The first two patients had excellent long-term outcomes but not at the same price and were still alive in January 2018 The world’s first coronary angioplasty took place on 16 September 1977, in Zurich, Switzerland. It was performed by Andreas R. Grüntzig in the presence of Bernard Meier. The world’s second case was performed jointly by Grüntzig and Martin Kaltenbach on 18 October 1977 in Frankfurt, Germany. The two cases could hardly be more different, but they both had a favourable long-term outcome over the ensuing 40 years and still counting. Case 1 A 38-year-old heavy smoker had been suffering from unstable angina for several weeks.1 He underwent an exercise stress test (EST) producing chest pain, ST-segment elevation, and ventricular tachycardia at peak exercise. Coronary angiography showed a significant proximal stenosis of the left anterior descending coronary artery (LAD, top left panel in Figure 1). Two days later, the lesion was unchanged and was subjected to the world’s first percutaneous coronary intervention (PCI). Thereafter the patient had no further chest pain, but an EST 2 days later showed some remaining ST-segment elevation during peak exercise. He was discharged on a vitamin K antagonist and had elective control coronary angiograms at 1 month (20 October 1977) and exactly at 10 years (16 September 1987) later. They both showed a pristine PCI result and no new lesions. He had stopped all his medications before the end of 1977 and ceased smoking for good. Twenty-three years later, he started to have angina again. Coronary angiography on 10 April 2000 showed only a mild lesion slightly proximal to the original one.2 Conservative treatment was decided but pain on exertion and at rest persisted. Coronary angiography was repeated on 9 September 2000. It showed the same mild lesion. Fractional flow reserve was normal at 0.83. Nonetheless, the patient insisted on treatment and received a bare metal stent (BMS). Symptoms subsided but returned 2 months later. Control angiography on 7 December 2000, showed a tight in stent re-stenosis which was balloon dilated. The patient again took acetylsalicylic acid and a statin for a few months but then stopped the medications. He remained symptom free for 14 years when angina re-occurred. A coronary angiogram on 6 November 2014, showed a tight stenosis between the original lesion and the BMS.3 It was treated with a long drug-eluting stent (DES, top panel right in Figure 1). The right coronary artery (RCA) showed a lesion for the first time (left bottom panel in Figure 1). It was also treated with a DES (centre panel in Figure 1). The left ventricle (LV) function was normal (right bottom panel in Figure 1, showing the LV in end systole). The patient was treated with prasugrel and a statin both of which he stopped again after a few months. There has been no recurrence of symptoms since and the last EST on 19 May 2015 was completely normal. He is currently 79 years old. Figure 1 View largeDownload slide First coronary PCI 1977 and again 2014. Figure 1 View largeDownload slide First coronary PCI 1977 and again 2014. Case 2 A 44-year-old man with stable angina and a positive EST because of a stenosis of the left main stem (LM) with an additional stenosis of the RCA was the world’s second patient to undergo PCI. On 18 October 1977, Grüntzig performed the procedure together with Martin Kaltenbach in Frankfurt, Germany. The LM lesion resisted maximum balloon pressure (about 5 Bar at the time), and the procedure was abandoned unsuccessfully. The patient refused coronary artery bypass grafting (CABG), and therefore M.K. re-attempted PCI in January 1978. This was again unsuccessful, but the RCA was successfully dilated. Although the symptoms improved they did not abate, and so the patient underwent CABG a few months later with saphenous vein bypass grafts to the LAD and the left circumflex coronary artery (LCX). He became symptom free, albeit not completely. A follow-up coronary angiogram after several months showed an excellent PCI result of the RCA and a patent LAD bypass graft. The LCX bypass graft was occluded. Twenty years later, in 1997, repeat coronary angiography for recurrent limiting angina showed disease progression in all three coronary arteries. Both vein grafts were now closed. Re-CABG with three arterial grafts was performed. Elective angiography 5 years later in 2002 showed all three arterial grafts patent, and the patient was asymptomatic. Currently, at 84 years, he is in good general health and symptom free. The two cases testify to the fact that coronary artery disease is a chronic disorder but can have a quite benign long-term prognosis. Both, PCI and CABG have a good potential to favourably influence its course. Conflict of interest: none declared. References References are available as supplementary material at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: firstname.lastname@example.org. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
European Heart Journal – Oxford University Press
Published: May 7, 2018
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