Rene G. Favaloro

Acute coronary insufficiency (impending myocardial infarction and myocardial infarction): Surgical treatment by the saphenous vein graft technique

Abstract The development of direct coronary artery surgery by the saphenous vein graft technique for the first time provides a method that immediately increases the supply of oxygen to the myocardium. As a result, the area of myocardial infarction no longer depends only upon oxygen consumption. Emergency surgery was performed on 29 patients from April 1968 to May 1971; 18 operations were performed upon patients with impending myocardial infarction and 11 upon patients with acute myocardial infarction. Nineteen patients underwent coronary cineangiography before the acute episode; 9 were studied during an acute episode. Patients with impending myocardial infarction were operated upon within 24 hours of the acute episode. Nine patients with acute infarction were operated upon within 4 to 5 hours, 1 within 8 hours, and 1 within 10 hours. Three patients died after the operation; 2 in the group with impending myocardial infarction and 1 in the group with acute infarction. Twelve patients underwent repeat cineangiographic evaluation. All grafts but 1 were open. In the group with impending myocardial infarction, postoperative left ventriculography showed good function of the left ventricle. In the group with acute myocardial infarction, 4 patients showed good function of the left ventricle. In 1 the ventricle was unchanged, and in 2 impaired contraction was demonstrated. Although the present clinical experience is limited, certain conclusions can be made: (1) Emergency coronary cineangiography can be performed with minimal risk. (2) Patients with impending myocardial infarction can undergo operation with a low mortality rate and minimal complications. These patients are ideal candidates. The operation can prevent myocardial infarction. (3) When operations are performed within 6 hours of an acute myocardial infarction, most of the heart muscle can be preserved. (4) In patients with acute myocardial infarction and cardiogenic shock, assisted mechanical circulation is mandatory as the first step. The increase of well oxygenated blood supply should improve myocardial perfusion.

Critical Analysis of Coronary Artery Bypass Graft Surgery: A 30-Year Journey

As there is even yet a lingering doubt in many minds with regard to some trees, whether they bear flowers and seed or not, it is the more important to show not only that they do, but for what purpose. Henry David Thoreau: Faith in a Seed The year 1997 marked three decades of coronary artery

Landmarks in the Development of Coronary Artery Bypass Surgery

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, Jose Maria 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 …

Heart Valve Replacement: Clinical Experience

HIS REPORT discusses our clinical experience in aortic and initral valve replacenient utilizing the Starr-Edwards prosT thesis. T h e basis for this report is a consecutive series of 224 operations performed in the period of September, 196 1, through February, 1964.t T h e reasons for the decision to utilize the Starr-Edwards prosthetic valve and to abandon the various types of valvuloplasty procedures have been detailed in previous coniniunications [ 10-1 51. Beginning in 1956, we tried a number of procedures designed to reestablish coinpetency of the aortic and the niitral valves, including corninissurotoiny, decortication, and a variety of plastic procedures designed to refurbish the valve cusps or leaflets. Many of these procedures warranted initial enthusiasm, but the late results were disappointing: Valves that were

Double Internal Mammary Artery-Myocardial Implantation Clinical Evaluation of Results in 150 Patients

A total of 248 double internal mammary artery-myocardial implantations have been performed at the Cleveland Clinic up to October 31, 1967. This report presents an analysis of the clinical experience with the first 150 patients. The majority of the patients were between 40 and 60 years of age. The overall hospital mortality was 9.3%. The lowest mortality rate (4.9%) was among patients between 51 and 60 years of age. The most common complication encountered in this series (22 patients) was atrial fibrillation. Acute myocardial infarction developed in 14 patients; all of them recovered with the usual medical treatment. All of the patients have been studied by Soness technique of selective coronary angiography and left ventriculography. We believe that this is mandatory in the selection of patients for coronary artery operations. The postoperative evaluation shows significant clinical improvement in the majority, 116 patients. Thirty-one have undergone postoperative angiographic studies. Of 61 opacified arteries, 58 remained patent, and 37 showed definite communication with coronary arteries. We believe our present operative technique allows us to increase myocardial perfusion in any region of the left ventricle.

Surgical treatment of coronary arteriosclerosis by the saphenous vein graft technique

Generally, editorials are written to present personal views on a specific subject. With few exceptions, they seldom add to scientific knowledge. Usually, the author is more preoccupied with flaunting his rhetoric and literary style than in concentrating on basic facts. One suspects that many editorials are written in a moment of “ideal inspiration,” perhaps on a weekend evening, sitting comfortably on a sofa, sipping a favorite cocktail, and looking out the window at a beautiful sunset. Medicine is less and less romantic and more and more mathematical. Critical analyses and hard data are required to substantiate any claims, medical or surgical. The surgical results of the “overworked” surgical team at the Cleveland Clinic are under continuous scrutiny and appraisal by a dedicated group of clinical cardiologists; significant conclusions have been reached in regard to the proper selection and evaluation of a surgical procedure.

Direct and Indirect Coronary Surgery

Early in 1962, the Cleveland Clinic team attempted to perform true endarterectomies. Nevertheless, the mortality rate was extremely high, due mainly to dissection of the distal portion of the coronary circulation or occlusion of important side branches, and the procedure was abandoned. The next method used was the pericardial patch-graft reconstruction. A longitudinal incision was made at the site of the obstruction precisely located by reviewing carefully the preoperative coronary cineangiography. A patch was sewn with fine 6-0 silk, generally with running sutures at both sides and interrupted sutures at the proximal and distal ends. There was low operative mortality

Reconstructive Coronary Artery Surgery: Postoperative Assessment

Results of 288 direct coronary artery reconstructive operations in 281 patients have been reported. Selected patients with segmental obstructive lesions in their coronary arteries can be helped with direct reconstructive surgery. Best results have been achieved in patients with isolated segmental obstructions in the predominant right coronary artery. With the saphenous vein graft technique, surgical mortality has been reduced to 5.1%, and angiographic evidence of improvement has been achieved in three of four of the survivors. The direct surgical reconstruction of segmental occlusive disease offers the advantage of immediate improvement of myocardial perfusion, attendant protection against myocardial infarction, and immediate improvement if not complete remission of symptoms of myocardial ischemia. Excellent long-term results have been obtained in many patients who underwent patch-graft reconstruction; early experience indicates that saphenous vein graft reconstruction can be accomplished for patients with a greater variety of obstructive lesions, with better reliability, and lower risk. Its ultimate role in the surgical treatment of coronary atherosclerosis, however, will require a longer period of observation.

Right artial approach for surgical correction of tetralogy of fallot

Abstract Total correction of tetralogy of Fallot was performed without a ventriculotomy in 39 patients aged 8 months to 39 years (mean age, 9.1 years) between May 1984 and July 1988. A teansatrial approach was used to resect the obstructed infundibulum and to dose the ventricular septal defect. In 14 patients, the pulmonary annulus was not enlarged (group 1). Twenty-five patients required a transannular patch (group 2), placed by extending the pulmonary artery incision 1 cm into the right ventricular infundibulum. Eleven patients had repair of pulmonary artery branch stenosis, and associated intracardiac anomalies were simultaneously corrected in 10 patients. After repair, the right ventricular to left ventricular systolic pressure ratios ranged from 0.36 to 0.59 (mean ratio, 0.45) in group 1 and 0.33 to 0.70 (mean ratio, 0.51) in group 2. There were no hospital or late deaths in group 1. Two patients in group 2 with a small left ventricle died shortly after operation. The 37 survivors were followed for 2 to 51 months. Postoperative catheterization in 7 patients detected no residual ventricular septal defects, mild pulmonary regurgitation in 2 patients (group 2), and right ventricular to left ventricular pressure ratios ranging from 0.25 to 0.42 (mean ratio, 0.34). Only 1 patient with a previous total repair by ventriculotomy is symptomatic and requires antiarrhythmic agents and diuretics. The other 36 patients are asymptomatic. In conclusion, tetralogy of Fallot can be safely repaired at any age without a ventriculotomy. The results indicate a minimal incidence of postoperative arrhythmias and pulmonary regurgitation, as well as improved right ventricular function.

A Revival of Paul Dudley White An Overview of Present Medical Practice and of Our Society

Paul D. White was born in Roxbury, Mass, on June 6, 1886. He graduated from Harvard Medical School in 1911 and became a House Officer at the Massachusetts General Hospital (MGH) the same year. An important landmark in his life was his trip to London, where he studied under Sir Thomas Lewis in 1913. He returned to the MGH in 1914. He became an instructor in medicine at Harvard Medical School in 1921. He was a member of the founding group of the American Heart Association and was its president from 1941 to 1943. He was also a founding member of the International Council of Cardiology in 1946 and was its president the same year. He was president of the International Society of Cardiology from 1954 to 1958, and in 1957 he founded the International Society of Cardiology Foundation. (Core biographical information comes from the excellent book Take Heart by Dr Oglesby Paul. He was a resident at Harvard Medical School, which included 2 years of study of heart disease under Paul D. White. I am grateful to my friend Dr Tom Ryan, who wisely gave it to me as a present for the purposes of this lecture.) Dr White wrote 12 books and ≈758 scientific articles. He won hundreds of well-deserved awards. He always kept an open mind for new developments. On his return from England in 1914, he brought with him the exciting new ECG developed by Einthoven in 1903. He was the first to use it in the United States for clinical research. I met him in London during the VIth World Congress of Cardiology. He was present during the discussion I held with Charles Friedberg on the early development of coronary artery bypass graft surgery. After the discussion, I had the chance to speak with him …