(Circulation. 2001;103:480.)
© 2001 American Heart Association, Inc.
In Memoriam |
Rene G. Favaloro, MD
The Passing of a Pioneer
When Dr Rene G. Favaloro (1923–2000), one of the preeminent cardiovascular surgeons of the later half of the 20th century, died on July 29, 2000 at the age of 77, the cardiovascular field lost one of its most respected and creative minds. A brief biographical sketch may help in understanding this most unusual and exceptional man.
Dr Favaloro was born in La Plata, Argentina. He grew up in a poor neighborhood of La Plata but was influenced by his maternal grandmother, who taught him an enduring love of the land and nature, and by an uncle, who was a general practitioner and was often accompanied by the young Favaloro on his daily rounds in the neighborhood. These influences framed Dr Favaloro’s sensitivity for his country (well portrayed in some of his books), awakened his social conscience (which was apparent by his challenges to the sociopolitical system of Argentina), and led him to pursue a medical career.
Dr Favaloro began his studies in the Medical Science Faculty of La Plata University, where he graduated at the top of his class in 1949. According to Dr Ricardo H. Pichel, Chancellor of the Favaloro University in Buenos Aires, Dr Favaloro was an observer and a listener who was eager to be mentored. Indeed, he was the fervent disciple of two great Argentinean masters of surgery, professors Federico Christmann and Jose Maria Mainetti, who fostered in him a deep interest in thoracic surgery. Such positive influences probably explain the great devotion of Dr Favaloro to teaching and mentoring. Indeed, it has been estimated that more than 400 cardiologists and cardiovascular surgeons have been mentored and/or trained under his decisive influence.
Around 1950, the first testimony to Dr Favaloro’s intellectual consistency appeared when he resigned from the successful career that he was developing as a surgeon at the La Plata University Hospital. In his book Memories of a Country Doctor, he wrote: "When I finished my internship I applied for a position as auxiliary house doctor, and I got this position, at the beginning temporarily. Later, when I was confirmed, I was requested to fill a form with my personal data and to write in a blank on the final line that I accepted the government’s policy and endorsement by the Peronist Party. I began to understand that my future was cloudy, because in order to grow and prosper I would accept ideas and concepts which were absolutely distant from my previous formation and my spirit."
Thus, his resignation served as an example of his intellectual principles, which prevailed throughout his professional career. More recently, when Dr Fuster proposed to Dr Favaloro that he share a highly distinguished cultural award with another individual, he declined the offer. He did not think it was appropriate for two individuals with so deeply different or opposite views to share such a distinction.
After resigning from his hospital post, Dr Favaloro’s social sensitivity and creativity began to evolve. For the next 10 years, he assumed the task of filling in for a country doctor whose practice was located in a small town called Jacinto Arauz, southeast of the province of La Pampa. He wrote, "In total, there were maybe 2000 people, when taking into account the rural surroundings. Here, one has to do everything, from internal medicine to pediatrics, obstetrics, emergency traumatology, and minor surgery. Nobody could pay either the physician or the hospital. The money they earned was not enough even to buy the prescribed remedies."
As a country doctor, Dr Favaloro branched into other fields, experimenting with preventive medicine at the most basic level, teaching his patients the basic rules of hygiene, and undertaking more sophisticated projects. For example, the first group of blood donors in the locality was established through his efforts. This was, in fact, a "mobile" blood bank; he knew where each donor lived and called them in as needed. Dr Favaloro gradually transformed his own house into a clinic with beds for hospitalization, an x-ray apparatus, and a surgical room where, together with his brother Juan Jose, he handled all surgical emergencies and even major surgery, such as colectomies, gynecological surgery, gastrectomies, and esophageal surgery.
Despite his rewarding work in La Pampa, Dr Favaloro’s interest in thoracic surgery remained keen. This, coupled with the latest news about the new techniques of open heart surgery, inspired him to consult his old teacher Dr Mainetti, who recommended that he further his studies by traveling to the Cleveland Clinic. Dr Donald Effler invited him to observe the work of the Department of Thoracic and Cardiovascular Surgery. Soon afterward, Dr Effler allowed Dr Favaloro to scrub and participate as a second assistant. He subsequently become Drs Effler and Grove’s permanent assistant. This entailed helping the anesthetist and the extracorporeal pump operator, as well as removing drains postoperatively. In short, he undertook a wide variety of supplementary tasks with the same degree of enthusiasm and physical stamina that he applied to all his activities. He then developed a lasting friendship with Dr Mason Sones, the father of coronary cineangiography, who taught him to read and interpret coronary and ventricular images.
As was recently detailed by Dr Denton Cooley, a great admirer of Dr Favaloro’s imagination and skills, Dr Sones had documented indirect revascularization in a patient who had undergone surgery with the Vineberg Technique 7 years earlier. Although Dr Favaloro and his colleagues routinely performed this technique, they were also beginning to investigate the use of saphenous vein grafts for direct revascularization. Previously, the saphenous vein had been used only for patch reconstruction of occluded coronary arteries, but the technique had a high rate of postoperative thrombosis and was eventually discontinued. Dr Favaloro reasoned that an alternative method of reconstruction could use the saphenous vein to connect the unoccluded proximal and distal sections of the vessel, thus bypassing the obstruction. On May 9, 1967, Dr Favaloro performed the first documented saphenous aortocoronary bypass in a 51-year-old woman who had total occlusion of the proximal third of the right coronary artery. Eight days later, Dr Sones confirmed by angiography that the bypass was patent; 20 days later, angiography showed total reconstruction of the artery. By 1968, Dr Favaloro and his colleagues were combining revascularization techniques with valve replacement and ventricular aneurysmectomy and performing the first bypasses for acute infarction.
Because Dr Favaloro revolutionized the natural history and quality-of-life of patients with ischemic heart disease, it is not surprising that Dr Mason Sones once said that 20th century cardiology can be divided into the pre-Favaloro and the post-Favaloro eras. Furthermore, according to Dr Favaloro’s book Surgical Treatment of Coronary Atherosclerosis, which was published in 1970, between 1962 and 1968, he made at least 25 first technical contributions in the field of cardiothoracic surgery that are of value today.
In the United States, Dr Favaloro made both economic and academic progress, but his love for Argentina was strong enough to draw him back in 1971. He developed the Favaloro Foundation, a center of his dreams for clinical activities, education, and research that was based on the Cleveland Clinic. Dr Favaloro personally financed the development of the basic research department of the Foundation. Indeed, it has been said that "the fact that a surgeon established and personally financed a basic research department in a country like Argentina is probably a unique event in world terms." In the ensuing years, the Favaloro Foundation evolved into an institute for cardiology, cardiothoracic surgery, and organ transplantation that had a substantial educational influence all over Latin America; today, it is recognized and admired worldwide.
Drs Branco Mautner and Bernardo Boskis from the Favaloro Institute (to whom we are grateful for some of the above biographical information) once wrote: "One great unknown remains. His period as a country doctor lasted for 10 years and was followed by his unexpected move to Cleveland. This period also lasted for 10 years and also ended with an unexpected decision: to return to Argentina. After his first 10 years of work back in his own country, he developed an Institute which after 20 years—we add—is a reality of outstanding achievement and a source of pride. The question we now ask ourselves is: what is the new challenge that Favaloro will be presenting in years to come?"
The answer to this question is his legacy. Dr Favaloro will be remembered as a man with a love for his country, a passion for work and ethics, and a strong sense of social responsibility. And, overall, he will be remembered as a great innovator and pioneer in the field of cardiothoracic surgery.
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