Cournand AF, Baldwin JS, Himmelstein A. Cardiac catheterization in congenital heart disease.
New York, The Commonwealth Fund., 1949.
Cournand A, Lequime J, Regniers P. L'insuffisance cardiaque chronique,
Etudes physiopathologiques. Paris. Masson and Cie., 1952
The contributions of right heart catheterization to physiology and medicine, with
some observations on the physiopathology of pulmonary heart disease.
Amer. Heart J., 1957,54, 161-71.
Andre Frederic Cournand was a young physician when he left France for the United States in 1930. He was recruited as a first year resident at Bellvue Hospital in New York. In 1932, he started his collaboration with Dickinson Richards on the physiology of the cardio-respiratory system. This collaboration would span over a period of four decades.
Cournand and Richards became aware of Forssmann's right atrial catheterization. Cournand also visited Dr Ameuille, his mentor in Paris, a pioneer in the technique of pulmonary angiography. They started their experimentation of cardiac catheterization in animal model with great results and reproducibility . In the early 1940's, they recorded the pressure in the right atrium and the right ventricle in man using a single lumen catheter connected to a Hamilton Manometer. Similar pressure measurements were done in patients with heart failure. Finally blood volume studies were done utilizing dye-dilution techniques. In their 1941 report, Cournand and Ranges showed that simultaneous sampling of right atrial and femoral arterial blood and collection of expired air allowed precise determination of cardiac output by the Fick principle.
As Andre Cournand mentioned in his Nobel lecture "An important progress in technique [of cardiac catheterization] was the development of a double-lumen catheter through which simultaneous pressures in two contiguous heart chambers and large vessels could be recorded."
Cournand perfomed the first right ventricular catheterization and pulmonary artery catheterization in 1942 and 1944 respectively.
That was a major step forward in the study of cardiorespiratory physiology as "subsequent progress in our knowledge of the dynamics of the pulmonary circulation in man is due in large part to the technique of catheterization of the pulmonary artery."
During World War II, Cournand and Richards applied the techniques of right heart catheterization to investigate the traumatic shock. Their research had a major impact in our understanding of the pathophysiology of this condition and its treatment. They showed that a blood volume reduction of 40-50% was associated with a significant decrease in cardiac output. They also showed that the peripheral vascular resistance was maintained in the case of hemorrhage whereas it was significantly augmented in severe burns. Finally, they demonstrated that "whole blood offered great advantages over plasma as sustaining therapy."
After World War II, Richards continued his research in the physiology of heart failure. He also made significant contributions to our knowledge of chronic pulmonary disease and pulmonary heart disease. In his Nobel lecture, Richards remarked:
"The principal factors inducing right ventricular strain, hypertrophy, and failure can be stated very simply: (1) pulmonary hypertension, from one cause or another; and (2) secondary influences throwing a burden on the right heart, such as anoxia, increased blood volume, polycythemia, increased cardiac output, disordered breathing mechanics...Clinically, the right heart often begins to show objective evidence of hypertrophy and dilatation when pulmonary arterial pressure exceed twice normal values...the primary constricting effects of anoxia send the pulmonary arterial pressures to higher levels; and secondary effects of both anoxia and hypercapnia place their added burdens on the heart...Even more widespread are the systematic effects of elevated CO2. The rise in alveolar and blood CO2 tension produces...a retention of bicarbonate, thus further raising blood and tissue CO2 levels, though of course relieving in part the uncompensated gaseous acidosis."
Cournand and his team used cardiac catheterization for the diagnosis of congenital heart diseases. They initiated their studies in 1946 and published their first monograph entitled, "Cardiac catheterization in congenital heart disease," in 1949. The book is divided into two sections. In the first section the methods used in the physiological studies were described. They included right heart catheterization, arterial puncture, and collection of expired air for measuring the oxygen consumption. Characteristic patterns of the blood pressure tracings were described and formula for the calculation of systemic and pulmonary blood flow and of blood shunts were outlined. The second part is an account of individual cases illustrating various types of malformation. The X-ray observations during catheterization and blood pressure tracings of some of these cases are depicted here.
In 1952, Cournand, Lequime and Regniers published a book on heart failure under the title "L'insuffisance cardiaque chronique, etudes physiopathologiques." This classic monograph is devoted to the physiologic study of the heart and the circulatory system in normal and pathologic conditions using cardiac catheterization. In this work, the authors described coronary sinus catheterization and its application for the study of coronary flow and output and investigation of cardiac metabolism. They also performed hemodynamic measurements in various physiological and pathological conditions and assessed the effects of cardiac drugs on systemic pressure, pulmonary artery pressure and cardiac output.
Another important contribution in right heart catheterization was made by Hellems and his colleagues. In 1949, these authors showed that the pressure obtained in a distal branch of the pulmonary artery (capillary wedge pressure) was correlating with the pressure of the left atrium. This finding led to the application of right heart catheterization for the diagnosis of mitral valve disease. This diagnostic tool was also used to evaluate the severity of mitral stenosis and to select appropriate patients for surgical correction of this condition.
In 1951, Gorlin and his son applied the hydraulic principles and formulas to calculate the mitral orifice area in vivo using right heart catheterization. These authors were able to demonstrate a strong correlation between the calculated and measured mitral orifice area at the time of operation or at post-mortem examination. The same principles were applied to calculate the orifice area of other valves and intracardiac shunts. In the summary of their article, these authors wrote: "...The chief value of these formulas is that they present an objective evaluation of surgical procedures designed to widen stenotic orifices or to abolish abnormal shunts. Furthermore, a theoretical prediction of the benefit to be derived from surgical widening of stenotic valves may be made."
Hellems HK, Haynes FW, Dexter L. Pulmonary "capillary" pressure in man. J Appl Physiol 1949;2:24-9
Dow JW, Gorlin R. Pulmonary "capillary" pressure as an index of left atrial mean pressure in dogs. Federation Proc 1950;9:33
Gorlin R, Gorlin SG. Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves , and central circulatory shunts. I. Am Heart J 1951;41:1-29