Professor Hein J.J. Wellens: 33 Years of Cardiology and Arrhythmology

Professor Hein J.J. Wellens: 33 Years of Cardiology and

Arrhythmology

Edited hy

J.L.R.M. Smeets, P.A. Doevendans, M.E. Josephson, Ch. Kirchhof and M.A. Vos

SPRINGER-SCIENCE+BUSINESS MEDIA, B.Y.

Library of Congress Cataloging-in-Publication Data

ISBN 978-94-010-5799-8 ISBN 978-94-011-4110-9 (eBook) DOI 10.1007/978-94-011-4110-9

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All Rights Reserved © 2000 Springer Science+Business Media Dordrecht

Originally published by Kl uwer Academic Publishers in 2000 Softcover reprint ofthe hardcover Ist edition 2000

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v

Contents

Introduction

Durrer D., Schoo L., Schuilenburg R.M., Wellens H.J.J.: The role of premature beats in the initiationand the termination of supraventricular tachycardia in the Wolff-Parkinson-White syndrome.Comment by Prof P. Coumel. MD. Circulation 1967; 36: 644-662

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Wellens H.J.J., Durrer D.: Supraventricular tachycardia with left aberrant conduction due to retro­grade invasion into the left bundle branch. Comment by Prof R. Slama. MD. Circulation 1968;38: 474-479 21

Wellens H.J.J., Reinier M., Schuilenburg R.M., Durrer D.: Electrical stimulation of the heart inpatients with Wolff-Parkinson-White syndrome; Type A. Comment by Prof A. Castellanos, MD.Circulation 1971; 43: 99-114 27

Wellens H.J.J., Reinier M., Schuilenburg R.M., Durrer D.: Electrical stimulation of the heart inpatients with ventricular tachycardia. Comment by Prof M.E. Josephson. MD. Circulation 1972;46: 216-226 43

Wellens H.J.J., Vermeulen A., Durrer D.: Ventricular fibrillation occurring on arousal from sleep byauditory stimuli. Comment by Prof Dr. A.A.M. Wilde. Circulation 1972; 46: 661-665 55

Wellens H.J.J., Durrer D.: Effect of digitalis on atrioventricular conduction and circusmovement ta­chycardias in patients with the Wolff-Parkinson-White syndrome. Comment by Prof E.D. Roblesde Medina, MD. Circulation 1973; 47: 1229-1233 63

Wellens H.J.J., Lie K.I., Durrer D.: Further observations on ventricular tachycardia as studied byelectrical stimulation of the heart. Chronic recurrent ventricular tachycardia and ventricular tachy­cardia during acute myocardial infarction. Comment by Prof A.L. Wit, PhD. Circulation 1974; 49:647-653 69

Lie K.I., Wellens H.J.J., Schuilenburg R.M., Becker A.E., Durrer D.: Factors influencing prognosisof bundle branch block complicating acute anteroseptal infarction. The value of His bundle re-cordings. Circulation 1974; 50: 935-941 79

Wellens H.J.J., Janse M.J., Van Dam R.Th., Van Capelle F.lL., Meijne N.G., Mellink H.M., DurrerD.: Epicardial mapping and surgical treatment in Wolff-Parkinson-White syndrome; Type A.Comment by Prof M.J. Janse. PhD. Am Heart J 1974; 88: 69-78 87

Lie K.I., Wellens H.J.J., Van Capelle F.lL., Durrer D.: Lidocaine in the prevention of primary ven-tricular fibrillation. Comment by Prof K.I. Lie. MD. New Eng J Med 1974; 291: 1324-1326 99

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Wellens H.1.1., Durrer D.: WPW syndrome and atrial fibrillation. Relation between refractory periodof accessory pathway and ventricular rate during atrial fibrillation. Comment by Prof J. Gallagher,MD. Am J Cardiol 1974; 34: 777-782 105

Wellens H.J.J., Durrer D.: The role of accessory atrioventricular pathway in reciprocal tachycardia.Comment by Prof R. Lazzara, MD. Circulation 1975; 52: 58-72 113

Wellens H.J.J., Lie K.I., Bar FW, Wesdorp lC., Dohmen H.1., Duren D.R., Durrer D.: Effect ofamiodarone in the Wolff-Parkinson-White syndrome. Comment by Prof G. Fontaine, MD. Am JCardiol 1976; 38: 189-194 133

Wellens H.1.1., Duren D.R., Lie KI.: Observations on mechanisms of ventricular tachycardia in man.Comment by Prof WG. Stevenson, MD. Circulation 1976; 54: 237-244 143

Wackers F.1.Th., Busemann Sokole E., Samson G., Van der Schoot lB., Lie KI., Liem KL., WellensH.1.1.: Value and limitations of Thallium-201-scintigraphy in the acute phase of myocardial in-farction. Comment by Prof F.J.Th. Wackers, MD, PhD. New Engl J Med 1976; 295: 1-5 155

Wellens H.J.J., Bar FWH.M., Lie K.I., Duren D.R., Dohmen H.1.: Effect of Procainamide, Propra­nolol and Verapamil on mechanism of recurrent ventricular tachycardia. Comment by Prof D.?Zipes, MD. Am J Cardiol 1977; 40: 579-585 163

Wellens H.J.J., Bar FWH.M., Lie KI.: The value of the electrocardiogram in the differential diag­nosis of a tachycardia with a widened QRS-complex. Comment by Prof A.J. Camm, MD. Am JMed 1978; 64: 27-33 173

Becker A.E., Anderson R.H., Path M.R.C., Durrer D., Wellens H.1.1.: The anatomical substrates ofWolff-Parkinson-White syndrome. A clinicopathologic correlation in seven patients. Comment byProf A.E. Becker, MD. Circulation 1978; 57: 870-879 183

Farre J., Ross D., Wiener I., Bar FW, Vanagt E.1., Wellens H.1.1.: Reciprocal tachycardias usingaccessory pathways with long conduction times. Comment by Dr. J. Fami. Am J Cardiol 1979;44: 1099-1109 197

Wellens H.1.1., Bar FW, Gorgels A.P., Vanagt E.1.: Use of Ajmaline in identifying patients with theWolff-Parkinson-White syndrome and a short refractory period of their accessory pathway. Am JCardiol 1980; 45: 130-133 215

Wellens H.1.1., Bar FW, Farre J., Ross D.L., Wiener I., Vanagt E.1.: Initiation and termination ofventricular tachycardia by supraventricular stimuli. Comment by Prof I. Wiener, MD. Am J Car-diol 1980; 46: 576-582 221

Ross D.L., Farre l, Bar FWH.M., Vanagt E.1., Brugada P., Wiener 1., Wellens H.J.J.: Spontaneoustermination of circus movement tachycardia utilizing an atrioventricular accessory pathway: inci­dence, site of block and mechanisms. Comment by Prof DL Ross, MD. Circulation 1981; 63:1129-1139 231

VII

De Zwaan c., Bar EWH.M., Wellens H.J.J.: Characteristic electrocardiographic pattern indicating a

critical stenosis high in left anterior descending coronary artery in patients admitted because of

impending myocardial infarction. Comment by DI: C. de Zwaan, MD, PhD. Am Heart J 1982;103: 730-736 245

Den Dulk K., Lindemans EW., Bar FW., Wellens H.J.J.: Pacemaker related tachycardia. Commentby Dr. K. den Dutk, MD, PhD. PACE 1982; 5: 476-485 253

Friedman P.L., Brugada P., Kuck K.-H., Roy D., Farre J., Bar FWH.M., Wellens H.J.J.: Inter- andintra-atrial dissociation during spontaneous atrial flutter: Evidence for a focal origin of the arrhyth-mia. Comment by P.L. Friedman, MD, PhD. Am J Cardiol 1982; 50: 756-761 265

Oorgels A.P.M., Beekman H.D.M., Brugada P., Dassen WR.M., Richards D.A.B., Wellens H.J.J.:

Extrastimulus related shortening of the first postpacing interval in digitalis induced ventriculartachycardia. Observations during programmed electrical stimulation in the conscious dog. Com-ment by Prof MR. Rosen, MD. J Am Coil of Cardiol 1983; I: 840-857 275

Roy D., Brugada P., Wellens H.J.J.: Atrial tachycardia facilitating initiation of ventricular tachycardia.Comment by Prof D. Roy, MD. PACE 1983; 6: 47-52 297

Weiss J., Brugada P., Roy D., Bar EWH.M., Wellens H.J.J.: Localization of the accessory pathwayin the WPW syndrome from the ventriculo-atrial conduction time of right ventricular apicalextrasystoles. Comment by Prof 1. Weiss, MD. PACE 1983; 6: 260-267 305

Oreen M., Heddle B., Dassen W, Wehr M., Abdollah H., Brugada P., Wellens H.J.J.: The value ofQRS alternation in diagnosing the site of origin of narrow QRS supraventricular tachycardia.Comment by MS. Green, MD. Circulation 1983; 68: 368-373 313

Kuck K.-H., Brugada P., Wellens H.J.J.: Observations on the antidromic type of circus movementtachycardia in the Wolff-Parkinson-White syndrome. J Am Coil of Cardiol 1983; 5: 1003-1010 321

Heddle WE, Brugada P., Wellens H.J.J.: Multiple circus movement tachycardias with multiple ac-cesory pathways. J Am Coil Cardiol 1984; 4: 168-175 331

Braat S.H., Brugada P., Den Dulk K., Van Ommen v., Wellens H.J.J.: Value of lead V4R for recog­nition of the infarct coronary artery in acute inferior wall myocardial infarction. Comment bys.H.J.G. Braat, MD. Am J Cardiol 1984; 53: 1538-1541 341

Waldecker B., Brugada P., Zehender M., Stevenson WO., Den Dulk K., Wellens H.J.J.: Importanceof modes of electrical termination of ventricular tachycardia for the selection of implantable an-titachycardia devices. Comment by Prof B. Watdeckel; MD. Am J Cardiol 1986; 57: 150-155 347

Stevenson WO., Brugada P., Waldecker B., Zehender M., Wellens H.J.J.: Clinical, angiographic andelectrophysiologic findings in patients with aborted sudden death as compared to patients withsustained ventricular tachycardia after myocardial infarction. Comment by Prof M Zehendel: MD.Circulation 1985; 6: 1146-1152 355

VIII

Kersschot I.E., Brugada P., Ramentol M., Zehender M., Waldecker B., Stevenson WG., Geibel A.,De Zwaan c., Wellens H.J.J. and The Interuniversity Cardiology Institute, The Netherlands: Ef­fects of early reperfusion in acute myocardial infarction on arrhythmias induced by programmedstimulation. A prospective, randomized study. Comment by I. Kersschot, MD. J Am Coli Cardiol1986; 7: 1234-1242 365

Lemery R., Brugada P., Cheriex E., Wellens H.J.J.: Reversibility of tachycardia-induced left ven­tricular dysfunction after closed-chest catheter ablation of the atrioventricular junction for intrac-table atrial fibrillation. Comment by E.C. Cheriex, MD. Am J Cardiol 1987; 60: 1406-1408 377

Bar EW., Vermeer E, De Zwaan c., Ramentol M., Braat S., Simoons M.L., Hermens W.T., Van derLaarse A., Verheugt EWA., Krauss X.H., Wellens H.J.J.: Value of admision electrocardiogram inpredicting outcome of thrombolytic therapy in acute myocardial infarction. Comment by Prof M.L.Simoons, MD. Am J Cardiol 1987; 59: 6-13 381

Wellens H.J.J., Brugada P., Bar EW: Indications for use of intracardiac electrophysiological studiesfor diagnosis of site or origin and mechanism of tachycardias. Comment by Prof S. Saksena, MD.Circulation 1987; 75: III no-U8 393

Gorgels A.P.M., Vos M.A., Letsch I.S., Verschuuren E.A., Bar EWH.M., Janssen J.H.A., WellensH.J.J.: Usefulness of the accelerated idioventricular rhythm as a marker for myocardial necrosisand reperfusion during thrombolytic therapy in acute myocardial infarction. Comment by A.P.M.Gorge/s, MD. Am J Cardiol 1988; 61: 231-235 401

Trappe H.-J., Brugada P., Talajic M., Della Bella P., Lezaun R., Mulleneers R., Wellens H.J.J.: Prog­nosis of patients with ventricular tachycardias and ventricular fibrillation. Role of the underlyingetiology. Comment by Prof H.I. Trappe, MD. J Am Coli Cardiol 1988; 12: 166-174 411

Lemery R., Brugada P., Della Bella P., Dugemier T., Wellens H.J.J.: Ventricular fibrillation in sixadults without overt heart disease. Comment by M. Talajic, MD. J Am Coli Cardiol 1989; 13:911-916 423

Lemery R., Brugada P., Della Bella P., Dugernier T., Van den Dool A., Wellens H.J.J.: Non-ischemicventricular tachycardia: clinical course and long-term follow-up in patients without clinically overtheart disease. Comment by R. Lemery, MD. Circulation 1989; 79: 990-999 431

Cruz EE.S. Cheriex E.C., Smeets J.L.R.M., Atie J., Peres A.K., Penn O.C.K.M., Brugada P., WellensH.J.J.: Reversibility of tachycardia-induced cardiomyopathy after cure of incessant supraventricu-lar tachycardia. Comment by F.E.S. Cruz Filho, MD. J Am Coli Cardiol 1990; 16: 739-744 443

Atie J., Brugada P., Brugada J., Smeets J.L.R.M., Cruz EE.S., Peres A., Roukens M.P., Wellens H.J.J.:Clinical and electrophysiologic characteristics of patients with antidromic circus movement tachy­cardia in the Wolff-Parkinson-White syndrome. Comment by I. Atie, MD. Am J Cardiol1990; 66:1082-1091 453

Wellens H.J.J., Atie, J., Smeets J.L.R.M., Cruz F.E.S., Gorgels A.P., Brugada P.: The electrocardio-gram in patients with multiple accessory pathways. J Am Coli Cardiol 1990; 16: 745-751 469

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Della Bella P., Brugada P, Talajic M., Lemery R., Tomer P., Lezaun R., Dugemier T., Wellens RJ.J.:Atrial fibrillation in patients with an accessory pathway: Importance of the conduction propertiesof the accessory pathway. Comment by P Della Bella, MD. J Am Coli Cardiol 1991; 17:1352-1356 477

Atie J., Brugada P, Brugada J., Smeets J.L.R.M., Cruz EE., Roukens M.P., Gorgels A., Bar EW.RM.,Wellens H.J.J.: Clinical presentation and prognosis of left main coronary disease in the 1980s.Comment by Prof Dr. F.WH.M. Bar. Eur. Heart J 1991; 12: 495-502 485

Rodriguez L.M., Smeets J., O'Hara G.E., Geelen P, Brugada P., Wellens H.J.J.: Incidence and timingof recurrences of sudden death and ventricular tachycardia during antiarrhythmic drug treatmentafter myocardial infarction. Am J Cardiol 1992; 69: 1403-1406 497

Mont L., Seixas T., Brugada p., Brugada J., Simonis E, Kriek E., Smeets J.L.R.M., Wellens H.J.J.:The electrocardiographic, clinical, and electrophysiologic spectrum of idiopathic monomorphicventricular tachycardia. Comment by L. Mont, MD. Am Heart J 1992; 124: 746-753 503

Lucas C.M.RB., Van der Veen EH., Cherieux E.C., Lorusso R., Havenith M., Penn O.C.K.M.,Wellens H.J.J.: Long-term follow-up (12 to 35 weeks) after dynamic cardiomyoplasty. Commentby C. Lucas, MD. J Am Coil Cardiol 1993; 22: 758-767 513

De Chillou c., Rodriguez L.-M., Doevendans P., Loutsidis K., Van den Dool A., Metzger J., BarEW.RM., Smeets J.L.R.M., Wellens RJ.J.: Effects on the signal-averaged electrocardiogram ofopening the coronary artery by thrombolytic therapy or percutaneous transluminal coronary an­gioplasty during acute myocardial infarction. Comment by CH. de Chillou, MD. Am J Cardiol1993; 71: 805-809 527

Metzger J.T., De Chillou C., Cheriex E., Rodriguez L.M., Smeets J.L.R.M., Wellens H.J.J.: Value ofthe 12-lead electrocardiogram in arrhythmogenic right ventricular dysplasia and absence of cor­relation with echocardiographic finding. Comment by J. Metzger, MD. Am J Cardiol 1993; 72:964-967 535

Rodriguez L.M., Smeets J.L., Baiyan Xie, De Chillou C., Cheriex E.C., Pieters E, Metzger J., DenDulk K., Wellens H.J.J.: Improvement in left heart function by ablation of AV nodal conduction inselected patients with lone atrial fibrillation. Am J Cardiol 1993; 72: 1137-1141 543

Konings K.T.S., Kirchhof C.J.H.J., Smeets J.R.L.M., Wellens H.J.J., Penn O.c., Allessie M.A.: High­density mapping of electrically induced atrial fibrillation in humans. Circulation 1994; 89:1665-1680 549

Vos M.A., Verduyn S.C., Gorgels A.P.M., Lipcsei G.C., Wellens H.J.J.: Reproducible induction ofearly afterdepolarizations and torsade de pointes arrhythmias by d-sotalol and pacing in dogs withchronic atrioventricular block. Comment by M.A. Vos, PhD. Circulation 1995; 91: 864-872 569

Crijns H.J.G.M., Smeets J.L.R.M., Rodriguez L.M., Meijer A., Wellens H.J.J.: Cure of interfascicularreentrant ventricular tachycardia by ablation of the anterior fascicle of the left bundle branch.Comment by Prof H.J.G.M. Crijns, MD. J Cardiovasc Electrophysiol 1995; 6: 486-492 583

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De Vreede-Swagemakers J.J.M., Gorgels A.PM., Dubois-Arbouw WI., Van Ree J.W, DaemenMJ.A.P, Houben L.G.E., Wellens HJJ.: Out-of-hospital cardiac arrest in the 1990s: A population­based study in the Maastricht area on incidence, characteristics and survival. Comment by Prof G.Breithardt, MD and Prof M. Borggrefe, MD. J Am Coli Cardiol 1997; 30: 1500-1505 591

Smeets J.L.R.M., Ben-Haim S.A., Rodriguez L.-M., Timmermans c., Wellens HJJ.: New methodfor nonfluoroscopic endocardial mapping in humans. Accuracy assessment and first clinical re-sults. Comment by J.L.R.M. Smeets, MD, PhD. Circulation 1998; 97: 24: 2426-2432 601

Wellens HJJ., Lau c.-P, Li.ideritz B., Akhtar M., Waldo A.L., Camm AJ., Timmermans C., TseH.-F., Jung W, Jordaens L., Ayers G., for the METRlX investigators. Atrioverter: an implantabledevice for the treatment of atrial fibrillation. Comment by Prof B. Liideritz, MD. Circulation 1998;98: 1651-1656 611

Zipes D.P., Wellens HJJ.: Sudden cardiac death. Comment by Prof H.E. Kulbertus, MD. Circulation1998; 98: 2334-2351 621

Geelen J.L.M.C., Doevendans PA., Jongbloed RJ.E., Wellens H.JJ., Geraedts J.P.M.: Molecular ge­netics of inherited long QT syndromes. Comment by P.A.F.M. Doevendans, MD, PhD. Eur HeartJ 1998; 19: 1427-1433 647

Nabar A., Rodriquez L.-M., Timmermans c., Van den Dool A., Smeets J.L.R.M., Wellens HJJ.: Ef­fect of right atrial isthmus ablation on the occurrence of atrial fibrillation. Observations in fourpatient groups having type I atrial flutter with or without associated atrial fibrillation. Comment byDr. Y. Lokhandwala. Circulation 1999; 99: 1441-1445 657

Timmermans C., Rodriguez L.-M., Ayers G.M., Lambert H., Smeets J.L.R.M., Vlaeyen J.WS., Al­bert A., Wellens HJJ.: Effect of butorphanol tartrate on shock-related discomfort during internalatrial defibrillation. Circulation 1999; 99: 14: 1837-1842. 667

J.L.R.M. Smeets, MD., PhD., Associate Professor of Cardiology, University Hospital Maastricht,Maastricht, The Netherlands.

PA. Doevendans, MD., PhD., Assistant Professor of Cardiology, University Hospital Maastricht,Maastricht, The Netherlands.

M.E. Josephson, MD., PhD., Professor of Medicine, Harvard Medical School, Director of the Har­vard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston, USA.

Ch. Kirchhof, MD., PhD., Assistant Professor of Cardiology, University Hospital Maastricht, Maas­tricht, The Netherlands.

M.A. Vos PhD., Associate Professor of Cardiology, University Hospital Maastricht, Maastricht, TheNetherlands.

Introduction

FRITS L. MElJLERThis book is published at the occasion of a congress,called 'Future of arrhythmology: lessons from thepast, promises for tomorrow', organized in April 2000as a tribute to Professor Hein Wellens. He will be 65later this year. It is a privilege and distinct pleasure tobe allowed and hopefully be able to write an Intro­duction for this collage of highlights of the scientificwork of Dr Hein Wellens and his group producedover a period of approximately 30 years. We all knowthat Dr Wellens, like myself, is a pupil of the famousDr Dirk Durrer, professor of Cardiology and ClinicalPhysiology at the University of Amsterdam. WhenWellens started to work in the Wilhelmina Gasthuisin Amsterdam in the mid-sixties, the Amsterdamgroup had established its name in animal experimen­tal electroeardiology, but the step from dogs, goatsand rats to humans had not yet heen taken. The tran­sition came with the excitation study of the isolatedperfused human heart in 1965 [1] and Durrer's studyof epicardial excitation of human patients with ostiumprimum defects 12] and WPW [3] during cardiac sur­gery together with Dr Jan Roos in Leiden. In my per­ception it has been Hein Wellens who had the cour­age and the foresight to take the knowledge and thetechniques, acquired in the previous 15 years by Dur­rer, Professor Henk van del' Tweel and others, to thepatient in the cath lab. Dr Wellens' name appears forthe first time inl967 [41 in the list of papers of theAmsterdam group.

This article is also the first puhlieation of thishook. The first paper with Wellens as first (and single)author, on AV conduction ahnormalities, appeared in196~ in Diseases of the Chest (5). t-:rom that time onthe name of Wellens as the principal author of numer­ous publications on cardiac electrophysiology, first inAmsterdam and later in Maastricht, became a land­mark for quality and innovation. Hein Wellens' thesis

at the University of Amsterdam published in 1971 on:'Electrical Stimulation of the Heart in the Study andTreatment of Tachycardias' 161 has set the stage forthe future development of clinical electrophysiologyof the heart.

It is not without (historical) interest to take note ofthe first part of Wellens' commentary on his first ar-

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tiele [41, taken from a hook published in 1986 (7) on35 years of Cardiology in Amsterdam in commemo­

ration of professor Dirk Durrer.The investigations reported in this article were

based on:I. Previous hypothesis of the presence of two con­

nections between atrium and ventricle in theWPW-syndrome with different electrophysiologicproperties allowing a circus movement with anter­ograde conduction over one AV-pathway and ret­rograde conduction over the other.

2. The definite demonstration of the presence of asecond atrio-ventricular pathway by epicardialmapping in a patient with WPW operated uponbecause of an atrial septal defect 131.

3. The availability of a safe versatile clinical stimu­lator allowing by timed premature stimulation theexposure of differences in electrophysiologie prop­erties of the two AV-connections resulting in in­duction of the circus movement tachycardia.

This is all common knowledge now, but in those daysit was new and revealing. In the last sentence of thiscommentary, typical Wellens' vintage, he gave mostof the credit for this study to his teacher Dr DirkDurrer. As described elsewhere both the observationsleading to the article and the writing o{ the article it­self will always be remembered as an exciting jour­nev intu a newly discovered land at the hands oj abrillian!, inspiring and /IlotivatinR Ruide. Nohody willaccuse me of degrading Durrer when I dare to say thatwithout the vision and ambitions of Hein Wellens,Leo Schoo would probably not have built the 'versa­tile clinical stimulator' mentioned ahove. From nowon Wellens' name appears in publications in connec­tion with members of the Amsterdam group for an­other 10 years, but after his transfer to Maastricht,Wellens was on his own and continued to be veryproductive. Against all odds, and helieve me therewere many, he managed to establish his own, nowworld famous, school of electrocardiology.

It will be clear that the whole development of clinicalelectrocardiology in the Netherlands is not a one-manshow. Durrer together with Henk van dcr Twccl laidthe hase for experimental cardiovascular electrophys­iology in The Netherlands. The stimulator thatWellens mentioned in his commentary was the finalrcsult of 15 years of trial and error in the animal

Smeet.1 et al (ed.I.), Professor IIeill./..I. Wellells: 33 lean o/Cwdio{ogr alld Arrhlllllll%gr. Pl'. xi-Xl.© 2000 Kh/\f'er Academic Pubhshers.

XII

laboratory [8J. Of course Wellens was lucky to findthe knowledge and the equipment enabling him toembark on his own ship and to chose his own course,but no one can or will deny that Wellens became hisown man and this is clearly demonstrated in thisbook.

The book takes us on a road of more than 30 years ofelectrocardiology in Amsterdam and Maastricht withsidesteps to therapeutic and diagnostics approaches tolife threatening arrhythmias. But also Wellens and hisgroup used their considerable electrophysiologicskills for better understanding of day-to-day clinicalelectrocardiography. Moreover they related sophisti­cated electro-physiology with the outcome of coro­nary angiography, allowing us to better predict thesize and location of myocardial damage from surfaceelectro-cardiography. They also developed clinicalelectrocardiographic tools and rules for differentiatingbetween wide-complex supra-ventricular tachycardiasand ventricular tachycardias.

Fellows from all over the world have flocked toMaastricht and have contributed to the success of thegroup. Wellens is the first to admit that. In this bookwe face the salient features of the success of presentday electrocardiology. The prognosis of patients withlife threatening arrhythmia's and conduction defectshas been significantly improved over the last 30years, at which we are looking back. Patients havealways been at the forefront of Wellens' mind. I haveno personal experience, but I learned from many peo­ple that Wellens not only is a master scientist and agifted teacher but also and in the first place a superbdoctor.

There are few people who can look back on a morefruitful scientific carrier than Hein Wellens, but hislife is not yet over. In this special year 2000, we will

witness a symposium on the future of arryhthmologyin which his pupils, followers and friends will presentlessons from the past and new ideas for tomorrow.The patient is the center of our universe and there isonly one way to improve care for our cardiac patientsand that is by medical science. The Maastricht schoolof cardiology has shown this and in the future it willnot let us down.

References

I. DUTTer D, Van Dam RTh, Freud GE, Janse MJ, Meijler FL,Arzbaecher RC: Total excitation of the isolated human heart.Circulation 1970; 41: 895-912.

2. DUTTer D, Roos JP, Van Dam RTH: The genesis of the ECG ofpatients with Ostium Primum defects (ventral atrial septal de­fects). Am HeartJ 1966; 71: 642-650.

3. DUTTer D, Roos JP: Epicardial Excitation of the ventricles in apatient with WPW syndrome. Circulation 1967; 35: 15-21.

4. DUTTer D, Schoo I, Schuilenburg RM, Wellens HJJ: The role ofpremature beats in the initiation and the termination of su­praventricular tachycardia in the Wolff-Parkinson-White syn­drome. Circulation 1967; 36: 644-662.

5. Wellens HJJ: Conduction abnormalities in A-V junction rhythmshortly after cardiac surgery Dis Chest; 1968: 54: 73-74.

6. Wellens HJJ: Electrical stimulation of the heart in the study andtreatment of tachycardias. Thesis, University of Amsterdam; HEStenfert Kroese NY/Leiden 1971.

7. Meijler FL, Burchell H.B., eds.: Professor Dirk Durrer; 35years of cardiology in Amsterdam. North-Holland PublishingCompany, Amsterdam, 1986; 282-283.

8. Wellens HJJ, Meijler FL: Medical physics and cardiology inAmsterdam: a unique and productive twosome. In: Strackee­Kater A, Van der Tweel M, eds. Van Hoofd en Hart; Henk vander Tweel 1915-1917. Royal Netherlands Academy of Sciences,Amsterdam, 1999: 53-59.

Amsterdam, April 2000

XIlI

The Amsterdam years of Hein Wellens

ARNOLD A.w. VAN LIER

How was the situation inAmsterdam in 1964 whenHein Wellens, who had just finished two years of pre­limenary training in the Westeinde and St.Anthony'sHospitals in the Hague and Voorburg, joined the Car­diological Department?

In 1957 Dr. DUffer was nominated as professor ofCardiology and Clinical Physiology. Pavilion VII ofthe Wilhelmina Gasthuis was vacant for his clinic andhe took over a team of professor Groen's assistants:Max Koster, Frits Offerijns, Bart Dekker, Henk PeIserand Frits Meijler as 'warriors of the first hour'. Theexperiments were eventually done in the ample loftof the surgical clinic of prof. Boerema with lodgingsfor the laboratory animals.

It was a great improvement when the clinic andlater on the catheterisation room were housed in Pa­vilion I of prof. Formijne, Durrer's teacher. It wasthere that Hein Wellens started his Amsterdam careeras youngest assistant. But his gifts, energy and effortswere such that already in 1967 he was appointed as'Chef de Clinique'. The Amsterdam research had bythen already achieved important results. Durrer andvan der Tweel had reported their fundamental findingsrelating to electrical activation in the hearts of dogsand goats in four articles (1953-1954) in the Ameri­can Heart Journal. Epicardial complexes of E. Bodenand EN. Wilson could be extended with intramuralregistrations using the ingenious needle electrode ofthe instrument makers Mr Tuinman and Mr Mintjes.

In the theses of DUffer, van der Kooy, Meijler, vanDam and van Lier the results of this first period werereported.

Frits Meijler had, after painstaking experimentsmastered, the technique of revival of animal and hu­man hearts. In 1970, the activation of a beating re­vived human heart was described for the first time.This was soon followed by the activation of the liv­ing heart of patients operated upon.

As 'Chef de Clinique', Hein Wellens maintainedthe standards and discipline introduced from the be­ginning by prof. DUffer. In the morning meetings at 8

o'clock sharp (and you did not dare be late) the as­sistants were tested and got a thorough turnout. Whenthey started their training, the first thing to do was tocopy from a senior the precious booklets with valu­able information about theory, practice and therapyfor example: causes of left and right BBB, 20 causesof coronary ischemia (a topic of Donald Duren) digi­talis, etc. I still see Hein sitting, with closed eyes,controlling if a cause was not mentioned for the sec­ond time.

Hein's excellent didactive gifts were combinedwith ample knowledge of the literature in a clear pre­sentation. He came to the core of the problem andexplained it in an understandable way. His 'convinc­ing' voice made him audible even in an auditoriumwithout a microphone. It will please Hein when helearns that after one of his presentations prof. DUffersaid to me: "Wellens is a master teacher".

During a long absence of prof. DUffer, HeinWellens kept the department going and managed totreat the patients of Durrer's private practice. Nobodyunderstood how this was possible.

There were regular guests, e.g., prof. Howard B.Burchell, a lifelong supporter of the Amsterdamclinic. Highlights were the courses of prof. Langen­dorf and prof. Pick, founding fathers of affythmology.We all learned from these contacts and Hein was al­ways an active participant. In turn he had the luckyquality: to let us participate in his knowledge. If youasked him about the state of affythmology, the answerwas: "Read the second Haneman Symposium", orabout medical or surgical treatment of unstable an­gina: "The best I know about this subject is writtenby C. Friesinger c.s. of Vanderbilt University in theAnnals of Thoracic Surgery". But, mind you, this wasachieved by hours of reading with the same disciplinehe asked from others that he imposed upon himselfin first place.

The following is an example of his efficiency. Inone weekend he wrote the article about the womanwith sinus node arythmia by lithiumcarbonate poison-

XIV

ing, and published it within three months in the Jour­

nal ofAmerican Medicine.Personally, I mostly appreciated his analysis of in­

tricate arrythmia's armed with a long legged woodencaliper on a projection screen.

Meanwhile the studies for his dissertation werecontinued and, with the excellent equipment and avery efficient crew, Hein achieved results never ob­tained before. There were moments of exuberant joy:in search of connections in the study of pre-excita­tion, a by-pass between the atrium and the bundle of'His' (James bundle) was demonstrated for the firsttime. Hein shouted: "Look, look this is marvellous,this is fantastic". But the patient, under the greensheet, interrupted: "Doctor if it is so fantastic for you,it certainly is not for me". Hein replied: "it is goodfor you too, because we have found the cause of yourpalpitations" .

Eighteen March 1971 was a glorious day becauseChiel Janse and Hein Wellens defended their theses.The first about the influence of frequency alterationson the refractory period, the second on the effect ofelectrical stimulation in the study and treatment of ta­chycardia's. Both met a tough opposition, but re­posted with astounding expertise. At this occasionyoung doctor Wellens pleaded for a national exami­nation after finishing the training for cardiologists.Despite all the efforts for postgraduate teaching awish not yet fulfilled after 28 years.

After years of preparations and fund raising in1972 Queen Juliana finally opened the newly builtCardiological Clinic (the brainchild of prof. Durrer).Later on bridges made a connection with the Physi­ological Laboratory of prof. Boeles and the Labora­tory for Clinical Physiology, also newly built. On theground floor there was a fully equiped CCU whereK.1. Lie was in charge; on the first floor were thewards for the patients as before with Hein Wellenstogether with Donald Duren. In the catheterisationroom there was the eminent Reinier Schuilenburg ofwhom prof. Durrer once said: 'How is it possible thathe managed to manipulate three catheters in oneheart' .

There was also a spacious room for phonocardio­graphy, the residence of Stien Lucardie. She camefrom Leiden University and had been trained by Dr.Hartman from the department of prof. Snellen. At thetime phonocardiography was an important part in thediagnosis of cardiac conditions to be compared withechocardiography now. When Hein came to Amster-

dam he did not rest before he had mastered from Stienthe theory, practice and tries of phono.

In the new environment the research of arythmia'swas systematically continued. These were fascinatingyears for Hein Wellens; wittnessed by the sixty pub­lications which carry his name as (co) author and hisnomination as full professor of Cardiology in 1974. J

In his oration prof. Wellens gave a superb lecture onthe state of the art of arrythmology detection and in­dicated lines for future research.

It seemed to be a never ending succes story, but itdid end unhappily for the Amsterdam school. Thereis a dutch proverb saying: 'With two captains on oneship it is difficult to navigate'.

But the succes would continue elswhere as profes­sor Wellens was to become a shining star in the crownof the Maastricht University.

I For more details see 35 Years of Cardiology in Amsterdam ed­ited by prof. FL. Meijler and prof. H.B. Burchell. The commentsby prof. Wellens on pages 25 J, 258. 282, 295, 313 and 321 arehighly recommended. The bibliography gives a full list of his pub­lications in the Amsterdam years.My thanks for valuable information or photographs go to: NurseA. Stoek, MJ. lanse, V. Mangert-Kats, EJ. Miiller, P. Slingerland.

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Two photographs at the opening of the new Cardiology Clinic hy Queen Juliana with prof. Durrer standing next to her and Wellens sitting

behind the short end of the table, with Donald DUren sitting at his right side and behind him nurse Stoek (1972)