Download Aubrey Leatham and the introduction of cardiac pacing to the UK

REVIEW
Europace (2010) 12, 1356–1359
doi:10.1093/europace/euq183
Aubrey Leatham and the introduction of cardiac
pacing to the UK
A. John Camm 1*, Sue Jones 2, Michael D. Gammage 3, and Edward Rowland 4
1
British Heart Foundation Professor of Clinical Cardiology, St George’s Hospital and University of London, Cranmer Terrace, London SW17 0RE, UK; 2ICD and Pacemaker Clinical
Lead, St. George’s Hospital, London, UK; 3Reader in Cardiovascular Medicine, The Medical School, University of Birmingham, Birmingham, UK; and 4The Heart Hospital (University
College London Hospital), London, UK
Received 26 April 2010; accepted after revision 19 May 2010; online publish-ahead-of-print 5 July 2010
In the early 1950s, Dr Aubrey Leatham established a cardiac unit at St. George’s Hospital, Hyde Park Corner, London. He developed and
taught the essential clinical skill of cardiac auscultation. Under his guidance a clinical department for the care of cardiac patients was developed and coupled to physiological academic research. He was a pioneer in cardiac pacing and, in 1961, Harold Siddons, O’Neal Humphries,
and Aubrey Leatham implanted the first ‘indwelling’ pacemaker in the UK in a 65-year-old man with repeated Stokes –Adams attacks due to
complete heart block. The nickel– cadmium ‘accumulator’, which powered the pacemaker, had to be recharged once a week.
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History † St George’s
In the early 1950s Dr Aubrey Leatham established a cardiac unit at
St. George’s Hospital, Hyde Park Corner, London. He developed
and taught the essential clinical skill of cardiac auscultation, such
that few cardiologists in the UK had not been taught by him, and
most cardiologists around the world knew of him. What prospered
under his guidance was a clinical department where the care of
cardiac patients was coupled to physiological academic research.
He was a pioneer in cardiac pacing.
On 19 October 2009 Dr Aubrey Leatham (Figure 1) travelled to
the Heart Rhythm Congress in Birmingham to receive the Lifetime
Achievement award from the Arrhythmia Alliance and Heart
Rhythm UK for his outstanding contributions to cardiac pacing.
He was persuaded to give a short lecture to explain the history
of cardiac pacing in the UK. His story was new to almost everyone
and it was decided to set it down for the record.
Aubrey Leatham was first persuaded to train as a ‘cardiologist’
and to study heart disease when he was invited by Sir John
Parkinson to join him at the National Heart Hospital in London
as a junior registrar. It was just at the end of the Second World
War, and Parkinson had first to arrange for Leatham to be
demobbed from the army so that he could take up this civilian
appointment. At the National Heart Hospital Leatham joined a
band of young physicians who gathered around Paul Wood, the
man who was largely responsible for the ‘Golden Age of Cardiology’ which developed in London during the 1950s and 1960s.
London became the world centre for the diagnosis and management of heart disease, and great number of trainees from all
over the world flocked there.
Leatham was encouraged by Paul Wood to apply for the post of
consultant physician at St. George’s Hospital which was then situated at Hyde Park Corner. At that time Leatham was one of the
first group of young physicians who had been trained almost exclusively as a specialist cardiologist and he anticipated great difficulty
in landing a job as a cardiologist when applying for a physician’s
post at a London teaching hospital. In those days (1954) almost
every physician was against specialization and particularly against
the cardiology specialty since heart disease formed much of their
general practice, and they believed that ‘super specialists’ should
be confined to single specialty hospitals such as the National
Heart Hospital in London. However, to his great surprise
Aubrey was appointed.
When he moved across to St. George’s he found himself in
charge of a department that consisted of himself, one technician
and one ECG machine. He set about establishing a new cardiac
department, which was built for him by stretching underground
across Knightsbridge. He assembled an impressive team to
provide a cardiology service for patients and to study heart
disease, along the general model that had been introduced by
Paul Wood. Dr Leatham was an early advocate of the multidisciplinary team approach and he realized that he needed, and
* Corresponding author. Tel: +44 208 725 3414; Fax: +44 208 725 3416, Email: [email protected]
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: [email protected].
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Aubrey Leatham and the introduction of cardiac pacing
Figure 3 Components of the first pacemaker built by Aubrey
Leatham and Geoff Davies.
Figure 1 Dr Aubrey Leatham.
Figure 4 External transcutaneous pacemaker built by Geoff
Figure 2 Mr Geoffrey Davies.
through lobbying and hard work he got, a bioengineer (Geoffrey
Davies; Figure 2) a physiologist/technician (Anne Ingram),
a medical physicist (Graham Leech), a pathologist, (Michael
Davies), a radiologist (Keith Jefferson), and a surgeon (Harold
Siddons and later John Parker).
Dr Leatham became well known for his investigations into the
origin and meaning of normal and abnormal heart sounds, and
cardiac murmurs. Together with Graham Leech he exploited electrocardiography, phonocardiography, and early echocardiographic techniques to investigate and report his numerous findings. Dr Leatham
had been trained in the bedside skills of auscultation, but when
informed by his meticulous experiments he became the most
renowned and skilful cardiologist of his age. He designed his own
stethoscope and by the time physicians of my generation trained in
cardiology it was imperative to own a Leatham stethoscope.1
The radiology, surgical, and technical team that had been
assembled at St. George’s was ideally placed to take advantage
of new developments in cardiology. For example, it was at
St. George’s under the direction of Dr Aubrey Leatham that the
techniques of coronary angiography and coronary surgery were
first introduced into the UK.
Davies.
In the late 1940s and early 1950s Dr Aubrey Leatham saw many
cases of atrio-ventricular (AV) block—it was a ‘hopeless’ disease
since nothing could be done for the patients other than to
comfort them. Over half of them died within 1 year of presentation. Leatham believed that it ought to be possible to stimulate
the ventricles to contract by using an electrical pulse. He asked
Mr Geoffery Davies to build him a ‘stimulator’ (Figure 3). At first
pacing was done via a thoracotomy, but pericardial infection was
a common and often fatal complication.
In an attempt to deal with the infection problem Dr Leatham
decided to follow the example of Paul Zoll who had reported
the use of an external transcutaneous pacemaker.2 Geoff Davies
was able to build an external pacing system (Figure 4) with
cutaneous electrodes built into a Bakelite telephone-like handset!
Importantly Dr Leatham was aware that ventricular extrasystoles
might induce ventricular fibrillation and from the outset, unlike
Zoll, Davies, and Leatham had designed and built a pacemaker
which was suppressed by the spontaneous rhythm—a so-called
demand pacemaker.3 But external pacing through the skin
proved to be very painful because of pacing the thoracic
muscles—in the first case of external pacing the night nursing
1358
sister switched off the pacemaker device being used in an unfortunate woman patient, in order to let her die in peace.
In order to reduce the pain associated with pacing Dr Leatham
believed that he had to stimulate the heart directly and he decided
to try the transvenous route to the right heart. Dr Leatham was
very wary of placing an electrode in the right ventricle because he
had undertaken very many right heart catheterizations in patients
with severe pulmonary hypertension and knew that the right ventricle
could be very irritable under such circumstances. It was not unusual
during a catheterization to unintentionally provoke severe ventricular
tachyarrhythmias with fatal consequences. He therefore went only as
far as placing the electrode wire in the low right atrium, sufficiently
close to the ventricle to achieve capture by high-voltage pacing;
usually around 20 V were needed to pace the ventricles, although
occasionally 10 V would suffice.4
As successful pacing commenced the blood pressure rose beat
by beat and within a few seconds normal pressure were reached
and the patient would usually regain consciousness. Unfortunately,
at 20 V the thoracic muscles were also stimulated and ventricular
pacing from the atria was often as painful as transcutaneous pacing.
However, the results were dramatic—he noticed that the stimulus
was closely followed by a wide ventricular complex, and reasoned
that the working myocardium, and not the remnants of the conduction system, must have been paced directly.
Pacing via the transvenous route also encountered problems
with infection, even when threading the wire through a long subcutaneous course. Once infection had set in it was necessary to
change to the contralateral jugular vein, and if that also became
infected there was no alternative but to recourse to pericardial
pacing via a thoracotomy. This was apparently an even greater
problem at the Brompton hospital, and moving from one side to
another because of infection became known as the ‘Brompton
Swing’ procedure. Unfortunately painful stimulation or eventual
infection would often lead to the abandonment of pacing and
the almost inevitable death of the patient.
The problem with infection was finally resolved when it became
possible to implant a pacemaker below the skin. Elmqvist and
Senning,5 working in Stockholm, first used such a device in 1958
and reported it in abstract form in 1960, and in April 1960 cardiothoracic surgeon Leon Abrams (working with medical engineer Ray Lightwood) implanted the UK’s first permanent pacing system in
Birmingham.6 The patient had developed AV block following a ventricular septal defect repair; Abram’s device (later developed as the
Lucas–Abrams pacemaker) used an external generator attached to
an induction coil. This coil was strapped over an implanted subcutaneous coil attached to pericardial leads. This approach avoided
both the infection risk and failure problems relating to electronic
component unreliability. Patients carried a spare device, could
change their own batteries and even adjust their pacing rate. The
first patient lived for 3 years, dying of an unrelated malignancy.
In 1961 Harold Siddons, O’Neal Humphries, and Aubrey Leatham
implanted the first ‘indwelling’ pacemaker in the UK in a 65-year-old
man with repeated Stokes–Adams attacks due to complete heart
block (Figure 5).7 The nickel cadmium ‘accumulator’, which
powered the pacemaker, had to be recharged once a week.
Early experience with pacing patients in complete heart block
revealed that the survival of older patients with heart block was
A. John Camm et al.
Figure 5 X-ray of first pacemaker implanted in the UK and
reported by Leatham in 1961.
restored to normal but that paradoxically younger patients with
AV block still tended to die sooner than their peers despite successful pacing. Michael Davies, a brilliant young cardiac pathologist
who was working with Dr Leatham at the time was able to show
that AV block in the elderly was most likely due to bilateral fibrosis
of the conduction system (bilateral bundle branch block) but that
coronary artery disease was much more likely to be the cause of
sudden AV block in younger patients.8 Presumably their untimely
deaths were more related to their ischaemic and infarcted myocardium rather than simple failure of AV conduction. On the other
hand, Dr Leatham working with Edgar Sowton neatly demonstrated that pacing could suppress ventricular tachyarrhythmias in
patients with coronary artery disease.9
Most of Dr Leatham’s pacing experience was with complete heart
block; the patient generally presented with repeated and dramatic
Stokes–Adams attacks and often died. In contrast Dr Leatham was
never convinced that sick sinus syndrome was worth pacing—he
had never seen someone die from the problem and he thought that
it was a far milder condition than complete AV block. However, he
was much more wary of brady–tachy syndrome because he documented a high incidence of stroke and other forms of thromboembolism, and was one of the first physicians to come rapidly to the
conclusion that such patients should be treated with warfarin.
During Dr Leatham’s aegis at St. George’s and the National
Heart Hospitals, Edgar Sowton, Alan Harris, Kanu Chatterjee,
Richard Sutton, and Tony Rickards, to name but a few, developed
their interest in cardiac pacing. His tenure lead to an intensely productive three decades of clinical research and development during
which the imprint of Aubrey Leatham was stamped on the international world of cardiac pacing and electrophysiology.
Dr Leatham retired from St. George’s Hospital in 1985, and was
much amused by the need to appoint three new cardiologists to
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Aubrey Leatham and the introduction of cardiac pacing
replace him, a very practical tribute to this remarkable man. His life
continues, together with his wife Judith; he still plays tennis, sails
dinghies, skis across country, and climbs mountains. Until very
recently he was able to see patients in his local hospital, where
he was able to diagnose almost every significant structural
disease of the heart with great accuracy simply by taking a good
history and making a thorough examination.
Conflict of interest: none declared.
References
1. Leatham A. An improved stethoscope. Lancet 1958;1:463.
2. Zoll PM. Resuscitation of the heart in ventricular standstill by external electric
stimulation. N Engl J Med 1952;247:768 – 71.
3. Cook P, Davies JG, Leatham A. External electric stimulator for treatment
of ventricular standstill. Lancet 1956;271:1185 –9.
4. Portal RW, Davies JG, Leatham A, Siddons AH. Artificial pacing for heart-block.
Lancet 1962;2:1369 –75.
5. Elmqvist R, Senning A. An implantable pacemaker for the heart. In: Smyth CN (ed.).
Proceedings of the Second International Conference on Medical Electronics, Paris, France,
June 24 – 27, 1959. London, UK: Iliffe and Sons; 1960. pp. 253 –4.
6. Abrams LD, Hudson WA, Lightwood R. A surgical approach to the management of
heart-block using an inductive coupled artifical cardiac pacemaker. Lancet 1960;1:
1372–4.
7. Leatham A. Complete heart block with Stokes–Adams attacks treated by indwelling pacemaker. Proc R Soc Med 1961;54:237 –8.
8. Harris A, Davies M, Redwood D, Leatham A, Siddons H. Aetiology of chronic
heart block. A clinico-pathological correlation in 65 cases. Br Heart J 1969;31:
206– 18.
9. Sowton E, Leatham A, Carson P. The suppression of arrhythmias by artificial.
pacemaking. Lancet 1964;2:1098 –100.
IMAGES IN ELECTROPHYSIOLOGY
doi:10.1093/europace/euq310
Online publish-ahead-of-print 26 August 2010
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An unexpected vein draining into the left atrial roof
Takanao Mine *
Department of Internal Medicine, Cardiovascular Division, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya 6638501, Japan
* Corresponding author. Tel: +81 798456553, Email: [email protected]
We investigated left atrium (LA) morphology using multidetector computed tomography in 500 patients and found 2 patients with an
LA roof vein. A 71-year-old male was found to have a roof vein that connected to the mid-roof of the LA (Panel A: volume-rendered
image, Panel B: endocardial view). A 68-year-old female was shown to have a right-sided roof vein (Panels C and D). The possibility of
this vascular variation should be kept in mind during procedures such as catheter ablation of LA in order to prevent complications such
as cardiac tamponade.
Conflict of interest: none declared.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: [email protected].