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AMERICAN SOCIETY OF ECHOCARDIOGRAPHY NEWS
AMERICAN SOCIETY OF ECHOCARDIOGRAPHY NEWS President’s Message THE FEIGENBAUM LECTURE: VISION AND VISIONARIES
Inge Edler, a clinical cardiologist, and Hellmuth Hertz, an electrical engineer, performed the first cardiac pulsed ultrasound study in 1953 in an attempt to find a better way to evaluate mitral valve disease, a goal that would not be fully attained for another 15 years.After the second World War, ultrasound research was declassified, and Edler and Hertz were able to adapt a Siemens ultrasonographic machine used for metal fatigue testing to image the heart. The system produced amplitude (A mode) images, which appeared as a number of moving spikes corresponding to ultrasound reflected from tissue interfaces. They coined the term ultrasound cardiography to describe their technique. The images were hard to interpret, they could not easily be quantitated, and there was no hard copy recording.The earth did not move. Investment bankers and venture capitalists did not descend on Lund, Sweden, to capitalize on this revolutionary discovery. How did echocardiography grow from these crucial yet humble beginnings to become the dominant noninvasive diagnostic cardiac procedure? John Julian Wild and John Reid performed the first American cardiac ultrasound studies on excised human hearts in 1957. Reid subsequently built an ultrasonoscope and, working with Claude Joyner, duplicated some of the early clinical studies of Edler and Hertz on mitral stenosis. In 1963 a young clinical investigator in Indianapolis with an interest in cardiac catheterization and electrophysiology was frustrated by his inability to adequately define pressure volume relationships in his patients with valvular heart disease. By chance he came across an advertisement for a BioSonar machine, which claimed that the device could measure instantaneous cardiac volumes; this led to a meeting with BioSonar at the next American Heart Association scientific sessions.The investigator used this A-mode ultrasound machine to image himself, and although volumes clearly could not be quantitated, he was fascinated by echo reflections from the back wall of his heart. He wondered what the study would look like in a patient with a pericardial effusion. Later that year he borrowed a SmithKline instrument used for detecting midline shift in the brain and studied patients with pericardial effusions. He detected an echo-free space between the two layers of pericardium, and laboratory experiments with dogs confirmed that this observation was related to the size of the pericardial effusion. Publication of his findings in the Journal of the American Medical Association in 1965 demonstrated the first serious clinical application of cardiac ultrasound (JAMA 1965;191:711-4). His subsequent report published in Circulation in 1966 showed that
Volume 12 Number 8
mitral annular motion provides information about left ventricular (LV) filling and produces a tracing that looks like a diastolic volume curve (Circulation 1966;34:611-9). This demonstration of important clinical indications for cardiac ultrasound led the young investigator, Harvey Feigenbaum, to become the father of American echocardiography. The noted baseball philosopher Yogi Bera said that it is difficult to make predictions, especially about the future. Were Harvey’s studies greeted with respect from his hospital leaders, long-term funding from the National Institutes of Health, and easy acceptance? Charlie Fisch, the chief of medicine at the time, seriously questioned his sanity and urged Phyllis Feigenbaum to try to talk some sense into her husband. He gave the same advice to Richard Popp, one of Harvey’s early fellows, telling the future president of both the ASE and the American College of Cardiology that Harvey was throwing away his career. Harvey, however, had that vision thing and a great deal of gritty determination. His only support came from Tom Davis, the assistant medical director of Smith, Kline & French Laboratories, who ensured that Harvey always had an instrument with which to work.This led to a long-standing appreciation for the contributions that industry makes and a desire to help develop new technology. The killer application that paved the way for echocardiography was the quantitation of LV size and function. A number of studies were performed in Indianapolis that
Journal of the American Society of Echocardiography 17A
showed how M-mode echocardiography, despite its limitations, could provide accurate quantitative information when significant segmental dysfunction was not present. Harvey could not get these studies accepted for presentation or publication, despite their now obvious clinical importance. They were published only after the recognition of echos from the interventricular septum and the performance of repeat studies of LV dimensions by Richard Popp when he moved to Stanford. Finally, echocardiography captured the imagination of many cardiologists. The next step was to teach people how to use this new technique.The first course in echocardiography was held for a brave set of persons willing to come to Indianapolis during a terrible snowstorm in January 1967. Harvey held an ongoing open house to train young investigators who could take the expertise they developed to other centers and expand the applications of echocardiography. These early students and their own trainees went on to develop many of the clinical applications of echocardiography. The struggle for acceptance did not end here. Senior cardiologists who had never trained in echocardiography did not appreciate it, and they continued to discount it. Harvey led the battle for general acceptance of quantitative studies, and he was often the token spokesman at meetings to discuss the evaluation of LV function. He sometimes felt like the voice in the wilderness. When 2-dimensional echocardiography became available, many of us focused on the more exciting application of echocardiography in valvular and congenital heart disease, intracardiac masses, and cardiomyopathies. Harvey reminded us that coronary artery disease was the key problem in clinical cardiology. It was essential that quantitative echocardiography play an important role in the evaluation and treatment of this condition. At a Bethesda conference on LV function, Harvey, along with Richard Popp,Walt Henry, and Alan Pearlman, could not convince the other cardiologists in the group that echocardiography could compete with nuclear studies. Disheartened but not defeated, Harvey was determined to prove that echocardiography was an equal or superior technique. Innovation was always the means to overcoming obstacles. Harvey recognized that the key to success was improved image storage and retrieval and the ability to perform echocardiography during an exercise stress test. He became the main proponent of stress echocardiography, and as the technique improved, he and his collaborators showed that the technique could compete with nuclear cardiology studies in the diagnosis and management of patients with coronary disease. Harvey has often said that it takes 10 years or more for a good idea to become a generally accepted product or technique. In the
early 1980s he developed a system of digital storage of echo loops with a floppy disk, and a network that would allow access to the data from different computer stations in the hospital.The studies were still a little fuzzy, the digital techniques jittery and only black and white; however, this was the precursor to the current wave of digital image manipulation. Harvey’s commitment to quality and high standards were an important part of the founding of the ASE. He served as the first president of the society. He is the first and only editor our journal has ever had. When Harvey speaks we all listen, and many of those listening are Harvey’s students, in one way or another. He has always been dedicated to developing young talent and sharing his insights with his colleagues.Therefore I thought that a very appropriate way to demonstrate our gratitude would be to honor Harvey with a lecture in his name at the ASE annual scientific sessions. The first lecture will be given at the 2000 scientific session, marking the 25th anniversary of the ASE. I was delighted when Harvey agreed to allow us to do so, and I suggested that the lecture recognize an established investigator who would present a review of an important body of his or her work. Harvey had a better idea. He was concerned that there are a decreasing number of young cardiologists interested in a career as an investigator in echocardiography. He suggested that a younger investigator should give the Feigenbaum Lecture. In this way the ASE could promote and recognize the importance of a research career in echocardiography. Harvey represents the young clinical investigator of the 1960s.Although he has mellowed with time, his passion for echocardiography has not diminished. Churchill said, “History with its flickering lamp stumbles along the trail of the past, trying to reconstruct its scenes, to revive its echoes, and kindle with pale gleams the passion of former days.”The society needs to identify and support investigators who demonstrate the passion and commitment that Harvey has shown for the past 40 years.These investigators represent a new generation of echocardiographers, who often combine an interest in echocardiography with clinical epidemiology, outcomes research, engineering, animal or human physiology, or molecular medicine.The continuing success of echocardiography in the new millennium will depend on their vision.The Feigenbaum Lecture, honoring the founder of our society, will recognize their accomplishments and help them draw inspiration from a visionary. Harry Rakowski, MD President American Society of Echocardiography
18A Journal of the American Society of Echocardiography
Volume 12 Number 8
Inge Edler, a clinical cardiologist, and Hellmuth Hertz, an electrical engineer, performed the first cardiac pulsed ultrasound study in 1953 in an attempt to find a better way to evaluate mitral valve disease, a goal that would not be fully attained for another 15 years.After the second World War, ultrasound research was declassified, and Edler and Hertz were able to adapt a Siemens ultrasonographic machine used for metal fatigue testing to image the heart. The system produced amplitude (A mode) images, which appeared as a number of moving spikes corresponding to ultrasound reflected from tissue interfaces. They coined the term ultrasound cardiography to describe their technique. The images were hard to interpret, they could not easily be quantitated, and there was no hard copy recording.The earth did not move. Investment bankers and venture capitalists did not descend on Lund, Sweden, to capitalize on this revolutionary discovery. How did echocardiography grow from these crucial yet humble beginnings to become the dominant noninvasive diagnostic cardiac procedure? John Julian Wild and John Reid performed the first American cardiac ultrasound studies on excised human hearts in 1957. Reid subsequently built an ultrasonoscope and, working with Claude Joyner, duplicated some of the early clinical studies of Edler and Hertz on mitral stenosis. In 1963 a young clinical investigator in Indianapolis with an interest in cardiac catheterization and electrophysiology was frustrated by his inability to adequately define pressure volume relationships in his patients with valvular heart disease. By chance he came across an advertisement for a BioSonar machine, which claimed that the device could measure instantaneous cardiac volumes; this led to a meeting with BioSonar at the next American Heart Association scientific sessions.The investigator used this A-mode ultrasound machine to image himself, and although volumes clearly could not be quantitated, he was fascinated by echo reflections from the back wall of his heart. He wondered what the study would look like in a patient with a pericardial effusion. Later that year he borrowed a SmithKline instrument used for detecting midline shift in the brain and studied patients with pericardial effusions. He detected an echo-free space between the two layers of pericardium, and laboratory experiments with dogs confirmed that this observation was related to the size of the pericardial effusion. Publication of his findings in the Journal of the American Medical Association in 1965 demonstrated the first serious clinical application of cardiac ultrasound (JAMA 1965;191:711-4). His subsequent report published in Circulation in 1966 showed that
Volume 12 Number 8
mitral annular motion provides information about left ventricular (LV) filling and produces a tracing that looks like a diastolic volume curve (Circulation 1966;34:611-9). This demonstration of important clinical indications for cardiac ultrasound led the young investigator, Harvey Feigenbaum, to become the father of American echocardiography. The noted baseball philosopher Yogi Bera said that it is difficult to make predictions, especially about the future. Were Harvey’s studies greeted with respect from his hospital leaders, long-term funding from the National Institutes of Health, and easy acceptance? Charlie Fisch, the chief of medicine at the time, seriously questioned his sanity and urged Phyllis Feigenbaum to try to talk some sense into her husband. He gave the same advice to Richard Popp, one of Harvey’s early fellows, telling the future president of both the ASE and the American College of Cardiology that Harvey was throwing away his career. Harvey, however, had that vision thing and a great deal of gritty determination. His only support came from Tom Davis, the assistant medical director of Smith, Kline & French Laboratories, who ensured that Harvey always had an instrument with which to work.This led to a long-standing appreciation for the contributions that industry makes and a desire to help develop new technology. The killer application that paved the way for echocardiography was the quantitation of LV size and function. A number of studies were performed in Indianapolis that
Journal of the American Society of Echocardiography 17A
showed how M-mode echocardiography, despite its limitations, could provide accurate quantitative information when significant segmental dysfunction was not present. Harvey could not get these studies accepted for presentation or publication, despite their now obvious clinical importance. They were published only after the recognition of echos from the interventricular septum and the performance of repeat studies of LV dimensions by Richard Popp when he moved to Stanford. Finally, echocardiography captured the imagination of many cardiologists. The next step was to teach people how to use this new technique.The first course in echocardiography was held for a brave set of persons willing to come to Indianapolis during a terrible snowstorm in January 1967. Harvey held an ongoing open house to train young investigators who could take the expertise they developed to other centers and expand the applications of echocardiography. These early students and their own trainees went on to develop many of the clinical applications of echocardiography. The struggle for acceptance did not end here. Senior cardiologists who had never trained in echocardiography did not appreciate it, and they continued to discount it. Harvey led the battle for general acceptance of quantitative studies, and he was often the token spokesman at meetings to discuss the evaluation of LV function. He sometimes felt like the voice in the wilderness. When 2-dimensional echocardiography became available, many of us focused on the more exciting application of echocardiography in valvular and congenital heart disease, intracardiac masses, and cardiomyopathies. Harvey reminded us that coronary artery disease was the key problem in clinical cardiology. It was essential that quantitative echocardiography play an important role in the evaluation and treatment of this condition. At a Bethesda conference on LV function, Harvey, along with Richard Popp,Walt Henry, and Alan Pearlman, could not convince the other cardiologists in the group that echocardiography could compete with nuclear studies. Disheartened but not defeated, Harvey was determined to prove that echocardiography was an equal or superior technique. Innovation was always the means to overcoming obstacles. Harvey recognized that the key to success was improved image storage and retrieval and the ability to perform echocardiography during an exercise stress test. He became the main proponent of stress echocardiography, and as the technique improved, he and his collaborators showed that the technique could compete with nuclear cardiology studies in the diagnosis and management of patients with coronary disease. Harvey has often said that it takes 10 years or more for a good idea to become a generally accepted product or technique. In the
early 1980s he developed a system of digital storage of echo loops with a floppy disk, and a network that would allow access to the data from different computer stations in the hospital.The studies were still a little fuzzy, the digital techniques jittery and only black and white; however, this was the precursor to the current wave of digital image manipulation. Harvey’s commitment to quality and high standards were an important part of the founding of the ASE. He served as the first president of the society. He is the first and only editor our journal has ever had. When Harvey speaks we all listen, and many of those listening are Harvey’s students, in one way or another. He has always been dedicated to developing young talent and sharing his insights with his colleagues.Therefore I thought that a very appropriate way to demonstrate our gratitude would be to honor Harvey with a lecture in his name at the ASE annual scientific sessions. The first lecture will be given at the 2000 scientific session, marking the 25th anniversary of the ASE. I was delighted when Harvey agreed to allow us to do so, and I suggested that the lecture recognize an established investigator who would present a review of an important body of his or her work. Harvey had a better idea. He was concerned that there are a decreasing number of young cardiologists interested in a career as an investigator in echocardiography. He suggested that a younger investigator should give the Feigenbaum Lecture. In this way the ASE could promote and recognize the importance of a research career in echocardiography. Harvey represents the young clinical investigator of the 1960s.Although he has mellowed with time, his passion for echocardiography has not diminished. Churchill said, “History with its flickering lamp stumbles along the trail of the past, trying to reconstruct its scenes, to revive its echoes, and kindle with pale gleams the passion of former days.”The society needs to identify and support investigators who demonstrate the passion and commitment that Harvey has shown for the past 40 years.These investigators represent a new generation of echocardiographers, who often combine an interest in echocardiography with clinical epidemiology, outcomes research, engineering, animal or human physiology, or molecular medicine.The continuing success of echocardiography in the new millennium will depend on their vision.The Feigenbaum Lecture, honoring the founder of our society, will recognize their accomplishments and help them draw inspiration from a visionary. Harry Rakowski, MD President American Society of Echocardiography
18A Journal of the American Society of Echocardiography
Volume 12 Number 8