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HISTORICAL STUDY

The Developmental Phase of Modern


Coronary Artery Surgery
Ret-6 Gerhimo Favaloro, MD

ecauseof the many questionsrelated to the devel- the early fifties, and though I was satisfied with our

B opmental phase of modern coronary artery sur-


gery that my colleaguesposedduring my partici-
pation in international meetings in recent years, I decid-
work in the countryside, in 1960 I beganto cherish the
idea of travelling to the United States to be trained in
thoracic and cardiovascular surgery. In 1961 I talked to
ed to enlarge a previous study published in 1983l and ProfessorMainetti, who understoodhow I felt and who,
present in detail the major events that occurred when after one of his many trips to that country, advisedme
I left Argentina-my home country-and joined the to go to the Cleveland Clinic. Not too many doctors in
Cleveland Clinic team in Ohio in 1962. Argentina knew about the Cleveland Clinic in those
I graduated from the Medical School at the Univer- days. Consequently I asked: “Why the Cleveland Clin-
sity of La Plata. Since my training as a resident in gen- ic?” He answeredvery quickly: “They have one of the
eral surgery, I had been attracted by thoracic surgery. best cardiology departments. They are far advanced,
As a consequence, I traveled on Wednesdays to the mainly in the cardiac laboratory, becauseof the work of
Rawson Hospital in Buenos Aires, where Enrique and Mason Sones.Besides,they have an excellent research
Ricardo Finochietto had organized a postgraduate pro- department, where Kolff is working, and I saw Effler in
gram, mainly to get acquainted with lung and esophage- the operating room and he is an excellent surgeon.” Dr.
al resection. After I finished my residency early in 1949, Mainetti wrote to his friend, George Crile, Jr., and at
those trips became a weekly duty. We were lucky to the beginning of February 1962 I traveled to Cleveland
have 2 outstanding surgeons in La Plata: Professor with my wife.
Federico Christmann and Professor Jose Marla Mai- I will never forget my 12 years in Jacinto Arauz, the
netti. I started my training with the latter, an energetic, village where we worked. They taught me many things,
unusually ambidextrous and skillful surgeon who be- but the most important thing I learned is that the pa-
came my master. I lived in the University Hospital, in a tients we treat in practice should be treated with honor,
small room, and thought only of my work and the and that they deserveour love and, oftentimes,our com-
teaching career I chose early on as a student teaching passion.
assistantin anatomy. But my destiny, for many reasons, After my arrival in Cleveland I went to see Dr.
led me to become a country doctor in a small village in Crile. We had a friendly talk and I was very impressed
the southwest of the dry pampas in May 1950. with his personality. Later on he becameone of my best
With tremendous effort, saving every penny-I friends at the Clinic. I had always admired his humanis-
come from a low-to-middle class family; my father was tic idealism. He telephonedDr. Donald Effler and after
a carpenter, my mother a dressmaker-I was able to a few minutes I was in Dr. Effler’s office with somefear
build up a small clinic with 1 operating room and an x- in my soul. I explained the reason for my trip and em-
ray machine. For the first time, surgery was performed phasized that I was ready to work with dedication
in that rural area; emergency operations became my and responsibility. I did not have the proper require-
principal work. My only brother-Juan Jose-also a ments-mainly, the Educational Council Foreign Medi-
surgeon, joined me 2 years later. From then on, the cal Graduate examination-and he made it clear that 1
broad spectrum of general surgery engagedmost of our could only be acceptedas an observer,without any pay-
time, becauseours was the only properly equipped and ment. I explained that I had been able to save some
organized clinic for more than 150 kilometers. money and was not asking for a salary, only a place to
Even though I was far from my University, I made learn. He sent me to the educational department to be
regular trips to La Plata and we received the most im- registered. My happinessended when the director gave
portant medical journals. The early contributions in car- me a hard time. Shortly before, a fellow from Argentina
diovascular surgery made a great impression on me in had been admitted to work in the researchdepartment;
he had signed a contract for 1 year and had disappeared
From the Department of Thoracic and Cardiovascular Surgery,
within the first 2 months, without giving notice, to join
GtiemesHospital, BuenosAires, Argentina. Dr. Favaloro is Head Pro- another hospital in the south of the state. As a conse-
fessorof Cardiovascular Surgery at El Salvador University School of quence, the director told me that he did not want any
Medicine, BuenosAires, Honorary Professorat the BuenosAires Na- other doctor from that “wild country.” The interview
tional University, and a member of the National Academy of Medicine. became very sour and finally I stood up and told him
Manuscript received April 24, 1990; revised manuscript received and
acceptedAugust 10,199O. that I was sorry about the circumstancesbut could not
Address for reprints: Rene G. Favaloro, MD, Acufia de Figueroa tolerate his insults to Argentina any longer. I thought:
1240,(1180) BuenosAires, Argentina. “This is the end of my dream.”

1496 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 66


wever, I went back to seeEffler; I explained what nary angiograms. I found the doors of Sones’office per-
ha appened. To my surprise he said: “Forget all manently open, learned that it was his habit to wear a
about it. Tomorrow you will start work at 8 o’clock.” white undershirt and that he was always willing to ex-
And this is the way I was admitted to the Cleveland change ideas with his associatesand the innumerable
Clinic. I had to buy my own white coats because,not visitors from all over the world who came to watch him
having been accepted officially by the educational de- work. With humility I asked for his advice in interpret-
partment, only the greens for the operating room were ing some of the movies that were difficult for me be-
causeof my lack of experience. From then on we devel-
sidesEffler and his partner, Dr. Larry Groves, the oped a deep and everlasting friendship.
membersof the Department of Thoracic & Cardiovas- After a few months it. became clear that 2 distinct
cular Surgery were: a senior resident, Dr. Niall Scully, groups of patients could be categorized: (1) those with
a junior resident, Dr. Alfonso Parisi, and sometimes a diffuse disease that involved most of the coronary
rotating fellow from general surgery. Most of the daily branches, very often with collateral vessels between
work was lung resection, esophagealrepair or resection, them, and (2) those with select, localized obstruc-
and mediastinal tumors. Only 3 or 4 open-heart surger- tions, mainly at the proximal segmentsof the coronary
ies, mainly relating to congenital diseases,were per- branches, with good distal runoff. The analysis of the
formed per week. Within 2 weeks, Effler invited me to tine left ventriculograms showed a definite correlation
scrub up and made me the second assistant in a left betweenthe severity of coronary arteriosclerosisand the
pneumonectomy. From then on I assisted him and state of the heart muscle. At that time only the right
Groves at every opportunity. I placed Foley catheters, anterior oblique projection was used. Later on, because
pushed beds back and forth to the intensive care unit, of my daily observation at the operating room, mainly
helped the anesthetists and Rose Litturi, who was in of patients with ventricular aneurysm and poor ventric-
charge of the pump equipment, clean, siliconize and set ular contraction, I suggestedto Mason that the left an-
the enormousextracorporeal machine with a Key-Cross terior oblique view was necessaryto visualize the sep-
oxygenator and electronic flow meter. In short, I did tum and lateral wall. Since then, both projections have
everything possible to show my gratitude. become mandatory for the analysis of the entire left
ventricle, to clarify the proper indication and operative
approach.
Just before my arrival at the Cleveland Clinic, two I studied for the Educational Council Foreign Medi-
important events had occurred. On January 5, 1962, cal Graduate examination mainly on weekends and
Effler and his associateshad been successful in over- have to confess that it was difficult to sit still for so
coming a severeobstruction at the left main coronary many hours, reviewing anatomy, physiology, biochemis-
artery2 using the patch graft technique described by try, after so many years had passed since I finished
Senning.3Sones,on January 12, examined a patient op- medical school. But 1 knew it was worthwhile and very
erated on by Vineberg in Canada in 1946 and used se- often I went to the library to become familiar with
lective opacification of the left mammary artery to re- books and journals of our field.
veal that collateral circulation arising from a systemic Surgical attempts under the leadership of Effler
artery implanted in a small tunnel was sufficient to di- were applied to most patients following Vineberg’s
minish the myocardial perfusion deficit in the territory ideas.5-7The patch repair technique was used in a select
perfused by the anterior descending branch of the left group and, as our experience accrued, so was resec-
coronary artery. His finding wa d in March in tion of scar tissue and ventricular aneurysm, when in-
another patient, operated on by dicated.8
ight from the start I was awn to the work of 1
Mason Sones, Earl Shirey and their colleagues, who ternal mammary artery
performed hundreds of top quality tine coronary angio- posterolateral thoracoto
grams down in the basement.4Studies of such precision nique, with meticulous dissection to avoid
and skill were at that time only available in the Cleve- We found that, if we left a sponge impregnated, with
land Clinic and, furthermore, were systematically papaverine attached to it, while we prepared the tunnel,
stored. Sones’ department was called spasmwas avoided and the artery lumen enlarged. The
there that I spent most of my free time after tinishing internal mammary artery was applied on the anterolat-
the day’s work in the Department of Thoracic & Car- era1wall of the left ventricle. Dr. David Fergusson,who
diovascular Surgery. I had rented a small apartment arrived from South Africa to join Sones’ department,
just acrossthe street in an old building with an amusing becamean expert in direct visualization of the mamma-
name-“Palais Royal.” Living so close to the Clinic, I ry arteries in the cardiac laboratory. Me analyzed
avoided traveling through the streets and roads, which postoperative studies he and the other members of
are covered with splow most of the winter in the Ohio had performed and found that the patency rate and thg
Great Lakes area. This way, I was able to prolong my degreeof connection with the coronary circulation were
activity late into the evening and sometimes even into directly related to the severity of the obstruetion and the
the night. presence of collateral circulation. The overall results
Slowly d steadily, with the help of the fellows were gratifying.9 Our work increased steadily. After
working in I started learning how to read tine coro- passingthe Educational Council Foreign Medical Grad-

THt AMERICAN JOURNAL OF CARDIOLOGY DECEMBER 15, 1990


uate examination, I became a regular junior fellow in our new approach was a good way to ameliorate myo-
1963 and the chief resident in 1964. cardial perfusion deficit. The most significant demon-
In 1965 Effler invited Sewell to operate on a patient strations were obtained in some patients whose repeat
in our hospital, and I helped him. His approach-the catheterizations showedthat their left coronary arteries
pedicle technique-allowed the surgeon to work far were totally occluded at the ostium and that their left
from the artery and consequently the dissection was ventricles were perfused by both implants by a sponge
done in a short time and with less trauma.‘O The draw- of collateral circulation.
back was that the tunnel had to be made with a bistoury We summarized the experiencewe had at the Cleve-
blade in order to place the pedicle in the heart muscle. land Clinic with the indirect approach at the annual
As a consequence,we combined the Vineberg and Sew- meeting of the American Association for Thoracic Sur-
ell techniques. After the dissection was done, the mam- gery in 1967.15Thinking back, I sometimesbelievethat
mary artery in the distal segment was free of all the we were expecting miracles, becausewe knew that sev-
surrounding tissue and only that portion was placed in- eral months were required to develop connections be-
side the tunnel, which was made in the classical fashion tween the systemic artery and the coronary artery tree.
of the original Vineberg operation. This approach be- Cardiologists referred us patients with intractable angi-
came known to us as the Vineberg-Sewell technique. na, impossible to control even under the strictest medi-
The midline anterior thoracotomy became a routine cal regimen. They demandedour help becausethe cine-
procedure for most of our open-heart operations and, angiograms revealedsevereobstructions at the left main
very often, when I lifted the sternum up to place the trunk level or severeproximal obstructions in the anteri-
Finochietto retractor, or, at the end of the operation to or descendingand circumflex branchesof the left coro-
control somebleeding, the mammary arteries were right nary artery without collateral vessels
there. I could seeand palpate them. In 1965 I dissected When we reviewed the first 585 patients who under-
someportions, mainly at the level of the fourth and fifth went bilateral internal mammary implant, we found
interspaces.I discussedthe idea of using both mamma- that 73 (12.4%) had left main trunk obstruction; 14 of
ries with Mason several times, but somebody told him the 43 patients who died after the operation belongedto
that necrosismight occur if the sternum was deprived of that group, and 71.1% of the perioperative myocardial
that blood supply. Reviewing the anatomy, I thought it infarctions were related to obstructions of the anterior
logical to think this a senselesswarning. Finally, in descendingcoronary territory. )
1966 (I was now a staff member of the Department of The midline anterior thoracotomy helped us accom-
Thoracic & Cardiovascular Surgery), I dissected both plish combined simultaneousproceduressince 1966.We
mammaries and implanted them in the left ventricle: performed ventricular aneurysmectomy,valve repair or
the right, parallel to the anterior descending branch, valve replacement with concomitant single or double
and the left, on the lateral wall in a tunnel underneath implantsI
the branches of the circumflex coronary artery and the Direct myocardial revascularization: As I havemen-
distal branches of the right coronary artery.11y12 I per- tioned, the direct approach arose in January 1962 with
formed 38 consecutive procedures without any mortal- the patch graft techique. Patients were carefully select-
ity, possibly because we selected the patients very ed and the results were gratifying for localized obstruc-
carefully. tions, mainly those on the right coronary artery, with an
The dissection was done with routine instruments acceptable operative mortality (10.5% of 142 patients).
and with the assistanceof one of the fellows who, by the Mortality was extremely high, however,in patients with
end, was always very tired after holding the sternum up left main trunk obstruction: 11 deaths in 14 patients.
with both hands. Consequently, I designed a special We tried different operative approaches,14including
self-retaining retractor,13 which, with some modifica- transection of the pulmonary artery (seepage 44 of ref-
tions, is used today in cardiovascular centers all over the erence 14). I was convinced and still do believe that the
world to dissect the internal mammary artery for inter- heart muscle of the left ventricle in patients with se-
nal mammary artery coronary anastomosis.I also de- vere diseaseat the left main trunk level functions under
signed the instruments so that we could make the tunnel severe chronic anoxia. Though the aorta was cross-
in the anterolateral and diaphragmatic wall of the left clamped (the only way to approach the left main trunk)
ventricle without distorting the heart. We never used for approximately 20 minutes, it was enoughto alter the
extracorporeal circulation to perform a double internal myocardial cell metabolism to an irreversible state. It is
mammary implant. We learned that by holding the worthwhile to mention that cardioplegia was not avail-
heart very gently (“as a lady,” I used to tell the resi- able at that time. Thesepoor results were the reasonfor
dents), we were able to avoid arrhythmias and hypo- the application of the double mammary implant in pa-
tension. tients with left main trunk obstruction, certainly our
When Vineberg learned that we were using this new worst enemy.
approach, he visited the Cleveland Clinic with somefre- In those years I used to go to the operating room
quency and we exchanged ideas between operations. with both the thrill of challenge and with fear in my
From then on we became close friends. When I re- soul, Sometimes,when the kidney transplantation team
turned to BuenosAires he wrote me now and then, until was desperatelylooking for a donor and they saw in the
his death on March 26, 1988. An extensivediscussionof surgical schedulethat I was ready to approachthat kind
Vineberg’s original ideas is found in the book14I wrote of patient once more, they would come and ask permis-
in 1970 (seepage 67 of reference 14). I still believe that sion to perform a crossmatchbefore the operation.
1498 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 66
One morning, just before we were getting ready for bypassfrom the anterolateral wall of the aorta was done
a left main trunk reconstruction, one of the residents, a on the fifteenth patient, as pointed out in page 337 of
fervent Catholic, told me of his inner struggle between my fust publication. l7 Because bypassesto the right
his duty as a surgeon and his religious sentiments, and coronary artery were performed at the beginning, the
informed me that he did not wish to participate in the distal anastomosis was done end-to-end with the ad-
operation becausehe felt guilty. After the operation we vance knowledge that the diaphragmatic distribution of
had a long talk. I told him that I too was a Catholic but the right coronary artery was the most important seg-
as a surgeon I felt that I had to make every effort to ment, supplying blood to the right ventricle and a por-
help those patients with the most difficult coronary ar- tion of the left ventricle in a dominant right coronary
tery disease.I informed him that he had chosen a very artery circulation. We preferred to direct the total flow
hard career in becoming a surgeon and that he should to the diaphragmatic posterior descendingand atrioven-
think well in advance of the consequences.A surgeon’s tricular branches. We switched to the end-to-side anas-
life means assuming responsibility for the risk that ac- tomosis later on. We therefore extended the technique
companieshis decision to operate.The deaths associated to the left coronary artery distribution.‘* At the begin-
with surgery are personal and the surgeon must endure ning we went slowly, becausewe did not know of any
their burden as long as he lives. He must never, of previous clinical application and were concerned with
course,consider his patients as experimental subjectsor the late evolution of the graft, mainly with thrombosis
as objects upon which to perfect his preferred treat- and dilatation. The fact that the proximal anastomoses
ment. I ended by saying that I did not believe we were were placed on the anterolateral wall of the aorta a cou-
breaking those ethical rules and that we were genuinely ple of centimeters above the natural ostium led me to
searching for a solution to an extremely difficult prob- believe that the graft would remain patent because it
lem. The review of 13,000 cineangiograms performed would follow the natural coronary flow pattern. Mason
by Sones and associatesshowed that only 32 patients was not so enthusiastic. He would say: “Let’s see if
survived total occlusion of the left main coronary artery. they plug at three months. We must carefully select the
Of course,all of them had diffuse collateral vesselsorig- patients and wait until we have the postop cinean-
inating in the right coronary artery. giogram.”
As our experiencegrew, longer patch reconstructions
were performed, but the postoperativetine coronary an- 1969
giograms showed that there was a direct relation be- The important landmarks achieved in 1968 were the
tween the extent of the repair and the rate of postopera- result of a team effort basedon the high-quality cinean-
tive thrombosis. The longer the repair, the greater the giograms performed by Sonesand colleaguesin Blo, the
failure. This was a result of the coronary artery being pioneer work by Proudfit et all9 on the natural evolution
effectively untouched, and so its inner surfacesretained of patients with coronary arteriosclerosisunder medical
irregularities that could disturb the flow pattern, lead- treatment, which allowed us to screen the proper surgi-
ing to the production of thrombosis and consequentoc- cal candidates and compare the operative results, and
clusion. the operations performed in the Department of Thorac-
Early in 1967 I thought that the use of the saphe- ic & Cardiovascular Surgery under the leadership of
nous vein could solve the problem. There was enough Effler. I will always thank him for giving me total free-
experiencein peripheral and renal artery reconstruction dom to work and for encouraging the development of
with that kind of graft at the Cleveland Clinic. Why not new ideas.
at the coronary level? I discussedthe idea with Mason As a consequencewe combined:
and some of his associatesand we decided that at the 1. The coronary artery bypass technique with left
beginning we should try grafting in the right coronary ventricular reconstruction (aneurysmectomy or scar tis-
artery and that the patient must have a totally occluded sue resection) following the ideas originated in 1966.16
vesselwith the distal segment visualized by collaterals. 2. Coronary artery bypass surgery with concomitant
If the graft occluded, the patient would suffer no harm. valve replacement, because tine coronary angiograms
The first operation was performed in May 1967 on a were regularly made of patients with valvular diseases.t4
51-year-old lady who had been catheterized by David 3. The application of the bypassoperation to the left
Fergusson.The proximal and distal segmentsof the to- coronary artery distribution (see page 47 of reference
tally occluded right coronary artery were reconstruct- 14).14The first operation was performed on a patient
ed with a segment of saphenousvein and 2 end-to-end with severeobstruction of the left main trunk and mini-
anastomoses.Soneswas very anxious to restudy the pa- mal changeson the left anterior descendingand circum-
tient and did so 8 days later. He called me and as soon flex branches. A single bypass to the proximal segment
as I finished one of the operations I went to the cardiac of the left anterior descendingbranch showed excellent
laboratory. Mason showed me the film on the Tage- perfusion of the entire left coronary artery in the post-
Arno. I had very rarely seen him so happy. The right operative study. Left main artery diseasehad been de-
coronary artery had been totally reconstructed and feated. This was one of the most gratifying rewards I
there was an excellent distal runoff. A few days later he have ever had in my life as a surgeon after many years
took a 16-mm movie of the pre- and postoperativestud- of suffering and sweating.
ies to a meeting in West Germany. 4. Emergency bypass surgery in impending infarc-
Very early in our experience we realized that the tion and acute infarction.20 The available literature,
interposedtechnique presentedsignificant limitations. A mainly the experimental contributions of Cox et al,21
THE AMERICAN JOURNAL OF CARDIOLOGY DECEMBER 15, 1990
convinced me that, if good oxygenated blood was avail- elusions we said: “When operationsare performed with-
able in the early hours of a myocardial infarction (and in 6 hours of an acute myocardial infarction most of the
certainly the bypass graft was able to supply it), the heart muscle can be preserved.” It still surprisesme to-
muscle could recuperate. In those days our patients day-only 11 patients were operatedon. We concluded:
waited for 2 or 3 months to be operated on. Our facili- “Cardiovascular surgeonsare at the threshold of a more
ties were limited becausewe only had 3 operating rooms aggressive surgical approach in the treatment of pa-
and those with threatening obstructions stayed across tients with acute coronary insufficiency. Further clinical
the street at the Bolton Square Hotel. As soon as we experience will be necessaryto substantiate the views
had a cancellation in our daily work they were immedi- presented here.”
ately admitted and operated on. When I wrote the monograph in 1970,14in the chap-
I used to arrive at the Cleveland Clinic around 7 ter dedicated to this subject I predicted: “Personally, I
o’clock in the morning. One day, one of the residents do hope that in the future, patients with acute myocar-
told me that a patient, in whom a previous tine coro- dial infarction will be treated in the sameway as those
nary angiogram showed a subtotal occlusion in the patients with a “dead leg” from acute thrombosis or
proximal segment of a large anterior descendingartery, embolization of the peripheral circulation are now treat-
was in trouble at the Bolton Square Hotel. We quickly ed. Those patients are admitted under the direction of a
went to seehim and found that at around 6 A.M. he had combined surgical and medical team. Emergency angi-
developedseverechest pain that had lasted for approxi- ography is performed and surgical intervention is rou-
mately half an hour. It was very clear that he had suf- tinely performed, with total recovery in a significant
fered an acute myocardial infarction. He was sweating, number of them. Further clinical experiencewill be nec-
with typical dusky color in his fingers becauseof poor essary to substantiate this point of view.” This has be-
peripheral circulation; he was dyspneic (the lungs were come a reality in somepatients with the introduction of
full of rales) and hypotensive. The electrocardiogram fibrinolytic agents in combination with surgery or angi-
confirmed an anterolateral myocardial injury. oplasty in the acute or subacute phaseof a myocardial
I ran to Bra and askedMason for permission to oper- infarction.
ate (he had performed the cineangiogram). As usual he 5. In December, I performed a double bypassto the
was concerned, becausehe respected and loved his pa- right coronary artery and anterior descendingbranch of
tients. I explained in detail the principal major experi- the left coronary artery, thus opening the door to multi-
mental contributions in the literature and that I did not ple bypass approachesin patients with multiple vessel
consider my suggestion an adventure; I thought there obstructions. It is worth mentioning that I had previous-
was already enough evidence accumulated to favor the ly done a double reconstruction with the interposed
use of the coronary bypass graft as the solution to this technique in March 1968 (see page 54 of reference
problem. On the other hand, we knew from the cinean- 14).‘4
giogram that this patient was in the middle of a large I summarized the advanceswe madein the operative
anterolateral myocardial infarction. Even if he survived, technique in a paper accepted for publication in The
he would lose a significant portion of the left ventricle. Journal of Thoracic and Cardiovascular Surgery in
Mason finally agreed. December 1968.18By the end of that year, the largest
I rushed the patient to the operating room and the series of patients in the world (171) had been accu-
whole team moved quickly. He was anesthetized in a mulated.
few minutes. I opened the chest and, as was the case
many times in emergency operations, the patient was 1969TO1970
cannulated in a few minutes. When we openedthe peri- In 1969 we gained more confidenceas the promising
cardium, the anterolateral wall of the left ventricle did results, from continuous observation, of long-term sur-
not contract, and it had a bluish color. A vent on the left vival, were compiled by Sheldon et al22,23 in detail, with
ventricle through the left atrium was mandatory to de- effort and dedication. The excellent contributions by
compressthe heart. The operation went smoothly. As Milwaukee’s Johnson et a1,24-27 showing that bypasses
soon as we finished the proximal anastomosis,red oxy- could be placed in the distal segmentsof the coronary
genated blood went to the anterior descendingcoronary artery distribution, widened the scopeof indications for
artery and its branches, the anterolateral wall started to coronary bypass surgery.
contract and, after approximately 25 minutes of support By December 1969,we had operatedon 570 patients
with the heart-lung machine, the patient was off bypass. and this surgical experiencewas presentedat the Sixth
The blood pressure improved and remained within nor- Annual Meeting of the Society of Thoracic Surgeonsin
mal limits. The next day he was extubated and had an Atlanta.** For the first time we reported that the coro-
uneventful recuperation, He was restudied within 10 nary arteries-mainly the anterior descendingartery-
days and the tine left ventriculogram demonstrated a could occasionally be found inside the myocardial mus-
small, localized area of deterioration on the anterolater- cle, and described the proper technique to overcomethe
al wall. The left ventricular end-diastolic pressure was problem. As is customary in our work, we learned this
normal. This was indeed a gratifying experience. lesson by suffering in the operating room. I will never
We published the first paper in The American Jour- forget the day when I could not find the coronary arter-
nal of Cardiology,2o where we reported 18 impending ies that were clearly visualized in the cineangiogram. I
infarctions and 11 acute infarctions. In one of the con- called Mason, showed him the heart (we were already

1500 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 66


in total bypass), and told him that I could not see the After Sawyer et al’s contribution,30 we performed in
coronary arteries and that perhaps he had given me a 1970 some endarterectomieswith the use of carbon di-
different tine study. He refused to accept my sugges- oxide, mainly in the right coronary artery, to find that,
tion. Together we went to review the film again (we had with the simple mechanical method used before, we ob-
a Tage-Arno in a small room close to the surgical tained similar results, as was reported by Groves et a1.31
suites), and he was right. I went back and was able to In the same year, as a consequenceof the superb
perform only a bypassto the very distal segmentof the work developedby New York’s Green et a1,32I started
anterior descendingbranch. The patient died 48 hours using the direct mammary coronary anastomosis. I
later becausethe flow through the vein was unable to talked to Green on several occasions and he told me
perfusethe entire left coronary distribution, highly com- that I would need over 100 hours in the laboratory to
promisedby proximal obstructions. The autopsy (I used learn how to use the microscope (that is the way he did
to perform my own dissection) demonstrated,to my sur- the anastomosis). I thought that this approach would
prise, that the coronary arteries (left anterior descend- never popularize mammary coronary anastomosis and
ing and circumflex branches) were inside the muscle. decided to dissectthe left mammary artery and connect
The high price we paid was worthwhile. From then on it to the anterior descendingartery with the routine in-
we could solve the problem with an adequate operative terrupted suture technique, with only the help of the
approach. In the same presentation we emphasizedfor lenses that we used in our daily work. I enlarged the
the first time the need for magnifying lensesto perform indication to the diagonal and circumflex branches. Af-
good distal anastomosesin small coronary arteries (we ter I left the Cleveland Clinic in 1971, Loop et aP3 em-
were applying them even in arteries of l-mm diameter). phasized and standardized this method and demon-
The overall mortality rate, including all the combined strated the excellent results on long-term follow-up.34
procedures,was 5.4%. It is interesting to note that 50% My book, “Surgical Treatment of Coronary Arterio-
of the patients received single or double mammary im- sclerosis,” I4 which was highlighted by Effler’s introduc-
plants. It was hard for us to stop using Vineberg’s tech- tion, appearedthat sameyear. I analyzed all the experi-
nique becauseof our previous clinical experiencewith it. ence gained at the Cleveland Clinic. The chapters on
Careful reading of the cineangiogram helped us com- the anatomy of the coronary arteries and the interpreta-
bine the direct and indirect approach. During the dis- tion of the different projections of the tine coronary an-
cussion after the presentation, surgeons were still con- giogram were very helpful, mainly to our surgical col-
cernedwith the problem of late thrombosis, mainly with leagues, as testified to by the comments and the innu-
aneurysm dilatation. By June 1970,281,086 bypasses merable letters I received.
were performed with an overall mortality rate of 4.2% Finally, the VI World Congress of Cardiology was
(see page 110 of reference 28). held at the Royal Festival Hall and Queen Elizabeth
I read our next presentation at the Fifth Annual Hall in London during 1970. I was invited to partic-
Meeting of the American Association for Thoracic Sur- ipate in a symposium dedicated to coronary artery sur-
gery in Washington in April 1970.2yIt concerned the gery with Drs. Ray Heimbecker, Arthur Vineberg and
application of the coronary bypass technique to the left Charles Friedberg. The organizing committee gave us
coronary artery and its divisions. We insisted upon the one of the smallest rooms. Cardiac adrenergic mecha-
use of magnifying lenses and the “non-touch tech- nisms were discussedat the sametime in the main audi-
nique”-that is, no dissection of the coronary arteries torium. I felt from the very beginning of the Congress
was neededto perform the distal anastomosis:the peri- the tremendous interest our sessionhad aroused among
cardium was cut on top by a number 15 bistoury blade the participants, a fact which was confirmed when I ar-
before the artery was opened. As a consequence,the rived an hour early to organize all my slides. The room
stitches (we were using interrupted sutures) incorporat- was already packed by hundreds of doctors, occupying
ed the epicardium and some of the subepicardial fat, a all the seats, some sitting in the central aisle on the
very important detail that surprised the hundreds of vis- floor, and others standing against the lateral walls.
itors at the Cleveland Clinic. When we were on the podium, ready to start, the doors
Once again, intramuscular coronary arteries were were closed,and I saw Paul Dudley White standing just
discussed.More distal anastomoseswere performed and in front of us. I thought: “How come that nobody
for the first time we demonstrated that even totally oc- leaves a seat to him, such an outstanding and human-
cluded vesselswere reconnected.The use of cephalic or istic physician who, together with Ignacio Chavez from
basilic arm veins as an alternative when the saphenous Mexico, was the first to set the foundations of cardiolo-
vein was not available was also discussed.Eleven cardio- gy early in the forties?”
vascular centers contributed to the discussionand it was The first speaker, Dr. Heimbecker, started his pre-
very pleasing to seethe growth of coronary bypass sur- sentation, and at the same time we could clearly hear
gery. There was a steady decrease in the number of the loud voices of the doctors who were complaining
combined single and double internal mammary implan- becausethey had been unable to enter the auditorium.
tations as a direct consequenceof the growth of multi- The lateral doors finally crushed becauseof the pressure
ple bypasssurgery. By August 1970,2y196 patients had from outside and innumerable physicians jumped into
undergone double, triple and quadruple grafts, with a the room. Somebody was able to protect the fragile
4.1% hospital mortality rate (see page 482 of reference body of Paul Dudley White. It was impossible to go on
29). with the session.The Secretary of the Congress talked

THE AMERICAN JOURNAL OF CARDIOLOGY DECEMBER 15, 1990


to us and finally told the audience that we would repeat closed the envelopewith tears in my eyesand left it on
the symposium at 6 o’clock. We knew in advance that it Effler’s desk. I went home. I confessthat I could not
would be impossible, becausea discussioncannot be re- control myself and cried while driving through the
peated and anyway Friedberg was traveling back to beautiful roads that took me to Pepper Pike, where I
America that same evening. However, the Secretary’s had lived since 1966. Effler wrote back accepting my
words calmed the audience down and the roundtable decision, “because I know that your roots have always
recommenced. Dr. Heimbecker presented his work on been in Argentina.” We had a long talk a few days
resection of acute myocardial infarction, Vineberg sum- later. I told him I had great faith in Loop and Chean-
marized his experience,and finally Friedberg and I dis- vechai, two outstanding fellows in our Department, and
cussed coronary artery bypass graft surgery. Charlie promised him that I would dedicate the rest of my time
was an outstanding speaker who knew how to sprinkle at the Cleveland Clinic to polishing them from the other
his statements with good humor. He started by saying: side of the table. They performed most of my operations
“These cardiac surgeons are unique. When the heart with dexterity and completed a successfultraining.
has a hole they close it, when the heart doesn’t have a My big problem was Mason. It was impossible for
hole they open one.” We all laughed at his comments, him to accept that I would break our commonwork and
but when I presented the number of procedures per- brotherhood. Repeatedly he tried to convinceme of my
formed at the Cleveland Clinic and the perioperative “mistake.” The last 3 months were dreadful. Even
mortality rate, Charlie voiced some doubts about “such though I may look like a strong and commanding sur-
a low mortality,” which was difficult for him to accept. geon, deep in my soul I am an extremely sensitive fel-
I flared up and invited anybody who wished to go to the low. Everywhere I went in the Clinic, staff membersof
Cleveland Clinic to check our files. In fact, some physi- different departments, the nurses, the technicians, ev-
cians did visit us on their way back to their native coun- erybody, interrupted my work and asked me to stay.
tries and were able to confirm the honest work per- Finally I decided to escape.I told everybodyI was leav-
formed at our institution. ing at the end of June or the beginning of July but ac-
At the same time Donald Ross invited me to per- ceptedan invitation to lecture in Bostonin the middle of
form someoperations at the National Heart Hospital in June and from that meeting we went straight to Argen-
London. I agreed and the first coronary bypasseswere tina. Only my secretary, Candice, a lovely young lady,
performed in England with his help. Some of the out- knew my secret, and she was brave enough to keep it. I
standing cardiovascular surgeonsfrom Europe watched wrote letters to Effler and Sones.Donald acceptedmy
the surgeries from behind us, almost on top of our decision, which “avoided a painful good-bye or fare-
shoulders. I have to confess that I felt a tremendous well.” Mason, once again, thought I was crazy.
responsibility and still remember the first operation, I left an important part of my life at the Cleveland
when, after opening the right coronary artery and plac- Clinic. I only know I worked hard in a friendly and
ing the first stitch, which I had left on the operative clean atmosphere.But my departure was not a farewell.
field, the sister (a scrub nurse) pulled it off and tore the Since then I go back as frequently as I can. When the
vessel.I prolonged the incision further distally and was plane is landing in Cleveland I know I am back home.
able to solve the problem. Of course, I told the sister: The most important trip was 4 weeks before Mason
“Please, don’t touch anything else on the operative died. I had learnt through a telephoneconversationwith
field.” During that week, at noon, we went to a pub his secretary that he was in very bad shape, talked to
opposite the hospital, where we exchanged knowledge Maria, and decided we would go and spenda weekend
and friendship. with him. It was a very difficult decision to make. I do
not know where I got so much strength from. On Friday
MY RETURN HOME and Saturday we reminisced together, recalling anec-
During my stay at the Cleveland Clinic I went back dotesfrom our common work, mainly a long trip to Eu-
to my home country for short periods of time. I partici- rope with our wives. During 3 weekswe had given lec-
pated in national cardiology meetings and also per- tures at different hospitals in France, Italy and Spain.
formed some operations in 2 hospitals in Buenos Aires. On that occasionwe went by car (I had rented a station
A large delegation from Argentina attended the World wagon) from Marseille to Verona and I think Mason
Congress in London and, once more, many colleagues was in direct communication with nature for the first
asked me to return home. From then on I gave serious time. It was the end of summer. He was amazedby the
thought to this matter and finally considered that my wheat prairies, the corn fields, the green valleys, the
work and my duties in the United States were no longer vineyards and the fruit trees. We ate delicate home-
needed. We had trained many capable fellows who made food and drank wine in small villages. This giant
would be able to continue the job. And a tremendous of modern cardiology was bathed by the sun in the mid-
challenge stood in front of me, in the south. dle of nowhere instead of by the lamps of the cardiac
In October 1970, late in the afternoon, I sat down laboratory where he spent all his life.
and wrote my letter of resignation to Effler. It was a These memories brought us happinessuntil Sunday,
very difficult moment for me becauseI loved the place when we spent the last moments alone. Finally we em-
where I was working and the family that we had built braced, cried together and said good-bye for the last
up in the Cardiology and Cardiovascular Department. I time in this world. He died on August 29, 1985. I will

1502 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 66


always thank God for having given me the opportunity (suppl II):&24-H-26.
10. Sewell WH. Surgery for acquired coronary disease. Springfield, IL: Charles
to share with Mason many years of common work, un- C Thomas, 1967.
derstanding and deep friendship. 11. Favaloro RG. Bilateral internal mammary artery implants-operative tech-
Final comments: I have summarized the contribu- nique. A preliminary report. Cleu Clin Quart 1967;34:61-66.
12. Favaloro RG. Double internal mammary artery implants-operative tech-
tions to myocardial revascularization performed at the nique. J Thomc Cardiouasc Surg 1968;55:457-465.
Cleveland Clinic. I apologize for writing so often in the 13. Favaloro RG. Unilateral self-retaining retractor for use in internal mammary
first person because I believe in team work and never artery dissection. J Thorac Cardiouasc Surg 1967;53:864-865.
14. Favaloro RG. Surgical Treatment of Coronary Arteriosclerosis. Baltimore:
claim any priority. Knowledge acquired in medicine is Williams & Wilkins, 1970.
the result of the efforts of many contributors through- 15. Favaloro RG, Effler DB, Groves LK, Sones FM Jr, Fcrgusson DJG. Myocar-
dial revascularization by internal mammary artery implant procedures. Clinical
out the years. In coronary surgery it started in 1910 experience. J Thorac Cardiouasc Surg 1967;54:359-370.
with the experimental work done by Alexis Carrel (see 16. Favaloro RG, Effler DB, Groves LK, Razavi M, Liebcrman Y. Combined
Table II of reference 1). simultaneous procedures in the surgical treatment of coronary artery disease. Ann
Thorac Surg 1969;8:20-29.
In 1971 I learned through direct communication 17. Favaloro RG. Saphenous vein autograft replacement of severe segmental
from Effler of Garrett’s first successful operation. In coronary artery occlusion. Operative technique. Ann Thorac Surg 1968;5:334-
November 1964 he was trying to perform a patch repair 339.
18. Favaloro RG. Saphenous vein graft in the surgical treatmenl of coronary
of a localized obstruction on the anterior descending artery disease. Operative technique. J Thorac CardiouascSurg 1969;58:178-185.
branch of the left coronary artery with the assistanceof 19. Proudfit WL, Shirey EK, Sones FM Jr. Selective tine coronary arteriogra-
phy-correlation with clinical findings in 1,000 patients. Circulation 1966;
Drs. S. Pitzele, M.K. Neugebauer and L.C.C. Zanger, 33:901-910.
and he decided to perform a saphenousvein graft by- 20. Favaloro RG, Effler DB, Cheanvechai CH, Quint RA, Sones FM Jr. Acute
passbecauseof some complications. coronary insufficiency (impending myocardial infarction and myocardial infarc-
tion). Surgical treatment by the saphenous vein graft technique. Am J Cardiol
We suggestedthat he locate the patient, restudy him 1971;28:598-607.
and publish the case,becauseif the vein was open, as it 21. Cox JL, McLaughlin VW, Flowers NC, Horan LG. The ischemic zone
was, we would have the longer demonstration of a pat- surrounding acute myocardial infarction. Its morphology as detected by dehy-
drogenase staining. Am Heart J 1968;76:650-659.
ent graft.35 Nevertheless, I think I must honestly re- 22. Sheldon WC, Soncs FM Jr, Shirey EK, Fergusson DJG, Favaloro RG, Effler
mark that, when the publication appeared in 1973, DB. Reconstructive coronary artery surgery: postoperative assessment. Circula-
rim 1969;39-4O(suppl 1):1-61-I-66.
thousandsof operations had already been done in Cleve- 23. Sheldon WC, Favaloro RG, Sones FM Jr, Effler DB. Reconstructive coro-
land, in other centers in the United States, and even nary artery surgery. JAMA 1970;213:78-82.
abroad. 24. Johnson WD, Lepley D Jr. An aggressive surgical approach to coronary
disease. J Thorac Cardiouasc Surg 1970;59:128-138.
Personally, I think the most gratifying aspect of my 25. Johnson WD, Flemma RJ, Lepley D Jr, Ellison EH. Extended treatment of
career refers to teaching: the deep rewarding feeling severecoronary artery disease: a total surgical approach. AnnSurg 1969;170:460-
that comes from sharing what we have accumulated 470.
26. Johnson WD, Flemma RJ, Lcpley D Jr. Direct coronary surgery utilizing
through many years of hard work, mainly with residents multiple-vein bypass grafts. Ann Thorac Surg 1970;9:436-444.
and fellows. This is the main reasonwhy I came back to 27. Johnson WD, Flemma RJ, Harding HW, Cooper GN Jr, Lepley D Jr.
Surgical principles in the direct reconstruction of left coronary flow. Ann Thor-m
Argentina. surg 1970;10:141-152,
Someother time I hope to be able to write of what 28. Favaloro RG, Effler DB, Groves LK, Sheldon WC, Sones FM Jr. Direct
followed my departure from the Cleveland Clinic. myocardial revascularization by saphenous vein graft. Present operative technique
and indications. Ann Thorac Surg 1970;10:97-1 Il.
29. Favaloro RG, Effler DB, Groves LK, Sheldon WC, Shirey EK, Sones FM Jr.
Severe segmental obstruction of the left main coronary artery and its divisions.
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4, Sones FM Jr, Shirey EK. Cine coronary arteriography. Modern Concepts 1972;64:514-522.
Cardiouasc Dis 1962;31:735-738. 32. Green GE, Stertzer SH, Reppert EH. Coronary arterial bypass grafts. Ann
5. Vineberg AM. Development of anastomosis between coronary vessels and Thorac Surg 1968;5:443-450.
transplanted internal mammary artery. Can Med Assor J 1946;55:117. 33. Loop FD, Spampinato N, Siegel W, Effler DB. internal mammary artery
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7. Vineberg AM, Buller W. Technical factors which favor mammary-coronary 34. Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams
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THE AMERICAN JOURNAL OF CARDIOLOGY DECEMBER 15, 1990