Harvey Feigenbaum: A Retrospective

The Innovator/Investigator 

As Harvey pointed out in a recent editorial in the Journal, “There is no one person responsible for the development of echocardiography.” However, no other person has made such fundamental contributions in so many areas. In 1965, when Harvey published his first article describing the echocardiographic features of pericardial effusion,1 echocardiography was a curiosity practiced in only a few places, with a primary but limited focus on the diagnosis of mitral stenosis. Inge Edler recounted that when he presented a movie summarizing his early work at the European cardiology meeting in Rome in 1960, there was “little interest” (personal communication). Paul Dudley White, on visiting Edler’s laboratory in Lund, Sweden, was reported to have commented to the effect that he did not think the technique would amount to much. The noninvasive diagnosis of pericardial effusion by echocardiography, for the first time, provided information not readily available by cardiac catheterization and established a unique role for the technique within cardiology and the general medical community. It also suggested the broader potential of the technique and introduced a period of exponential growth that continues to the present.

Harvey was initially attracted to echocardiography as a potential noninvasive method to assess left ventricular (LV) function, and the LV has always been his primary focus. He quickly recognized that the excursion of the LV posterior wall echo correlated with LV function; however, LV size could not be determined until instrumentation improved to permit reliable recording of the interventricular septum.2 Once septal and endocardial visualization became possible,3 the Indiana group performed the first studies showing a relationship between the echocardiographic minor dimension and LV size.2, 4 These early M-mode studies were followed by a series of reports describing the role of echocardiography in measuring left atrial size,2 the diagnosis of mitral valve prolapse,5 left atrial tumors,2, 6, 7 bacterial vegetations,8 septal motion in left bundle branch block,9 atrial septal defect,10 D-transposition of the great vessels,11 pulmonary valve motion in pulmonic stenosis,12 pulmonary hypertension,13 and infundibular pulmonic stenosis,14 and the first attempt to use echocardiography to diagnose diastolic dysfunction.15

In the mid-1970s, recognizing that coronary disease was the most common disorder presenting to cardiologists, Harvey’s focus gradually shifted in that direction.16 Although early M-mode studies by the Indiana group demonstrated characteristic changes in LV wall motion in patients with ischemic dysfunction,17, 18, 19, 20 he realized the limitations of M-mode as a tool for evaluating the segmental dysfunction characteristic of coronary artery disease. As a result, he collaborated with engineers in the Fortune Fry Research Laboratories at Indiana University (Indianapolis, IN) to develop one of the first two-dimensional (2D) instruments. The Indiana laboratory was among the pioneers in the development of clinical 2D echocardiography producing numerous early studies on valvular, congenital, and ventricular disease.20, 21, 22, 23, 24, 25, 26 In the critical area of coronary artery disease, the Indiana group first described the 2D echocardiography feature of acute myocardial infarction and its complications,20, 27 along with the first noninvasive images of the coronary arteries.20 The 2D studies in patients with acute myocardial infarction were only possible because of Harvey’s insistence that the large and cumbersome 2D instrument be portable. Understanding the importance of diagnosing coronary disease before permanent damage occurred, Harvey pioneered, and for years was the principal advocate of, 2D stress echocardiography.27, 28, 29, 30, 31 In collaboration with John Freeland, he helped develop the first digital imaging systems and the quadscreen format that together made stress echocardiography practical and led to its general acceptance.32

During this period, Harvey’s other role at Indiana University was director of the catheterization laboratory, and he had an understanding of hemodynamics that was equaled by few others. This was an enormous benefit to the echocardiography research program because both laboratories were always interested in the same questions. When controversy arose about the relative value of echocardiography, Harvey could effectively argue the strengths and limitations of both in any forum; and often he did.

These investigative efforts were also facilitated by Harvey’s continual search for innovations that would make the technique of echocardiography more powerful and practical. I remember Harvey’s pride in the cart he had designed to push the M-mode echocardiography machine from the echocardiography laboratory to the hospital at Indiana University–a long walk. The cart had a large handle for control, wheels large enough not to get stuck between the elevators and landing, a crank to raise the echocardiography machine for easy viewing for differently sized operators, and a shield around the oscilloscope screen to block the light. Little things–attention to detail.

Many advances were made possible by Harvey’s collaboration with engineers and industry leaders. He quickly recognized the potential of new innovations that he adopted and popularized. These included the strip chart recorder for M-mode recording, the first-generation 2D scanner, the first offline echocardiography analysis systems, the combination of exercise and echocardiography, and digital echocardiography.

The Mentor 

Harvey was a busy man. He ran a catheterization laboratory, an echocardiography laboratory, and a research program. He took care of patients, had staffing responsibilities on the medicine service, wrote articles and books, ran courses, traveled, and trained fellows (always on the move–never a wasted moment). Despite all of these accomplishments, he has always said that he took the greatest pride in the people he trained. Over the years the Indiana program trained hundreds of physicians in echocardiography, many who have gone on to become leaders in the field. Fellows were attracted to Harvey’s enthusiasm, enormous energy, passion for his work, and constant flow of ideas. His ideas were original and important, and a fellow’s work was quickly rewarded by presentation and publication. Working in the echocardiography laboratory at Indiana was always enjoyable; there was great camaraderie, and a sense that everyone’s contribution was important and valued.

Dominant figures in any field can either cast such a broad shadow that little can grow beneath them or reflect so much light that everyone around them is illuminated. Working with Harvey was like standing on a brightly lit stage where everyone could see even the smallest accomplishment. He encouraged growth and offered suggestions, but allowed people to pursue their own interests, even when they were different from his, always acknowledged successes, and never dwelled on mistakes. He was easy to work with because he always said exactly what he thought–there were no hidden agendas. He also offered lessons for life: always maintaining the separation in time between work and family. Harvey was just as critical of the work done in his own laboratory as he was that of others. I recall showing him a scatter plot with a good correlation but one notable outlier. When Harvey asked what happened with that point, I said I would check. When I came back, the point was gone. When asked what happened, I said that I had reanalyzed it and had made a mistake. To my chagrin the response was, “You can’t do that, if you reanalyze one you have to reanalyze them all.” This was followed after a second by, “You always learn the most from your outliers.” Over the years working with fellows I have always been amazed at how easily points can move in or disappear from a scatter plot when questioned; the fine line between exploring a question and proving a point; and the importance of outliers in understanding the real accuracy of a technique and opening new doors for investigation.

Harvey has always been interested in recognizing young investigators. When the ASE decided in 2000 to name a lecture in his honor, he requested that the Feigenbaum lectureship be awarded to an accomplished young investigator. On presenting the plaque to this year’s speaker, he noted proudly that she could trace her roots back three generations to the Indiana program. Not the first time this had happened and surely not the last.

The Teacher 

What good is a prophet without disciples?

To expand the use of echocardiography, Harvey began an active teaching program. The first echocardiography course in the United States was held in Indiana in 1968. Fifty people attended including Inge Edler. Harvey then began accepting weekly visitors to the laboratory to learn echocardiography. Among these 1-week wonders were many early leaders in the field including Al Parisi, Tony DeMaria, Bob Kraus, Richard Meyer, and Stanley Goldberg. Tony DeMaria recalls that when visiting the Indiana echocardiography laboratory in 1972, there were two loose-leaf notebooks of reprints on a shelf containing the world’s literature on echocardiography at the time (personal communication). As demand to learn echocardiography increased, Harvey began conducting larger 3-day courses several times a year, always with a focus on performing and interpreting echocardiograms. Beginning in 1975, Harvey directed a series of national courses, the first of which attracted more than 400 people. In 1972 he published the first textbook, Echocardiography, which is now in its sixth edition.33 Harvey has also been, and remains, a widely respected national and international lecturer. In recognition of his accomplishments as a teacher, the American College of Cardiology honored him with its gifted teacher award in 1998.

The Sonographer 

Early in the evolution of echocardiography, Harvey recognized the need for sonographers to perform the time-consuming task of recording the echocardiogram. In the Indiana laboratory, the sonographers were far more than simply data gatherers. They were involved in teaching fellows and visitors, lecturing at the local courses, and providing preliminary analyses of studies, and were an integral part of the research effort. The Indiana laboratory served as an example to other programs and helped define the professional role of the sonographer. The value Harvey placed on the sonographer was further validated by his decision to include Sonia Chang as a member of the original board of directors of the ASE, thus setting the precedent for sonographers to be full professional members and leaders of the society. In a recent history of echocardiography, Harvey devoted nearly 20% of the text to the role of sonographers, including personal reflection on the first two sonographers to work in the Indiana laboratory.34

The ASE 

In the mid-1970s the Social Security laws provided full reimbursement for tests performed by radiologists and pathologists (as nonself-referring physicians) and 80% for everyone else. Given this structure, Harvey recognized that echocardiography was in danger of being lost to cardiology where it had developed. Although he argued against this in several joint forums, he found himself a single voice and, therefore, decided to form the ASE. The idea was presented to the faculty of the 1975 Update in Echocardiography course in Indianapolis, IN. The concept was unanimously accepted and that faculty became the first board of directors of the ASE. The society was incorporated in Indianapolis, IN, with Harvey and those in the adjacent offices as the incorporators; membership roles were maintained by the catheterization laboratory secretary in her spare time, with Jim Dillon as the treasurer and Harvey as the first president. From that small beginning the ASE has grown, as hoped, to be the voice of echocardiography with more than 13,000 members, and 9 of the 17 subsequent presidents can trace their roots to the Indiana program.

The JASE 

When, after years of discussion, the ASE decided to start a scientific journal to replace its newsletter, the ASE communicator, Harvey was the only individual who everyone agreed had the stature and skill to make the journal a success. As the founding and only editor for the last 20 years, Harvey has overseen the continued growth of the JASE from an idea to its current place as a primary reference source for echocardiographers.

Throughout his career, when there were others to take over what he started, Harvey moved on to new challenges that were always present and needed his unique talents. Remarkably, after more than 40 years, Harvey retains his enthusiasm for and love of echocardiography. At the last American College of Cardiology meeting, one of our fellows presented a poster on echocardiographic findings in a mouse model of aortic disease at one of the sunrise poster sessions (personal communication). When I asked him how it went; he commented that, “at that hour” there were only a few people around, “but Dr. Feigenbaum came by.”

In recognition of his many contributions to cardiovascular research and teaching, Harvey has received numerous awards and citations including: Distinguished Professor of Medicine at Indiana University, 2005; Distinguished Scientist Award of the American Heart Association; Texas Heart Institute Medal and Ray C. Fish Award for Outstanding Achievement in Cardiovascular Disease, Houston, 1976; Modern Medicine, Award for Distinguished Achievement, 1977; Lewis A. Conner Lecture, American Heart Association, 1977; Richard and Hinda Rosenthal Award, American Heart Association, Outstanding Achievement in Cardiovascular Research, 1979; Distinguished Alumnus, Indiana University School of Medicine, 1980; Distinguished Alumnus, College of Arts and Sciences, 1986; Tufts Award in Echocardiography, Tufts University School of Medicine, 1986; Gifted Teacher Award, American College of Cardiology, 1988; Robert J. and Claire Pasarow Foundation, Award for Excellence in Cardiovascular Medicine, Los Angeles, Calif, 1989; Eugene Drake Memorial Award, American Heart Association, 1992; Discovery Award in Science, Indiana Columbus Society, 1992; Luminary Award for Scholarly Accomplishment in Science, Pisa, Italy, 1997; Louis F. Bishop Lecture, American College of Cardiology, 1998; World of Difference Lifetime Achievement Award from the Indiana Health Industry Forum, 1998; included among the 20th Century’s Leading American Innovators in Cardiovascular Disease at a Roche Exhibit at the 1998 American College of Cardiology and American Heart Association national meetings; Annual Feigenbaum Lecture at the annual meeting of the American Society of Echocardiography inaugurated in 2000; and 2002 Cor Vitae Award from the Midwest Affiliate of the American Heart Association. He received the Primio Mantevergine Award as Father of Modern Echocardiography in Naples, Italy, in June 2004, and is the recipient of the Pioneer Award from Mayo Clinic for Development of Echocardiography at a 50th celebration meeting.

It is said that some people look at a swamp and see a magic kingdom. Harvey looked at a reflection from the back wall of his heart and saw the potential for what has become the most widely used cardiac imaging technique in the world. In this issue we highlight several of the areas of echocardiography that Harvey pioneered–pericardial effusion, left ventricular function, stress echocardiography, and digital echocardiography–describing his early contributions and tracing the evolution of these lines of research to the present–a small token of appreciation.