones who do.