Harold James Charles (Jeremy) Swan: the man behind the “sailing catheter”

Jeremy Swan
Harold James Charles “Jeremy” Swan (1922-2005)

Jimmy Tam Huy Pham
Garden City Hospital – Michigan State University, Garden City, MI (Spring 2016)

 

“Pressures in the right side of the heart and pulmonary capillary wedge can be obtained by cardiac catheterization without the aid of fluoroscopy… The frequency of premature beats was minimal, and no other arrhythmias occurred.” – N Engl J Med, 1970.1

With these descriptions, a new balloon-tipped catheter was born and revolutionized the methods of monitoring critically ill patients and the study of pulmonary vascular medicine. The pulmonary artery catheter (PAC) has been widely used for monitoring critically ill patients over the years. The PAC provides simultaneous monitoring of pulmonary artery pressures, cardiac filling, cardiac output and mixed venous oxygen saturation, and has an important role in complex cases.

In the fall of 1969, reportedly after watching a sailboat with a large spinnaker make good progress in the calm sea of Santa Monica, California, Swan, along with William Ganz, devised the first flexible pulmonary catheter with an inflatable balloon.2 A thermistor was later incorporated into the shaft for measurement of cardiac output.

In 1956, Werner Forssmann, André F. Cournand, and Dickinson W. Richards were awarded the Nobel Prize for their seminal work on heart catheterization that could be used to study the pathophysiology of congenial and acquired heart disease.3 In the following years, technical improvements were made to advance many studies about the right heart pressure. In 1964, Ronald D. Bradley, a British intensivist and a former student of Swan, introduced the miniature diagnostic catheters that can be used in severely ill patients. In 1965, Fife and Lee constructed self-guiding pulmonary artery catheters. In 1969, Scheiman, Abbot and Rapaport used a flow-directed right heart catheter; however, all the improvements still required the use for fluoroscopy and a specialized environment. 4-6 In 1970, Swan and Ganz introduced the balloon flotation catheters that significantly impacted the practice of clinical cardiology. For the first time, a catheter could be used at bedside and no fluoroscopy was required. The “Swan-Ganz” catheter was further developed for measuring cardiac output, right atrial and right ventricular pacing and for measuring right-sided pressures, including pulmonary capillary wedge pressure. The Swan-Ganz catheter became the standard of care in monitoring heart physiology for many years.7

Swan was born in seaport town of Sligo, in the Northwest of Ireland as Harold James Charles Swan. His mother, however, persisted in calling him Jeremy to limit family confusion and the name remains through the years.8

At seventeen he matriculated at the Saint Vincent’s Castleknock College in Dublin and graduated from there in 1939. He subsequently received his M.B. from the University of London, St. Thomas’s Hospital in 1945 where he remained as an intern and junior resident in medicine. In 1946, he passed the Membership examination ahead of his fellow students and joined the Royal College of Physicians of London. He then entered the Royal Air Force Medical Service as a medical specialist assigned to the Middle East Theater and was later put in charge as the medical director of the Medical Division of the Royal Air Force Fifth Hospital in Habaniyia in central Iraq. Upon returning to London in 1948, Swan began his research fellowship in physiology at the University of London under the direction of Henry Barcroft, (Professor, Department of Physiology, Queens University, Belfast, Ireland, 1935–1948) and was awarded his Ph.D. in 1951.9

In 1949, he published as a sole author the first paper on the effects of the newly discovered noradrenaline on muscle and skin blood flow in humans and demonstrated that the bradycardia it caused could be blocked with atropine.10

In 1951, Swan migrated to the United States to become a research associate, at the Mayo Clinic in Rochester, Minnesota, under the tutelage of Earl Howard Wood (Professor, Department of Physiology, University of Minnesota, Mayo Clinic, Rochester, Minnesota, 1951–1982) where he developed his skills in new procedures of cardiac catheterization. Then Swan became a consulting physician at the Mayo Clinic in 1956.

In 1959, Swan further trained with Bengt Jonsson and Ulf Rhude in Stockholm to gain first-hand experience in the then new discipline of cardiac angiography. He returned to Rochester and established the diagnostic catheterization and angiographic laboratory at St. Mary’s Hospital where he developed skills in cardiovascular diagnostic investigation and, in particular, in the management of small infants and critically ill adults. Swan became the Director of the Cardiac Catheterization Laboratory, and remained there until 1965. While serving as a director, he also served as the Professor of Physiology at the University of Minnesota Graduate School.

In 1965, Swan moved to California for the appointed position as Chief of Cardiology at the Cedars-Sinai Medical Center in Los Angeles. This appointment at the teaching hospital affiliated with the University of California Los Angeles (UCLA) also afforded him the opportunity to become a professor and mentor many brilliant minds.

Swan repeatedly described Henry Barcroft and Sir Henry Dale as major influences on his professional life. Earl H. Wood of the Mayo Clinic was also mentioned as a powerful and frequently decisive influence in Swan’s interest in cardiac and pulmonary vascular physiology. Earl was often known for demanding intellectually honesty and technical excellence in those he taught.  He instilled in Jeremy the fundamental principle that diagnose and treatment of cardiological problems must be sufficiently related to the basic biological sciences.11

Dr. Swan’s name is particularly associated with the activities of the American College of Cardiology. An invited lecturer in several of the meetings in the 1950s, he became a full Fellow at the College in 1968. He was appointed a member of the Executive Committee of the College in 1971, its President in 1979 and 1974, designated a Distinguished Fellow in 1985, and Chairman of the Bethesda Conference Committee of the College from 1984 to 1989.

Elected a Fellow of American College of Physicians in 1970, he was a member of its Scientific Committee from 1974 to 1980, and in 1985 was honored with a Mastership of the College. He was elected a Fellow of the Royal College of Physicians, London, in 1974.

His special honors and awards include that of International Visitor, Israel Heart Society, in 1968; James B. Herrick Award of the American Heart Association (1985); Award of Honor, University of Southern California (1987); the George C. Griffith Professorship of the American Heart Association, Los Angeles (1988); and perhaps most meaningful of all, the Stokes Medal of the Irish Cardiac Society in Dublin (1989).

He served as a member of editorial boards of almost all of the significant journals in cardiology and acted as an expert reviewer for a majority of journals in the United States and several overseas. He delivered named lectures too numerous to list and was honored by a number of national and foreign medical societies. For years, he also served as medical editor and on-camera host for the Lifetime Medical Television weekly program “Cardiology Update.” In addition, he produced and hosted video highlights for the First, Second, and Third Annual Congresses of the European Society of Cardiology in Vienna in 1988 and in Nice in 1989 and 1990. He was recipient of the Cummings Award for outstanding contributions to cardiovascular medicine.

He published more than 100 peer-reviewed articles in the fields of basic and clinical cardiac physiology and earned an international reputation in vascular physiology and congenital heart disease.12

Jeremy was born on June 1, 1922 to parents of Irish Catholic physicians in a family of four brothers. His father was Dr. Harold John Swan who occasionally administered his services to William Butler Yeats during the 1930s. His mother was Dr. Marcella (Kelly) Swan who gave Jeremy sulfa drugs, as penicillin was not available at the time, which saved his life when he was struck with meningitis and lapsed into a coma. Jeremy came from an extensive background of doctors – as many as 50 percent of his parent’s familial relatives were doctors.

In his early years at Cedars-Sinai, Jeremy met his second wife Roma Shahbaglian. For many years, Roma and Jeremy became the most visible and beloved couple in the cardiology circle.13

Tragedy struck Swan in 1990 when his beloved daughter Katherine, a Harvard physician, died after her struggle with metastatic cervical cancer. Tragedy struck again when Swan suffered a stroke in 2001 that lead to severe residual hemiparesis. Despite his physical limitations, Jeremy continued to mentor many young physicians and cardiologists until he took his last breath in his own hospital, from complications following a heart attack, on February 7, 2005. He was survived by his second wife and six children from his first marriage to Pamela Skeet (two sons, four daughters, and one daughter deceased; marriage dissolved) along with eleven grandchildren and one great granddaughter.14

“He leaves behind a legacy of tremendous accomplishment and inspiration to cardiologists and cardiology trainees all over the world. He will be remembered for his grand vision, leadership, wisdom and brilliance.” – Dr. John G. Harold, chief of Cedar-Sinai’s medical staff.15

 

References

  1. Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D. Catheterization of the heart in man with the use of a flow-directed balloon-tipped catheter. N Engl J Med. 1970;283:447-51
  2. Swan HJC. The pulmonary artery catheter in anesthesia practice. Anesthesiology. 2005. 103:4, 890-93
  3. Forssmann-Falck R. Werner Forssmann: a pioneer of cardiology. Am J Cardiol. 1997;79(5):651-60
  4. Bradley RD. Diagnostic right-heart catheterization with miniature catheters in severely ill patients. Lancet. 1964;2:941
  5. Fife WP, Lees BS. Construction and use of self guiding right heart and pulmonary artery catheter. J Appl Physiol. 1965;20:148
  6. Scheinman MM, Abbot JA, Rapaport E. Clinical uses of a flow-directed right heart catheter. Arch Intern Med (Chicago). 1969;124:19
  7. Chatterjee K. The Swan-Ganz catheter: past, present and future. A viewpoint. Circulation. 2009;119(1):147-52
  8. Gidwani UK, Mohanty B, Chatterjee K. The pulmonary artery catheter: A critical reappraisal.Cardiology Clinics.2005;31(4):545–65.
  9. Swan HJC. The Pulmonary Artery Catheter in Anesthesia Practice. Anesthesiology. 2005;103(4):890-93
  10. Swan HJC. Effect of noradrenalin on the human circulation. Lancet. 1949;254(6577):508-17
  11. Hurst JW. H. J. C. Swan. Clinical Cardiology. 1988;22(10):727-28
  12. Palmieri TL. The inventors of the Swan-Ganzcatheter: H J C Swan and William Ganz. Curr Surg.2003;60(3):351-2.
  13. Forrester JS, Kaul S, Shah PK. Harold James Charles (“Jeremy”) Swan. Am J Cardiol. 2006;97(10):1545-46
  14. Stern S. A brilliant cardiologist and spiritual mentor: Jeremy Swan (1922-2005). Cardiology Journal. 2007;14(1):107-8
  15. Cardiology Online. H J C Swan, M D, Chairman emeritus of cardiology, inspired physicians, changed the world. http://www.cardiologyonline.com/journal_articles/Jeremy_Swan.htm. Accessed March 26, 2016.

 

Editorial comment

In the late 1960s the NIH-sponsored Myocardial Infarction Research Units (MIRUs) were evaluating hemodynamic monitoring as a means of reducing mortality from heart failure and cardiogenic shock after myocardial infarction. At the Cornell MIRU cardiologists would monitor left ventricular end diastolic pressures by using retrograde small Teflon catheters, but this process was simplified in 1970 by the development of the Swan-Ganz balloon-tipped pulmonary catheter in the Cedars-Sinai MIRU.  The catheter could be inserted into a peripheral vein, allowing one to measure pulmonary wedge pressures as well as cardiac output by using a thermistor as part of the catheter [1,2]. It was a major breakthrough and led to the widespread proliferation of such catheters. In the 1980s some 20-40% of seriously ill patients in intensive care units underwent pulmonary artery catheter insertions.

Then in the 1990s clinical reports began to question the safety and accuracy of using the Swan-Ganz catheter. Its use peaked in the mid-nineties and decreased by over 60% by 2004 [3] after publication of clinical trials and meta-analyses [4-9] indicated no clinical benefit from its use. In fact, in one pathfinding study there was a 24% increase in mortality in patients receiving a pulmonary artery catheter within 24 hours of admission to the intensive care [4]. Larger studies also demonstrated no six month mortality differences in patients with or without pulmonary artery  catheters insertion but some increase in pulmonary emboli [5-9]. Also, cardiac output measurements by the thermistor technique in comparison with the more accurate indwelling flow probes proved unreliable and underestimated cardiac output unless this changed by more than 30%. In addition, erroneous measurements could be obtained due to suboptimal patient positioning and transducer placement, or during mechanical ventilation. Despite these findings, pulmonary artery catheters continue to have a role in the assessment of pulmonary artery hypertension and acute right ventricular failure. Nor should they diminish the ingenuity and value of Jeremy Swan and William Ganz in developing a catheter in the 1970’s to monitor hemodynamics at the bedside at a time when major efforts were being done to improve the survival of patients with complicated myocardial infarction

References

  1. Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med. 1970;283:447–451.
  2. Ganz W, Donosco R, Marcus HS, Forrester JS, Swan HJ. A new technique for measurement of cardiac output by thermodilution in man. Am J Cardiol. 1971;27:392–396.
  3. Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in the United States, 1993 to 2004. JAMA. 2007;298:423–429
  4. Connors AF, Speroff T, Dawson NV, Thomas C, Harrell FE, Wagner D, Desbiens N, Goldman L. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA. 1996;276:889–897.
  5. Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;348:5–14.
  6. Richard C, Warszawski J, Anguel N, Deye N, Combes A, Barnoud D, Boulain T, Lefort Y, Fartoukh M, Baud F, Boyer A, Brochard L, Teboul JL. French Pulmonary Artery Catheter Study Group. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2003;290:2713–2720.
  7. Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, Brampton W, Williams D, Young D, Rowan K. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomized controlled trial. Lancet. 2005;366:472–477.
  8. Binanay C, Califf RM, Hasselblad V, O’Connor CM, Shah MR, Sopko G, Stevenson LW, Francis GS, Leier CV, Miller LW. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005;294:1625–1633
  9. .Harvey S, Young D, Brampton W, Cooper AB, Doig G, Sibbald W, Rowan K. Pulmonary artery catheters for adult patients in intensive care. Cochrane Database Syst Rev. 2006;3:

 


 

Jimmy Tam Huy Pham is an Internal Medicine resident physician at Garden City Hospital, Michigan. He is interested in public health, general medicine, cardiology, and translational research. He enjoys reading and writing history of medicine, poems, and creative non-fiction. His published works can be found at jimmytamhuypham.com.

 

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