Revolutionizing the Cardiac Catheterization Field

You have worked as a nurse and independent consultant in the invasive cardiology field since its earliest days. What was it like during that time? When you’ve worked in the invasive cardiology field for over thirty years as I have, there certainly are some interesting stories to tell. Invasive cardiology came into being and literally evolved before my eyes, beginning for me in the late 1960s. It has truly been fascinating to be a part of such a new and rapidly evolving field. I initially worked as a nurse in the operating room at Granada Hills Community Hospital. In 1968, while still working in the O.R., I started afternoons in the cardiac catheterization laboratory. Only diagnostic procedures were performed at that time, of course. Patients basically had two options before the days of interventional cardiology: 1) medical therapy, or 2) coronary artery bypass graft surgery. Can you describe the first diagnostic cardiac catheterization procedures you participated in back in the late 1960s and early 1970s? For me, it all began in 1968 when local cardiologist Dr. Edwin Zalis came to our institution with the goal of performing diagnostic cardiac catheterizations. He had completed an 8-week invasive cardiology fellowship at UCLA. This doctor brought along one of his CCU nurses to be trained in setting up for catheterization procedures. His nurse only completed one procedure before leaving the job due to pregnancy. Unfortunately, she had not passed along the knowledge and skills she had acquired in the UCLA training program. At that point, Dr. Zalis looked to the operating room nursing staff for potential assistance because O.R. nurses tended to be more familiar with instrumentation, table set-up, procedural set-up and protocols. I had worked as an O.R. nurse for about twelve years and was ready for a new challenge, so I accepted the offer to become a cardiac catheterization nurse. I made various changes in the catheterization laboratory in terms of instrumentation. Because we were all new at cardiac catheterization the physicians included it was definitely a case of "see one, do one, teach one." And that is exactly what I did: I observed my first catheterization procedure, actually assisted on the second one, and proceeded to teach others from that point on. Heart catheterizations used to take a considerable amount of time about two to three hours. This was particularly true at UCLA because it was a teaching hospital. Those who became adept at the diagnostic procedures were able to perform them in less time. Manipulating catheters while looking at a screen was a very new skill to learn and was not easy at first. The catheters were relatively large in the early days: 8F diameters were used back then as opposed to the 5F“6F catheters used today. In addition, the image intensifiers were fixed machines. The patient was placed in a cradle, which was rocked into various positions in order to obtain the necessary images. The invasive cardiologists were required to share the multi-purpose fluoroscopy x-ray room that belonged to the radiology department and the radiologists were very possessive about their rooms! Radiology only allowed the cardiology team to use their rooms after 5:00 pm, when the radiologists were finished with their day’s work. Thus, diagnostic heart catheterizations were often performed as late as 10:00 and 11:00 pm. Another difference in those days was that instrumentation was not disposable; all equipment needed to be sterilized for re-use. Were you aware that you were on the cutting edge of a new field? No, not really. I was just enjoying the opportunity to learn something new! Next thing I knew, a year and a half into the job, I had opened up eight catheterization laboratories in the San Fernando Valley, California. Every hospital in California wanted a cath lab, and in this state, there’s a hospital on practically every street corner. One hospital administrator I spoke with at the time told me that cardiac catheterization was just a fad; that it wouldn’t last. I laugh when I think about how wrong he was! Historically speaking, the first left heart catheterizations were performed because a surgical procedure became available for the treatment of angina. The Vineberg surgical procedure was initially performed in Canada. The Vineberg procedure involved tunneling a bleeding mammary artery into the heart, where it was left to form vessels in other words, angiogenesis. Angiogenesis took about six to seven months, however, so the patient did not experience relief from angina until the process of angiogenesis was complete. It wasn’t long after the Vineberg procedure that coronary artery bypass graft surgery was launched. Diagnostic cardiac catheterization (coronary cine angiography) became necessary with the advent of CABG because there was a need to visualize the arteries. Before CABG, however, visualizing the arteries was irrelevant because there was nothing that could be done to treat the blockages that might be found. What was the general attitude when interventional procedures appeared on the horizon? There was certainly some controversy surrounding interventional procedures in the early days. Dr. John Simpson of Stanford University, who invented the over-the-wire system in his garage, was considered very radical and was referred to as a heretic by his peers. Dr. Andreas Gruentzig considered the technique far too dangerous. Before the John Simpson's over the wire system, Andreas Gruentzig's fixed wire balloons were used and could only reach proximal large vessels. With the advent of the over-the-wire system, more distal access was available even though the balloon diameters were 7 and 8Fr. Dr. Simpson launched the company Advanced Cardiovascular Systems (ACS), manufacturer of balloons and wires that were soon considered the "Porsches" of their kind due to their excellent design and construction. Dr. Geoff Hartzler of Mid America Heart Institute at St. Luke's Hospital, Kansas City, Missouri, took the over-the-wire system beyond expectations and initiated techniques still being used today. It is truly fascinating to witness the evolution of interventional technology. There is no way to convey the incredible changes or compare the early balloons with the new sleek stents. Who were some of the physicians you were working with at that time? Dr. Harris Schoenfeld was one of the very first physicians I worked with. He moved to California from New York to join Dr. Edwin Zalis. Later, I worked with Dr. Thomas Jacobson, Dr. Allen Rosenbluth, Dr. Steven Salzman, and many other physicians here in the Valley. In 1971, I quit my job at Granada Hills Hospital Cath Lab because I was not allowed to take a much-needed vacation. From that time on, I became an independent consultant to physicians who needed assistance in trouble-shooting problems at their cath labs or guidance in set-up and training of staff. In fact, Dr. Zalis was my first customer. He asked me to troubleshoot a problem he was experiencing at his cath lab where morbidity rates had suddenly risen. Three of Dr. Zalis’ patients experienced myocardial infarctions during their diagnostic procedure, and he wanted to determine if it was a statistical phenomenon or if it was due to procedural error (i.e., air injected into the vessel, improperly sterilized equipment, etc.). At that time, of course, there were no clinical studies to which we could refer. I was asked to ensure that every step preceding the heart catheterization was properly performed so as to eliminate the possibility of oversight or negligence. Ultimately, we found nothing procedurally wrong, but determined that there would be a certain percentage of patients whose outcomes would not be satisfactory. In the early days, we were extremely careful with our procedures because the field was so new. Diagnostic cardiac catheterization was such a young field and there was so much to learn. During this time, we also learned that the iodine or other chemical mixtures used in contrast media could cause arrhythmias. My experience as an operating room nurse served me well in terms of trouble-shooting instrumentation and procedural problems. In fact, I became viewed as somewhat of an "expert" to the physicians in the Valley in terms of setting up and training staff for the catheterization laboratory. How did you begin opening catheterization laboratories? After I helped troubleshoot at Dr. Zalis’ lab, I took over as his scrub nurse and trained some of his staff members. He then asked me to help launch cath labs at two other sites. With the help of Mary Ann Armijo, a CVT at the lab, we discussed the instrumentation and equipment needs with the hospital administrators at these other sites and provided general guidance to their cath lab staff. At the same time, Drs. Schoenfeld and Jacobson also asked for help on two labs each. During this time, I carried all that was necessary to perform a right and left cardiac catheterization in the trunk of my car (tray, catheters, tubing, solutions etc.). What were lead aprons like at the time? Front lead aprons or the extremely heavy wraparound aprons were used in the early cath lab days. In the mid-1970's, I stumbled upon a very small company called Infab (located at the Van Nuys airport in a hanger), which manufactured innovative lead skirts and vests. These lead skirts and vests were an immediate success with all the local hospitals. Infab is now located in Camarillo, CA. What was it like to share space with radiology? In the beginning, radiologists were very resistant to the idea of cardiologists performing cine angiography, which they considered their domain. Regarding cine films, we had no way of developing them at that time, so at the end of the day, we used to take the films over to the movie studios where they were developed along with the studio’s daily rushes. So Hollywood played a minor role in helping to develop the field of invasive cardiology! Can you share more about your experience training catheterization laboratory staff? The physicians, such as Dr. Salzman, Dr. Zalis, Dr. Jacobson and Dr. Schoenfeld, all wanted me to be their scrub nurse, but since I couldn’t be everywhere at once, I helped train other nurses for the job. In fact, my sister Maria Schwiebert, who is also a nurse and my partner, was my first trainee. We taught nurses to scrub, circulate and monitor, and technologists were taught to scrub. Northridge Hospital, West Hills Medical Center, St. Joseph’s Hospital in Burbank, Valley Presbyterian, and Encino Hospital were some of the hospitals where we trained nurses to work in the cardiac cath lab. That’s why my e-mail name is "ISCSMom" I was a mother of sorts, and those I trained were my children. Needless to say, I had quite a large family! My sister and I soon became the support staff for these Valley-area catheterization laboratories. If one of their nurses was ill or on vacation, they called us to fill in. In 1983, I formed I Seymour Associates (ISA), a company which provided independent contract nurses to area cath labs. I felt that nurses should be able to have the same independence that I had over the years. Independent nursing allowed these nurses, many of whom had young children and busy home lives, to manage their own work schedules. In the beginning, the hours cath lab nurses worked were often odd, because most catheterization procedures in the Valley were performed in radiology labs after hours. There were very few dedicated cath labs at that time. Ultimately, I found that the independent contract nurse was a more reliable, responsible staffer. They managed their own schedules and took great pride in their work. My company rapidly gained a good reputation as a result. Today, the company is called I Seymour Cardiovascular Services. For liability reasons, the partnership incorporated. We currently have fifteen independent nurses and techs working. In any event, we have never had a lawsuit brought against us in the twenty years we have been operating. What were some of your duties while working with various physicians? Since I set up the procedure, I always had another nurse scrubbing. In Los Angeles, the doctors handled the injection of contrast media, but because I had nurses scrubbing, I convinced our physicians that the nurse could do the injections; we were licensed to do this sort of task. In the greater Los Angeles area, the technologists were allowed to scrub. They helped with the catheter and wire exchanges, but never got near the manifolds or did any dye injecting. The technologists also did the filming. In the San Fernando Valley, the physician did the filming and the nurse the injecting. Thus, the nurse was like a first assistant to the cardiologist. The physician would put the catheter in and position it, and the nurse would inject dye into the coronary arteries, while the physician took the pictures. In the early days, during angioplasty, it was necessary to trace pressure gradients to determine the difference in pressures between the distal and proximal vessels. A step up in pressure distal to the lesion and proximal to the lesion always occurs. The cardiologist used to send a wire down and balloon the lesion. The wire was then removed and the pressure would be measured from the distal and proximal ends. Since I worked with so many different cardiologists, I became a sort of conduit of information between them. These physicians were all in the learning phases they all had roughly the same level of knowledge and skill in cardiac catheterization. They would often tap into each other’s knowledge through me. During a procedure, for example, and because I regularly attended the major seminars, I was often asked by the cardiologist, "What would Dr. Hartzler do if he saw this?" or "What would Dr. Schoenfeld do if he encountered this?" And since I worked with all of these doctors, I was familiar with the techniques and "tricks of the trade" that these cardiologists used in certain situations. I often served as the physicians’ "go-between," perhaps because they wanted equality with their peers. On the other hand, they were perfectly comfortable coming to me! Ultimately, the patient was the beneficiary of this knowledge network. Have you ever undergone a cardiac catheterization procedure? No, but my colleagues wonder what will happen if and when I do! I would probably have undergone one by now if I didn’t have failing kidneys. I am headed for dialysis before long and once that happens, I am sure I will undergo cardiac catheterization because of my family history (two brothers have had CABG and one has stents). When the time comes, the biggest challenge will be to decide who will perform my procedure, since I know so many highly skilled interventionists. I have even considered going to Mayo Clinic or some other large center outside of California so as not to offend any of the physicians here! I believe that I will have Dr. Schoenfeld perform my cardiac catheterization, though, because not only is he very talented, but he is also one of my oldest and dearest friends. Have you been involved in continuing education programs during your career? Yes. Before the Society of Invasive Cardiovascular Professionals (SICP) was formed, I helped to launch the American College of Cardiovascular Invasive Specialists (ACCIS) in 1984, which later became a national organization. I was president of ACCIS for three years. The organization was formed to provide continuing education programs specifically designed for cardiac catheterization nurses who were hard-pressed to find programs that addressed cath lab topics. ACCS invited local invasive cardiologists to lecture on topics such as balloon angioplasty, contrast media, pharmacology, new devices, and so forth. The national CVT society (NSCT/NSPT) eventually took ACCIS over, but it was no longer as active as it initially had been. Who are some of the other invasive cardiologists you have met over the years? I have attended some of Dr. Simpson’s seminars and have had the opportunity to talk with Dr. Hartzler in the past, as well as attending his seminar at Mid America Heart Institute. Besides the cardiologists already mentioned, such as Drs. Simpson, Hartzler, Myler and Stertzer, there have been many talented pioneers in interventional cardiology whom I've had the privilege of meeting over the years, like Drs. Richard Schatz (pioneer in stents) and Paul Tierstein at Scripps, Dr. Ray Mathews of Good Samaritan, Dr. Ara Tilkien of Holy Cross, Dr. William Gifford of St. Joe's, Drs. DelVicario and Grollman of Little Co. of Mary, Dr. Litvak of Cedar Sinai, and many more. We have worked out of state in Michigan, Utah, Nevada, Hawaii, Washington, Texas, and Georgia as well. I attribute my great success to my love of the field, and the fact that the opportunities for learning and experiencing new things continues. Invasive cardiology has been for me a labor of love and an adventure that never ends. Irene Hinojosa Seymour was born in Los Angeles California in 1935. She graduated from St. Vincent College of Nursing in 1955. Prior to her invasive cardiology career, her early nursing work included ER Industrial nursing, OB, and Med./Surg. Irene married Alan Seymour in 1955. She has four children.

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