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.
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 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.
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 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 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 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.