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From the Institute of Cardiology and Cardiovascular Surgery of the
Favaloro Foundation, Buenos Aires, Argentina.
For you to find the truth, in the
first place, you have to believe in the truth with all your heart
and with all your soul, and believing in the truth with all your heart
and with all your soul means saying what you think is true wherever and
whenever, but, most especially, at the least opportune moment.
(...) Whenever wisdom is found in a scientific work, there
cannot be the slightest doubt it is passion's doing, a painful passion
much deeper and dearer than simple curiosity.
Miguel de Unamuno
Since my
training as a resident in general surgery at the University Hospital in
La Plata, I have been attracted by thoracic surgery. As soon as I
graduated, I started traveling every Wednesday 44 miles to the Rawson
Hospital in Buenos Aires, where the Finochietto brothers had organized
a postgraduate program, mainly to learn lung and esophageal
resections.
As a resident, I lived in the hospital, where I witnessed the early
attempts in thoracic surgery. In 1949, Professor Clarence Crafoord was
invited by the head professor, José María Mainetti, to
give lectures and operate on patients in our institution. I was
extremely lucky to participate as his second assistant. Crafoord was
indeed a master surgeon. I still remember today my happiness at being
so close to one of the most important pioneers in thoracic and
cardiovascular surgery. I was also impressed by his
anesthesiologist. With a small machine (he brought his own equipment)
and high doses of curare, the operation went smoothly, and certainly we
learned enormously.
In those days, I thought only about my work and an academic career that
I had started earlier as a student assistant professor in
anatomy. I was convinced that my future would be connected
exclusively to the university, because I realized that teaching gave me
a genuine spiritual pleasure.
For several reasons, however, the main one being my refusal to sign a
political declaration supporting the "national doctrine," an
essential requirement at the time to be nominated for any position at
the University Hospital, my destiny led me to become a country doctor
in a small village in the southwest of the dry pampas in May 1950. With
tremendous effort and saving every penny, I was able to build up, from
an old house, a clinic with operating facilities, laboratory, and x-ray
equipment. My only brother, Juan José, who was also training as a
surgeon at the same University Hospital in La Plata, joined me 2 years
later.
The broad spectrum of general surgery (we generally dealt with
emergencies) constituted most of our daily work, because our clinic was
the only one in the region that was properly equipped and organized.
Regular trips to Buenos Aires and La Plata and reading the most
important medical journals kept us well informed of new developments.
As an example, the high mortality of diffuse peritonitis, which was
very common in the countryside in those days, decreased significantly
when Laborit's method of pharmacological hypothermia (meperidine,
promethazine, clorpromazine)1 2 was applied in
conjunction with high doses of antibiotics and corticoids.
The early contributions in cardiovascular surgery in
the 1950s made a great impression on me, and although our work was
gratifying, in 1960 I began to cherish the idea of traveling to the
United States to train in thoracic and cardiovascular
surgery. I talked to my master Professor Mainetti, who understood my
feelings. After one of his many trips to the United States, he advised
me to go to the Cleveland Clinic. He wrote to his friend George Crile
Jr, and at the beginning of 1962 I traveled to Cleveland with my wife.
I was already 38 years old, and I had as a treasure the large
experience accumulated in hundreds and hundreds of operations.
Crile was the first person I met at the clinic. Over the years, he
would become one of my best friends. We shared many thoughts, and I
always admired his humanistic idealism. He introduced me to Dr Donald
B. Effler. In my broken English, I managed to explain the reason
for my trip. Effler made it clear that not having the proper
qualifications, mainly the certificate of the Educational Council of
Foreign Medical Graduates, I could only be accepted as an observer,
without receiving any payment. Because I had been able to save some
money, I pointed out that I was not asking for a salary, only for an
opportunity to learn.
Most of the daily work was thoracic surgery. Only 3 or 4 open-heart
operations per week, mainly for congenital diseases, were performed.
Within 2 weeks, Effler invited me to scrub up in a left pneumonectomy.
From then on, I collaborated with him and Dr Larry Groves, his partner.
In addition, I placed Foley catheters, pushed beds back and forth to
the intensive care unit according to Effler's rules (to be sure a
fellow would always be present, for the safety of the patients),
helped the anesthetists, and also cleaned, siliconized, and set the
enormous heart-lung machine with a Key-Cross oxygenator. I did
everything possible to show my gratitude.
From the beginning, I was drawn to the work of Drs Mason Sones, Earl
Shirey, and collaborators in the catheterization
laboratory placed in the basement (the famous
B10), where hundreds of cine coronary
angiograms were systematically stored, together with a summary of the
clinical record of each patient. At that time, studies of such
precision and quality were available only at the Cleveland
Clinic.3
After finishing the day's work in the Department of Thoracic and
Cardiovascular Surgery, I spent most of my time in
B10. I had rented a small apartment just across
the street. Living so close to the clinic, first, spared me from
traveling through the streets and roads covered with snow most of the
winter in the Ohio Great Lakes area, and second, it allowed me to
prolong the review of the films in the evening and sometimes until late
at night. Slowly and steadily, with the help of the fellows working in
B10, I started learning how to read and interpret
cine coronary angiograms.
The doors of Sones' office were open most of the time. He was always
willing to exchange ideas with his associates and the innumerable
visitors that came from all over the world. After several weeks, I
humbly introduced myself and asked for his advice in interpreting some
of the movies that I could not understand because of my lack of
experience. That was the beginning of a deep and everlasting
friendship.
After a few months of reviewing cine coronary angiograms, it
became clear that there were 2 distinct groups of patients: (1) those
with diffuse disease in most of the coronary branches, often
with collaterals between them, and (2) those with localized
obstructions, mainly at the proximal segments with good distal
runoff.
The analysis of the cine left ventriculogram showed a clear
correlation between the severity of coronary
arteriosclerosis and the state of the heart muscle.
Only the right anterior oblique projection was used. Later on,
mainly as a result of our observations in the operating room, I
suggested to Mason that the left anterior oblique view was necessary to
visualize the septum and the lateral wall.
In January 1962, just before my arrival, 2 important events had
occurred at the Cleveland Clinic: (1) using the patch graft technique
described by Senning,4 Effler and his associates
had been able to repair a severe obstruction of the left main
coronary artery5 (Figure 1
Therefore, since 1962, myocardial revascularization
has started with (1) a direct approach in localized proximal
obstructions with the patch graft technique (pericardium or saphenous
vein) and (2) an indirect approach with the left internal mammary
artery implant.
Indirect Myocardial Revascularization
The left internal mammary artery was meticulously dissected by
means of a left posterolateral thoracotomy. A small tunnel was made on
the anterolateral wall of the left ventricle where the artery was
inserted. Postoperative studies performed within a year demonstrated
that the patency rate and the degree of connection with the
coronary circulation were directly related to the severity of
the obstruction and the presence of collateral circulation. The overall
results were gratifying.6
Our work increased steadily. After passing the Educational Council of
Foreign Medical Graduates examination, I became a junior fellow in 1963
and senior resident in 1964. In 1965, following Sewell's
ideas,7 we dissected the mammary artery with the
surrounding tissue, including the veins, in a short period of time and
with less trauma.
The midline anterior thoracotomy became a routine procedure for most of
our open-heart operations, and very often when I lifted up the sternum
to place the Finochietto retractor, or at the end of the operation to
control some bleeding, I could see and palpate the mammary arteries. I
started dissecting some portions, mainly at the level of the fourth and
fifth intercostal spaces. On several occasions, I discussed with
Mason the idea of using both mammary arteries. Somebody told him that
necrosis might occur if the sternum were deprived of that blood supply.
I carefully reviewed the anatomy to confirm that this was a
senseless warning. In 1966, being already a staff member of the
Department of Thoracic and Cardiovascular Surgery, I
dissected both mammary arteries and implanted the right one on the
anterolateral wall of the left ventricle parallel to the anterior
descending branch and the left one on the lateral wall underneath the
branches of the circumflex and right coronary
artery.8 9 To facilitate the dissection, I
designed a self-retaining retractor10 that, with
some modifications, is used today in cardiovascular
centers all over the world.
We summarized our experience on indirect myocardial
revascularization at the annual meeting of the
American Association for Thoracic Surgery in
1967.11 I still believe that our new approach was
a good way to ameliorate myocardial perfusion deficit. The most
significant demonstrations were obtained in some patients whose repeat
catheterizations showed that their left
coronary arteries were totally occluded at the ostium and that
their left ventricles were perfused by both implants through a sponge
of collateral circulation (Figure 2
Nevertheless, we have to accept that, in retrospect, the only justified
indications were the ones found among patients with diffuse disease and
with collateral circulation. The recent advances in
angiogenesis12 13 14 15 16 17 18 opened a new field of
unlimited dreams, raising the possibility of combining, for example,
the Vineberg technique with angiogenesis inductors.
The dissection of the mammary artery by means of a midline anterior
thoracotomy was another important landmark: it gave us the ability to
accomplish combined simultaneous procedures. In 1966, we
started performing ventricular aneurysmectomy,
valve repair, or valve replacement with concomitant single or double
implants.19
Direct Myocardial Revascularization
As I already mentioned, direct myocardial
revascularization started in January 1962 with the
patch graft technique. The results were gratifying on the right
coronary artery. Conversely, mortality was extremely high in
patients with left main trunk obstruction (11 deaths in 14 patients).
We tried different operative approaches, including transection of the
pulmonary artery.20 Cardioplegia was not
available, and even though the aorta was clamped for
In those years, I used to go to the operating room with both the thrill
of challenge and fear in my soul. Sometimes when the kidney
transplantation team was desperately looking for a donor and they saw
in the surgical schedule that such a patient was ready to undergo
surgery once more, they would come and ask permission to perform a
crossmatch before the operation.
As our experience grew, longer patch reconstructions were performed.
However, the postoperative cine coronary angiograms showed that
there was a direct relation between the extent of the repair and the
rate of postoperative thrombosis: the longer the repair, the greater
the failure. This was the consequence of the coronary artery
being untouched, so that its inner surfaces retained irregularities
that could disturb the flow pattern. The turbulence induced thrombosis
and consequent occlusion.
Early in 1967, I thought that perhaps the problem could be solved by
use of segments of saphenous vein. At the Cleveland Clinic, we had
gathered a broad experience in peripheral and renal artery
reconstruction with that kind of graft. Why not use it at the
coronary level? I discussed the idea with Mason and some of his
collaborators. We decided that we should try it first in patients with
totally occluded right coronary arteries with the distal
segments visualized by collaterals from the left coronary
artery. If the graft occluded, the patient would suffer no harm.
The first operation was performed in May 1967 on a 51-year-old woman.
The proximal and distal segments of the totally occluded right
coronary artery were reconstructed with a segment of saphenous
vein and 2 end-to-end anastomoses. Mason was very anxious to restudy
the patient, and he did so 8 days later. He called me, and as soon as I
finished an operation, I went to the cardiac laboratory. Mason showed
me the film on the Tage-Arno viewer. I had rarely seen him so
happy. The right coronary artery had been totally
reconstructed, and there was an excellent distal runoff (Figure 3
Very early in our experience, we realized that the interposed technique
presented significant limitations. A bypass from the
anterolateral wall of the aorta was done on the 15th patient, as
pointed out on page 337 of my first publication21
(Figure 4
At the beginning we proceeded slowly, because we did not know of any
previous clinical application and we were concerned with the late
evolution of the graft, mainly with thrombosis and dilatation. The
placement of the proximal anastomoses on the anterolateral wall of the
aorta
Important landmarks were achieved in 1968.
1. The bypass technique was applied to the left coronary artery
distribution. The first operation was performed on a patient with
severe obstruction of the left main trunk and minimal changes on the
left anterior descending and circumflex branches. A single bypass to
the proximal segment of the left anterior descending branch showed
excellent perfusion of the entire left coronary artery in the
postoperative study (Figure 5
2. We combined coronary artery bypass graft (CABG) with left
ventricular reconstruction (aneurysmectomy or scar
tissue resection).19
3. CABG with concomitant valve repair or replacement was achieved,
because cine coronary angiograms were regularly performed in
patients with valvular disease.22
4. In December, we performed a double bypass to the right
coronary artery and anterior descending branch of the left
coronary artery, thus opening the door to multiple bypass
approaches in patients with multiple vessel obstructions (Figure 6
5. Emergency CABG was performed in patients with
AMI.23
Patients who were operated on with Vineberg's approach frequently died
suddenly or within a few minutes in the immediate postoperative period
as a consequence of a myocardial infarction clearly detected on the
ECG. I always tried to be present at the autopsies. Careful
examination of the heart could not visualize the area of the
infarction, and Lawrence McCormack, head of the
cardiovascular section of the Department of Pathology,
used to tell me that it was very difficult to detect it by the common
histological techniques. Mac (as we called McCormack)
used to say "he died too suddenly." It was difficult to understand
the lack of correlation between the clinical and ECG signs and the
pathological findings.
The literature available, mainly the contributions of
Braunwald, Sonnenblick, and
collaborators24 25 26 27 28 and particularly an
experimental study by Cox and collaborators,29
convinced me that if good, oxygenated blood could be
supplied in the early hours of a myocardial infarction (and certainly
CABG was able to do it), the muscle could recuperate. I shared these
thoughts with all the members of our team.
In those days, our work was limited because we had only 3 operating
rooms. As a consequence, our patients waited for 2 to 3 months to be
operated on. Those with threatening obstructions stayed across the
street at the Bolton Square Hotel. As soon as we had a cancellation in
our daily work, they were admitted immediately.
I used to arrive at the Cleveland Clinic at
I ran to B10, and we analyzed with Mason
the clinical picture and the cine angiogram he had performed. He agreed
with the diagnosis. This patient was in the middle of a large
anterolateral myocardial infarction. Even if he survived, he would lose
a significant portion of the left ventricle. Once again I summarized to
him the major experimental contributions that supported my intention to
perform an emergency CABG and that I did not consider my suggestion an
adventure. Finally, Mason acceded.
I rushed the patient to the operating room. He was anesthetized
immediately and, following our previous experience in emergency
operations, we connected him to the heart-lung machine within a few
minutes. When we opened the pericardium, the anterolateral wall of the
left ventricle did not contract properly, and it had a bluish color.
The operation went smoothly. As soon as we finished the proximal
anastomosis, red, oxygenated blood went to the anterior
descending coronary artery and its branches, the anterolateral
wall started to contract, and after
When I wrote the monograph in 1970, in the chapter dedicated to this
subject I predicted: "Personally, I do hope that in the future,
patients with acute myocardial infarction will be treated in the same
way as those patients with a `dead leg' from acute thrombosis or
embolization of the peripheral circulation are now treated.
Those patients are admitted under the direction of a combined surgical
and medical team. Emergency angiography is performed and surgical
intervention is routinely done, with total recovery in a significant
number of them. Further clinical experience will be necessary to
substantiate this point of view."20,p128 Today,
with the introduction of fibrinolytic agents in combination with CABG
or angioplasty in the acute or subacute phase of a myocardial
infarction, this has become a reality for some patients.
In 1971 we reported in the American Journal of
Cardiology23 the operation
performed in 18 impending infarctions and 11 acute infarctions. In one
of the conclusions, we said: "When operations are performed within 6
hours of an acute myocardial infarction most of the heart muscle can be
preserved." It still surprises me today—only 11 patients with AMI
were operated on. We concluded: "Cardiovascular
surgeons are at the threshold of a more aggressive surgical approach in
the treatment of patients with acute coronary insufficiency.
Further clinical experience will be necessary to substantiate the views
presented here."
By the end of 1968, the largest series in the world (171 patients) had
been accumulated. I summarized the advances in an article accepted for
publication in the Journal of Thoracic and
Cardiovascular Surgery in December
1968.30
In 1969 we gained more confidence as a consequence of promising results
on midterm survival compiled by Sheldon et
al.31 32 The excellent contributions by Johnson
et al33 34 35 36 in Milwaukee, showing that bypasses
could be placed in the distal segments of the coronary artery
distribution, widened the scope of indications for CABG surgery.
By December 1969, we had operated on 570 patients, and this surgical
experience was presented at the Sixth Annual Meeting of the
Society of Thoracic Surgeons in Atlanta.37 For
the first time, we reported that the coronary arteries, mainly
the anterior descending artery, could occasionally be found inside the
myocardial muscle. The proper technique to overcome the problem was
described. In the same presentation, we emphasized the need
to use magnifying lenses to perform good distal anastomoses in small
coronary arteries (we applied them even in arteries of 1-mm
diameter). The overall mortality rate, including all the combined
procedures, was 5.4%. It is interesting to note that 50% of the
patients received single or double mammary artery implants. It was hard
for us to stop using Vineberg's technique because of our previous
clinical experience with it. Careful reading of the
cineangiogram helped us to combine the direct and indirect
approaches. By June 1970, 1086 bypasses had been performed, with an
overall mortality rate of 4.2%.
I read our next presentation at the Fifth Annual Meeting of
the American Association for Thoracic Surgery in Washington, DC, in
April 1970.38 It concerned the application of the
coronary bypass technique to the left coronary artery
and its divisions. We insisted on the use of magnifying lenses and the
"nontouch technique," ie, no dissection of the coronary
arteries was needed to perform the distal anastomosis: the pericardium
was cut on top by a No. 15 bistoury blade before the artery was opened.
As a consequence, the stitches (we were using interrupted sutures)
incorporated the epicardium and some of the subepicardial fat, a very
important detail that surprised the hundreds of visitors at the
Cleveland Clinic.
The use of cephalic or basilic arm veins as an alternative when the
saphenous vein was not available was also discussed. There was a steady
decrease in the number of combined single and double internal mammary
implantations as a direct consequence of the growth of multiple bypass
surgery. By August 1970, 196 patients had undergone double, triple, and
quadruple grafts, with a 4.1% hospital mortality. Eleven
cardiovascular centers contributed to the discussion,
and it was very gratifying to see the growth of CABG surgery.
In the same year, as a consequence of the superb work of George Green
in New York City,39 I started using the direct
mammary-coronary anastomosis. I talked to Green on several
occasions, and he told me that I would need at least 100 hours in the
laboratory to learn how to use the microscope (that is the way he did
the operation). I thought that this approach would never popularize
mammary-coronary bypass, and I decided to dissect the left
mammary artery and connect it to the anterior descending artery with
the routine interrupted suture technique, with only the help of the
lenses that we used in our daily work (Figure 8
My book Surgical Treatment of Coronary
Arteriosclerosis,20
highlighted by Effler's introduction, appeared the same year. I
analyzed all the experience gained at the Cleveland Clinic.
Chapter 2, which dealt with the analysis of the
coronary anatomy and its correlation with cine
coronary angiography in its different projections, was very
helpful, as testified to by the comments of the innumerable letters I
received.
The Sixth World Congress of Cardiology was held at the
Royal Festival Hall and Queen Elizabeth Hall in London in 1970. I was
invited to participate in a symposium dedicated to coronary
artery surgery together with Ray Heimbecker, Arthur Vineberg, and
Charles Friedberg. The organizing committee gave us one of the smallest
rooms. The cardiac adrenergic mechanism was to be discussed at the same
time in the main auditorium. From the very beginning of the Congress, I
felt the tremendous interest our session had aroused among the
participants. When I arrived an hour before the meeting to organize all
my slides, the room was already packed with hundreds of doctors, taking
all the seats, some sitting in the central aisle on the floor, and
others standing against the lateral walls. When we were on the podium,
ready to start, the doors were closed. As the first speaker,
Heimbecker, started his presentation, we could clearly hear
the loud voices of the doctors who were complaining because they had
been unable to enter the auditorium. The lateral doors finally crushed
due to the pressure from outside and innumerable physicians jumped into
the room. Somebody managed to protect the fragile body of Paul Dudley
White, who was standing right in front of us. It was impossible to go
on with the session. After talking with us, the secretary of the
congress addressed the audience and promised to repeat the symposium at
6 PM. We knew in advance that it would be impossible,
because a discussion cannot be repeated and, besides, Friedberg was
traveling back to America that same evening. However, the secretary's
words calmed the audience down, and the round table recommenced.
Heimbecker presented his work on resection of AMI, and Vineberg
summarized his experience. Finally, Friedberg and I discussed CABG
surgery. He was an outstanding speaker who knew how to sprinkle his
statements with good humor. He started by saying: "These cardiac
surgeons are unique. When the heart has a hole they close it, when the
heart doesn't have a hole they open one." We all laughed at his
comments, but when I presented the number of procedures
performed at the Cleveland Clinic and the perioperative
mortality rate, Charlie voiced some doubts about "such a low
mortality," which was difficult for him to accept. I flared up and
invited anybody who so desired to go to the Cleveland Clinic to check
our files. Some physicians did visit us on their way back to their
native countries and were able to confirm the honest work performed at
our institution.
I believe the Sixth World Congress had a big impact and opened the
doors for the worldwide use of CABG. Thousands of doctors from all over
the world were exposed to a critical analysis that showed the
benefit of this new approach among patients with severe
coronary arteriosclerosis.
That week, Donald Ross invited me to perform some operations at the
National Heart Hospital in London. I agreed, and the first
coronary artery bypasses in England were performed with his
help. Most of the outstanding cardiovascular surgeons
from Europe watched the surgery from behind us, almost on top of our
shoulders, and participated in informal discussions between operations,
most of them held in a pub opposite the hospital, where we exchanged
knowledge and friendship.
In 1970, I decided to return to my home country. It was a difficult
decision. I gave serious thought to this matter and finally considered
that my work and my duties were needed in Latin America. One day in
October, late in the afternoon, I wrote my letter of resignation to
Effler. I closed the envelope with tears in my eyes and left it on his
desk. I wrote:
"... as you know, there is no real cardiovascular
surgery in Buenos Aires...
"Destiny has put on my shoulders once more a difficult task. I am
going to dedicate the last one third of my life to build a thoracic and
cardiovascular center in Buenos Aires. At this
particular time, the circumstances indicate that I am the only one with
the possibility of doing it. The department will be dedicated, beside
the medical care, to postgraduate education with residents and fellows,
postgraduate courses in Buenos Aires and the major cities inside the
country, and clinical research. As you can see, we will follow
Cleveland Clinic principles. ...
"Believe me, I would be the happiest fellow in the world if I could
see in the coming years a new generation of Argentinians working in
different centers all over the country able to solve the problems of
the communities with high-quality medical knowledge and skill.
"I know all the difficulties involved because I had practiced before
in Argentina. At age 47, the logical and realistic resolution would be
to remain at the Cleveland Clinic. I know I am taking the difficult
road. You might remember Don Quixote was Spanish. If I do not accept
the position as Head of that department in Buenos Aires, I will be
living the rest of my life thinking of myself as a good solid s. of a
b. My conscience would constantly be telling me, `You chose the easy
way.'"
Twenty-seven years later, I believe my decision was correct: more than
350 fellows have graduated from our Foundation in
cardiology and cardiovascular surgery.
Today they are spread all over Latin America.
My big problem was Mason. It was impossible for him to accept that I
would break our common work and brotherhood. Repeatedly he tried to
convince me of my "mistake." The last 3 months were dreadful. Even
though I may look like a strong and commanding surgeon, deep in my soul
I am an extremely sensitive fellow. Everywhere I went in the clinic,
staff members of different departments, nurses, technicians, everybody,
interrupted my work and asked me to stay. Finally I decided to escape.
I told everybody I was leaving at the end of June or the beginning of
July. However, I accepted an invitation to lecture in Boston in the
middle of June, and from there my wife and I left for Argentina. Only
my secretary, Candice, a lovely young lady, knew my secret, and she was
brave enough to keep it. I wrote letters to Effler and Sones. Effler
accepted my decision, which "avoided a painful goodbye or
farewell." Mason, once again, thought I was crazy.
Our work on CABG continued in Buenos Aires, where, first of all, we
organized a classification of ischemic
cardiomyopathy to analyze all the data
related to coronary arteriosclerosis with
accuracy and the proper clinical angiographic correlation comparing
medical and surgical treatment and drawing logical conclusions for
proper indications. It was very valuable among patients with unstable
angina. The first randomized study on this important group of patients
reported significant benefit in patients at high risk when CABG was
indicated.40 41
We continued our experimental work on AMI in monkeys from northern
Argentina that confirmed that within the first 6 hours, the majority of
the heart muscle could recuperate if the coronary flow were
reestablished.42 As a consequence, cine
coronary angiography was performed in patients with AMI and
subacute myocardial infarction, and significant experience was
gathered (583 patients up to 1983). The angiographic characteristics of
340 patients with angina after AMI were carefully analyzed for
the first time, and 6 different categories were established,
facilitating the surgical indications.43 One
hundred seventy-four patients were operated on (44.7% within 10 days),
with 7 deaths (4.1%).
We have always believed that angina is a late and luxurious
manifestation of coronary artery disease. The natural history
shows that the incidence of prodromata among patients with a first
myocardial infarction varies between 15% and 65% (with pain, only
between 27% and 45%).44 45 46 47 48 49 50 51 52 53 Moreover, half of
all deaths due to coronary arteriosclerosis
are sudden,54 55 and
Since 1972, all the patients who required visualization of a vascular
territory (neck vessels, abdominal or thoracic aorta,
peripheral circulation) were studied in our department by
cine angiography.78 79 As a consequence, we
decided to perform concomitant coronary angiograms even when
angina was not present. In patients without angina, we found that
28.3% had 1-vessel disease, 14.1% had 2-vessel disease, 25.8% had
3-vessel disease, and 6% had left main trunk obstruction. We should
add to this group of patients with silent ischemia those with
associated valvular disease, those with a positive exercise
test (with or without concomitant radionuclide imaging), those with
abnormal ambulatory ECG (Holter), those with abnormal ECGs on routine
examination (particularly those with evidence of a previous silent
myocardial infarction), and even those with a definite family history
or the presence of other risk factors, mainly abnormal lipid levels,
hypertension, and diabetes.
The first asymptomatic patient I operated on, in 1968, was
a young fellow (48 years of age) with an unfortunate family history (3
of his brothers died of coronary atherosclerotic disease). He
came for consultation fearfully. The cine coronary angiography
demonstrated severe 3-vessel disease. Although he was totally
asymptomatic, CABG was indicated.
We followed this policy when we established the Institute of
Cardiology and Cardiovascular Surgery
(ICYCC) of our Foundation. From June 1992 to December 1997, 210
asymptomatic patients were operated on, with 3 hospital
deaths. I would like to emphasize that the final decision with regard
to the treatment of asymptomatic patients should be made
responsibly, starting with a thorough clinical record and
continuing with noninvasive methods, from a simple ergometric test to
the more complex radionuclide imaging, stress
echocardiography, and, of course, cine
coronary angiography.
The Debate
At the beginning, mainly during the first decade, it was extremely
difficult to convince our medical colleagues of the value of CABG. Even
though we demonstrated that building those new channels established a
pathway similar to the native coronary artery—blood traveled
from the proximal portion of the ascending aorta to the native
coronary artery distribution—many of them denied its value.
Probably the failures of previous attempts at myocardial
revascularization, originating with
Jonnesco's80 81 ideas in 1920, judged only on a
clinical basis, contributed to the widespread skepticism. On the other
hand, although cine coronary angiogram had started in 1958, not
many centers had the facilities to reproduce the cine angiograms
performed at the Cleveland Clinic; more importantly, they did not know
how to interpret or read them.
Undoubtedly the work of Sones and collaborators in combination with the
correlation between the clinical and ECG findings established by
Proudfit et al82 constituted a major breakthrough
in the knowledge of coronary
arteriosclerosis. It gave birth to a new language
that demanded years of learning for most cardiologists. That was my
impression after participating in innumerable national and
international meetings. One example will be enough. In 1969, I was
invited to conduct a workshop at the National Heart, Lung, and Blood
Institute in Bethesda, Md, mainly to review controversial clinical
patients. The problem started the moment we had to read the cine
angiogram on the Tage-Arno viewer: I had to stop, rewind, and
replay the film many times for them to understand. I decided to
interrupt the projection to explain in detail, on a blackboard, the
anatomy of the coronary artery tree with the
nomenclature of the different branches and its relation with the
myocardium being perfused. Thereafter, the interchange of
knowledge became much easier.
The opinions were highly divided. Retrospective and prospective matched
studies and comparison with groups included in life tables were the
methods used to compare the long-term effect of CABG. I still remember
the controversies with George Burch, Charles Friedberg, William Licoff,
Henry Russek, Henry McIntosh, and many others. Even though we were
sometimes on opposite sides, we never got involved in personal issues.
On the contrary, the more we debated, the greater was the level of
mutual respect and deep friendship.
In March 1978, I had the privilege of delivering the Louis F. Bishop
Lecture at the Annual Meeting of the American College of
Cardiology.83 At that time, we
already had clear evidence that the new blood supply (1) improved
myocardial performance; (2) relieved angina pectoris; (3)
improved the quality of life; (4) prolonged life in properly selected
patients with left main coronary obstruction and double- and
triple-vessel disease, including patients with abnormal ventricles and
lower ejection fraction; (5) diminished the incidence of sudden deaths;
and (6) appeared to decrease the number of myocardial infarctions. The
rate of perioperative myocardial damage played a
significant role when comparisons were made.
The need for randomized trials was repeatedly emphasized. Consequently,
from 1977 to 1983, 4 of them appeared: the VA Cooperative Study in
1977,84 the National Cooperative Study on
Unstable Angina under the auspices of the NHLBI in
1978,85 86 the European Study in
1979,87 88 89 90 91 and the CASS Study in
1983.92 93 I analyzed them carefully in
previous publications.94 95 Although nobody can
deny that they contributed to clarification of some issues, I think
they presented significant pitfalls that masked the final
conclusions. The main one was that patients were always considered to
belong to the therapeutic group to which they were initially assigned
(intention-to-treat principle), regardless of the therapy received
subsequently. The CASS Study crossover rates at 5 years were 10%,
21%, and 38% for single-, double-, and triple-vessel disease,
respectively. The operative mortality in patients who were assigned to
medical therapy but later underwent surgery was 2% (50% were patients
with triple-vessel disease). Therefore, we have to agree that the
medically treated group was highly benefited by the intention-to-treat
policy. In my opinion, crossover should be considered failure of
therapy.
A critical analysis of randomized trials has been done by
Feinstein.96 In this era, in which a physician
has to become a mathematician to understand most of the contributions
(knowing about risk reduction and odds reduction is not enough), it
would be wise to read his comments.
Since Andreas Gruentzig performed the first coronary
angioplasty in 1977, thousands of patients have been benefited by this
procedure. As a result, at present, 3 different treatments are
advised: medical, CABG, or percutaneous transluminal
coronary angioplasty (PTCA). Our responsibility has increased.
PTCA is indicated in most patients with single-vessel disease. The
discussion is still open for patients with multivessel disease. Each
patient must be analyzed conscientiously, avoiding personal
inclinations and desires. I have the impression that there is an
overutilization of PTCA either with or without stent. Randomized trials
comparing PTCA and CABG have not been very successful in this regard. I
have done a careful and detailed analysis of the 5 largest
studies.95 Once again, they include in the PTCA
group a low-risk population of 3-vessel disease.
As an example, in the BARI trial, 90% of the exclusions were done by
the angioplasty operator (in 49.8%, CABG was indicated). "Indeed,
60% of clinically eligible patients were judged unsuitable for PTCA
but were suitable for CABG. Clearly, choosing patients with multivessel
involvement based on their suitability for PTCA selects patients with
less advanced coronary atherosclerosis. ...
Approximately 33% of patients with multivessel disease were considered
potential candidates for either PTCA or
CABG."97
It is surprising to find out that Detre et al,98
in a recent survey of the centers that participated in the BARI trial
and 75 other institutions, concluded that nearly 12% of the patients
who required revascularization would be eligible
for the BARI trial.
It is worth mentioning what I pointed out many years
ago77,83: single-, double-, and triple-vessel
disease is not a valid classification to analyze patients with
coronary artery disease, and it is inadequate for comparison of
results of different treatments.
In 1983, Ringqvist99 corroborated that the number
of proximal obstructions and the state of the left ventricle played a
significant role. Survival at 6 years varied between 16% and 92%!
This proves once again that conclusions drawn from the analysis
of single-, double-, and triple-vessel disease classifications are of
limited value.
Recently, Jones et al, from Duke University,100
classified 9263 patients (CABG, 3890; PTCA, 2924; and medical
treatment, 2449) into 9 categories by the presence of 75% and 95%
obstructions and 75% and 95% proximal left anterior descending
obstructions. The analysis clearly demonstrated that CABG
improved survival in relation to the number, severity, and location of
the obstruction.
Final Comments
In 1972, I wrote: "I do not have any doubt that the long
follow-up will prove that prolongation of the cardiac patient's life,
improvement of his health, and a return to productive living are
now realistic results of surgical
procedures."101 Twenty-six years later,
hundreds of publications confirm these early predictions. Nevertheless,
from the very beginning I stressed that CABG is only a palliative
treatment.102
Campeau,103 104
Bourassa,105 and Grondin106
demonstrated the progression of the disease at the coronary
level and the deterioration of the veins and their relationship to the
cholesterol level, namely lipoproteins.
Loop's contribution107 108 showed the advantage
of the internal mammary artery graft. Arterial
revascularization with 1 or 2 mammary
arteries, plus the gastroepiploic, inferior
epigastric, and radial arteries, became our grafts of choice mainly in
young patients. However, the future will depend on the preservation of
the native coronary artery tree. Our efforts should be
concentrated on secondary prevention. There is enough information
showing that this attitude is mandatory at this time: it not only
ameliorates progression but also may contribute to regression of the
disease. Each one of us, clinician, surgeon, or interventional
cardiologist, has the obligation of laying the greatest emphasis on
prevention. It is disappointing to corroborate that only 15% to 25%
of the patients with CABG or PTCA undergo an intensive risk-factor
management program in the United States,109 and
the EUROASPIRE survey conducted in 9 countries by the European Society
of Cardiology in 3569 patients 6 months after CABG,
PTCA, AMI, or acute ischemic episode showed that 19% were
smoking, 53% had moderate or elevated blood pressure, 44% had
elevated blood levels of cholesterol, and 25% had a
prevalence of obesity.110
Epilogue
At the Cleveland Clinic, there was a similar bench. It was big enough
to allow an entire medical team to join their individual efforts and
ameliorate the devastating effect of coronary
arteriosclerosis, Mason Sones being the
indisputable leader. I have always thanked God for having given me the
opportunity to share my duties with him. William Proudfit and his
collaborators also worked on the same bench. His analysis of
hundreds of cine angiograms together with the correlation with the
clinical history provided us with enough evidence to choose and improve
the indications. Donald B. Effler, head of the Department of Thoracic
and Cardiovascular Surgery, was also part of the same
team. His guidance, advice, and tolerance deserve my gratitude. The
bench was properly located at the Cleveland Clinic. There, an
atmosphere of brotherhood, academic freedom, respect for our patients,
and responsibility allowed us to grow steadily.
I must apologize for often writing in first person, for I have always
believed in team work. "We" is more important than "I." In
medicine, the advances are always the result of many efforts
accumulated over the years.
Selected Abbreviations and Acronyms
Footnotes
Reprint requests to Favaloro Foundation, Ave Belgrano 1746, 1093 Buenos Aires, Argentina.
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© 1998 American Heart Association, Inc.
From Bench to Bedside
Landmarks in the Development of Coronary Artery Bypass Surgery
Key Words: bypass • coronary disease • myocardial infarction • ischemia • catheterization
), and (2) in 2 patients from Canada
operated on with the Vineberg technique (left internal mammary artery
implantation), Sones had shown that collateral circulation arising from
that systemic artery was sufficient to diminish the myocardial
perfusion deficit in the territory perfused by the anterior descending
branch of the left coronary artery.
View larger version (136K):
[in a new window]
Figure 1. 1962. Top, Significant obstruction on left main
trunk (arrow). Bottom, Patch graft repair.
View larger version (70K):
[in a new window]
Figure 2. 1966. Top, Total occlusion of left
coronary artery. Middle, Right internal mammary artery implant.
Bottom, Left internal mammary artery implant. 
). 
20 minutes, the
heart muscle of the left ventricle functioned under severe chronic
anoxia and could not tolerate the lack of oxygenated blood
even though it lasted only a short period of time. ). A few days later he took a 16-mm
movie of the preoperative and postoperative studies to a meeting in
West Germany.
View larger version (135K):
[in a new window]
Figure 3. 1967. Top, Right coronary artery totally
occluded. Bottom, Reconstruction by saphenous vein graft interposed
technique. ).
View larger version (207K):
[in a new window]
Figure 4. 1967. Reconstruction of right coronary
artery with coronary artery bypass technique. 2 cm above the natural ostium led me to believe that
the graft would remain patent because it would follow the natural
coronary flow pattern. Mason restrained my premature optimism.
He would say: "Let's see if they plug in 3 months. We must select
the patients carefully and wait several months after the operation
until we have the cineangiogram." ). Left main
artery disease finally had been defeated.
View larger version (83K):
[in a new window]
Figure 5. 1968. A, Severe obstruction of left main
coronary artery. B, Single CABG to anterior descending branch
of left coronary artery perfused entire left coronary
artery. ). It is worth mentioning that I had
previously done a double reconstruction with the interposed technique
in March 1968.20 54
View larger version (148K):
[in a new window]
Figure 6. 1968. A, Severe obstruction at beginning of right
coronary artery. B, Severe obstruction of proximal segment of
anterior descending branch of left coronary artery. C, CABG to
right coronary artery. D, CABG to anterior descending branch of
left coronary artery. 7 AM. One
day, one of the residents told me that a patient in whom a previous
cine coronary angiogram showed a subtotal occlusion in the very
proximal segment of a large anterior descending artery was in trouble
at the hotel. We quickly went to see him and found that at 6
AM, he had developed severe chest pain that had lasted for
30 minutes. He was sweating, with the typical dusky color in his
extremities due to poor peripheral circulation; he was
dyspneic (the lungs were full of rales) and hypotensive. It was very
clear that he had suffered an AMI. The ECG confirmed an anterolateral
myocardial injury. 25 minutes of support with
partial extracorporeal circulation, the patient was off bypass. The
blood pressure improved and remained within normal limits. The
following day he was extubated and had an uneventful recuperation. He
was restudied within 10 days, and the cine left ventriculogram
demonstrated a small, localized area of deterioration on the
anterolateral wall (Figure 7). The left
ventricular end-diastolic pressure was normal.
This was indeed a gratifying experience.
View larger version (117K):
[in a new window]
Figure 7. 1968. Left ventriculogram after a single CABG to
anterior descending branch of left coronary artery applied in a
patient with acute myocardial infarction. Top, Diastole.
Bottom, Systole. ). After I left the Cleveland Clinic in
1971, Loop et al emphasized and standardized this method and
demonstrated the excellent results on long-term follow-up.
View larger version (148K):
[in a new window]
Figure 8. 1970. Left internal mammary artery graft to
anterior descending branch of left coronary artery without
microscope. 50% occur in patients
with no previous antecedent ischemic heart
disease.56 We know that myocardial
ischemia is frequently painless57 58 59 60 and
that it is an important determinant of mortality and
morbidity61 62 63 64 65 66 67 68 69 70 71 72 always related to the extent of
coronary artery disease.73 74 75 76 We decided
to perform cine coronary angiography in totally
asymptomatic patients. The most important group consisted
of patients with a single previous myocardial infarction. Up to 1983,
we found in a group of 344 patients that in anterolateral myocardial
infarction, 43% had multiple-vessel disease and 3% had left main
trunk obstruction.77 In posterolateral myocardial
infarction, 55% had multiple-vessel disease and 4% left main trunk
obstruction. It was logical to think that if a patient had only 1
myocardial infarction, most should have only 1 major obstruction, but
this occurs in only 51.8% and 40.8% of anterolateral and posterior
infarctions, respectively.
I still keep the bench on which my father, a cabinet-maker, taught
me to carve simple pieces of wood into unique, beautiful furniture. In
his workshop, shoulder to shoulder, I also learned from him the
principle that would guide me for the rest of my life: only by
persistent efforts, with passion and honesty, will our dreams come
true.
AMI
=
acute myocardial infarction
BARI
=
Bypass Angioplasty Revascularization
Investigation
CABG
=
coronary artery bypass graft
CASS
=
Coronary Artery Surgery Study
EUROASPIRE
=
European Action on Secondary Prevention Through Intervention to Reduce Events
NHLBI
=
National Heart, Lung, and Blood Institute
PTCA
=
percutaneous transluminal coronary
angioplasty
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