Part XI – Dr. René Geronimo Favaloro & CABG – Standing on Tall Shoulders – The History of Cardiac Surgery by Thomas N Muziani PA-C, CP

“I am a slow walker…but I never walk back” – Abraham Lincoln

During the 1960’s, the United States was experiencing an explosive transformation. Post World War II had provided, for the very first time in history, a true middle class. The GI bill allowed returning soldiers to buy homes, cars and appliances on credit. Television became entertainment, information and our baby sitter. Dinner moved from the dining room table to in front of the TV. Viet Nam was etching its imprint into our collective psyche, in color every night. It forced Americans out of their complacent torpor.

For modern medicine anniversaries mean little. We do not celebrate the advent of vaccination (14 May 1796), ether anesthetic (16 October 1846) or the discovery of insulin (11 January 1922). I always found a little bit of irony in the fact that many people know the date when Princess Diana died, but hardly anyone knows that we just passed a milestone of 50 years of coronary artery bypass grafting (CABG).

On 9 May 1967 René Geronimo Favaloro performed his first CABG. By the mid 1970’s, Dr. Favaloro and his colleagues had performed over 1000 operations. When surgeons throughout the United States read or heard about the outstanding results of Favaloro and colleagues, they were quick to adopt the technique. This author is a very biased disciple of Dr. René Favaloro. He was a wonderful friend and a brilliant surgeon who endured a litany of unfair and unwarranted treatment that ended with his suicide in 2000. But he was not the first person to perform the operation. More importantly, he was very quick to modify his initial approach to CABG. Coronary artery bypass grafting used to be labeled “myocardial revascularization with saphenous vein graft and heart-lung machine”; way too long to write on the chalk board in the OR. Dr. Favaloro and many other surgeons subjected the operation to constant modification over the years. Like all significant medical interventions the CABG demanded constant refinement.

The concept for CABG had existed for decades. Sir Alexis Carrel, in 1910, published in Annals of Surgery and account of an operation that he performed on a dog: he used a segment of carotid artery to anastomose the descending aorta to the left coronary artery. Since some people measure innovation based on the “idea”, then Alexis Carrel would have no peer for CABG. However, Carrel reported only one, unsuccessful attempt. The dog developed ventricular fibrillation and died. Carrel determined the procedure would only be successful if it could be accomplished in under three minutes, a time limitation beyond anyone’s skill.

Placing great importance on a Nobel Laureate such as Dr. Carrel and his thoughts about the operation and time limitations, surgeons attempted other approaches to mitigate coronary artery disease over the next fifty years. Some reduced cardiac workload with thyroidectomy or sympathectomy. Others tried to promote increased blood supply to the myocardium by dusting the heart with asbestos or talcum powder to induce vascular adhesions. There were surgeons that sutured omentum onto the heart, ligating or implanting the internal thoracic artery, or ligating the coronary sinus. CABG, however, was not forgotten completely. During the 1940’s and 1950’s, Toronto surgeon Gordon Murray conducted numerous animal experiments. He excised coronary segments, inserted interposition grafts, and placed bypass grafts from various arteries. The outcomes for most of these procedures were ventricular fibrillation and graft thrombosis.

Vladimir Demikhov, a prominent Moscow surgeon, experimented with coronary bypass grafts, successfully anastomosing the internal thoracic artery in dogs in July 1953. In 1964, Michael DeBakey performed a cursory inquiry of fourteen laboratories throughout the world conducting experiments on coronary bypass grafting. With the average success rate being reported of just 50 percent, he did not believe any of the emerging techniques warranted investigation for human use.

In 1960, German émigré Robert Goetz at Van Etten Hospital in the Bronx (New York City), anastomosed the right internal thoracic artery onto the right coronary artery. In 1962, David Sabiston utilized a saphenous vein graft to create a bypass from the ascending aorta to the right coronary artery. In Leningrad, Vasilii Kolesov performed a successful internal thoracic artery bypass graft in February 1964; he completed over thirty operations by 1969. In November 1964 Edward Garrett and DeBakey placed a saphenous graft between the aorta and left coronary artery. Donald Kahn and William Longmire each performed two procedures in 1966.

Almost all of these surgeons became discouraged with their outcomes. Goetz’s colleagues prevented him from performing a second bypass procedure. Sabiston failed to find value in the operation after his patient died from a post-operative stroke. Garrett’s patient experienced a perioperative infarction. One of Longmire’s patients died during surgery and the other patient’s graft failed. Only Kolesov pursued an extended case study. But then again, historically, Russia has always played by a different set of rules and allowed its surgeons a great swath of freedom without a governor.

So, if there was a prize for the surgeon who operated on a human, Goetz would win. He was also first to publish, though he buried his achievement in a two-sentence addendum to a 1961 article regarding his  animal experiments. Kolesov published his results–in Russian–in 1965. Longmire published in 1966, but in a French journal.

Then we have Dr. René Geronimo Favaloro. A repressive political regime of the Peronist Party in Argentina forced Dr. Favaloro into self-imposed exile during the 1950’s. His dream was to become a cardiothoracic surgeon. With nothing more than a letter of introduction, he managed to work his way into the United States and present himself at the Cleveland Clinic.

There he met Dr. Donald B. Effler, the Chief of Cardiovascular Surgery. Donald Effler, realizing the innate talent Favaloro possessed kept him very busy with a full schedule of surgeries. At the end of the day, when most people were going home, Favaloro migrated down to the lab to pour over hours and hours of coronary angiograms and studying coronary arteries. While working his way up from resident to staff surgeon, he gained voluminous empirical knowledge on coronary techniques; from internal thoracic artery implants and endarterectomy to patch grafts.

In 1966 his attention became focused on CABG. Favaloro later explained that he learned about saphenous vein grafts from vascular surgeons who used them to repair renal artery stenosis. He was also very well aware of Kolesov’s work. Kolesov had submitted a manuscript to the Journal of Thoracic and Cardiovascular Surgery in November 1966. The journal’s editor, Brian Blades, sent it to Donald Effler, Favaloro’s mentor, for comment.

Dr. Favaloro performed a saphenous vein interposition graft on 9 May 1967. He completed another thirteen before performing his first aorta-to-coronary graft on 19 October. When he published the results from his first fifteen patients in April 1968, he mentioned another 40 in an addendum. His results were soon corroborated by two other surgeons, Dudley Johnson in Milwaukee and George Green in New York. Their collective case series buttressed Dr. Favaloro’s claim regarding the value of CABG. American surgeons embraced the operation enthusiastically. They performed over 100,000 procedures annually by 1977, and over 600,000 in 1997. CABG also provided a crucial stepping stone for coronary angioplasty.

Technical innovations improved clinical outcomes and reduced complication rates. Beating heart CABG and minimally invasive procedures became popular in the 1990’s. New diagnostic technologies (e.g., intravascular ultrasound and fractional flow reserve) allow for more careful patient selection. Patients now have a plethora of options, including hybrid procedures with a combination of angioplasty, stents, and bypass grafts. Biomedical engineers are working on developing synthetic vascular grafts and numerous implanting procedures. Coronary artery bypass grafting has prolonged numerous lives and increased the quality of life for millions. However, nothing we have accomplished so far has actually mitigated the progression of coronary disease. Denton Cooley once made the comment: “The only way to guarantee you will never contract coronary disease…would be to have your grandfather castrated…hopefully, long before you were born”.