The Heart Healers (22 page)
Authors: James Forrester
I still recall the first time I saw a before-and-after angiography on a CAD patient who had vein bypass surgery in 1968. Compared to our usual tunneling procedure, which required both faith and a vivid imagination, the Favaloro procedure showed blood charging down a previously obstructed vessel, followed by an obvious transient “blush” in the heart muscle. It seemed miraculous: seeing blood flow restored to a floundering heart muscle was like seeing a gasping fish thrown back into water. The images were so convincing it seemed almost absurd to question whether the procedure worked. The only question we had was if the benefit justified the risk. Although he was not the first to perform coronary artery bypass surgery, by the end of 1968, Favaloro had the largest series of bypass surgeries in the world, 171 cases, and by June 1970, just three years after his first surgery, he had an astonishing 1,086 cases. After his disastrous beginning, Favaloro’s surgical mortality rate with his bypass procedure was only 4%, incredibly low for a new procedure. Today he is universally recognized as the surgeon who fathered coronary artery bypass surgery (soon called CABG, and pronounced cabbage), which clearly relieves angina. Since CABG carried an immediate 4% operative mortality, we knew that many more years of follow-up would be required to demonstrate that CABG reduced long-term mortality rate, but no one could reasonably doubt that the inscription of this final exclamation point was only a matter of time.
Favaloro’s publication was like Cortez’s legendary proclamation to “burn the boats” after landing on the coast of the Yucatán peninsula. There would be no turning back. Although most of us devoutly believed in the efficacy of the bypass surgery, some annoying naysayers persisted. New Orleans’s renowned old guard, crotchety cardiologist Dr. George Burch, claimed CABG was new wine poured into an old bottle, snorting, “If you were offered an anti-angina pill that cost $10,000 and had a 5% chance of killing you, would you take it? Of course not. Well, that’s bypass surgery.” But the younger generation of cardiologists ignored the adamant claims of Burch and his calcified old guard. As physicist Max Planck observed, “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.”
In New York cardiac surgeon Dr. George Green, building on a report by Albert Einstein’s cardiac surgeon Dr. Robert Goetz, championed the idea that if a vein extracted from the leg could bypass the coronary obstruction, an artery might be even better. Once again, prior failure informed future success. Green freed up the internal mammary artery (IMA), the same vessel Vineberg had used to tunnel into the heart. But when Green got the IMA free from the chest wall, he connected its free end directly to the side of the coronary artery, again just beyond the obstruction. He was performing bypass surgery with an artery instead of a vein.
Green’s reasoning proved to be resoundingly correct in a way we never imagined. Follow-up studies of Favaloro’s vein bypass surgery showed that at one year after bypass surgery, about one in five veins were occluded. In contrast, 95% of IMAs were wide open. Clearly the thicker walled artery, nature’s vessel for transporting blood under high pressure, was superior to a thin walled vein. In the decade following Favaloro’s landmark saphenous vein bypass surgery, cardiac surgeons began using the IMA as their first choice vessel. They did not abandon the leg vein; rather when more than one vessel was needed, they used the leg vein on the less important coronary artery. The left anterior descending coronary artery typically has first dibs on the IMA.
It took another decade, however, before a completely unanticipated, massive limitation of vein bypass surgery became apparent. When angiograms were repeated at ten years after surgery, half of the vein grafts were closed, clogged with an accelerated form of atherosclerosis. We had logically assumed that transplanted veins would behave just like arteries. But in the short space of a decade, the veins fell victim to a virulent form of atherosclerosis far worse than that in arteries. We had been too quick to believe in our magical solution. Once again our humanity was showing. We were desperate for a solution to this new problem.
In the mid-1990s as a Principal Investigator on a National Institutes of Health–funded multicenter trial of the long-term effects of lowering cholesterol levels in patients after CABG, my colleagues and I found that aggressive lowering of LDL (low-density lipoprotein) cholesterol (“bad cholesterol”) levels with a statin drug reduced atherosclerosis in bypass grafts, with a 30% reduction in the need for new revascularization procedures over seven and a half years of follow-up. Our research proved that long-term cholesterol lowering therapy is mandatory following bypass surgery. Bypass surgery had given us a powerful answer to the problem of chest pain caused by coronary obstructions. On the other hand, we had to admit that surgery alone had little effect on the progression of disease.
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FOUR YEARS AFTER
his landmark surgery in Cleveland, Favaloro again heard the call of his lifetime dream, his commitment to his people. He would again return to Argentina, possessed as always by his vision of creating Argentina’s own Cleveland Clinic. But this time he returned not as an unknown hat-in-hand exile from the Pampas begging for support, but as an Italian Caesar, marching home as a conquering hero. René Favaloro had become, and remains today, Argentina’s most famous citizen. Sones begged him to stay, but to no avail. When word began to circulate that he was leaving the Clinic, offers of jobs poured in. From Miami he was offered a starting annual income of $2 million, an unheard of doctor’s salary in the 1970s. But Favaloro was unmoved. His philosophy of life is captured and preserved in a lecture he delivered to students in Israel at that time. “I would like to ask especially of the younger people to understand that material things are temporary, only ideals last forever … the battle cry should be education and scientific development for a society in which social justice is the priority.”
On his return to Argentina, Favaloro used his status as national hero to raise both private and government support for the Favaloro Foundation, which in 1975 became one of the largest dedicated cardiology programs in the American hemisphere. The foundation’s mission statement describes its founder’s core philosophy: “advanced technology at the service of medical humanism.” The Favaloro Foundation, like the Cleveland Clinic, offered the full spectrum of treatment, education, and research. Although he was the world’s most famous surgeon, throughout his career Favaloro referred to himself as a “country doctor.” True to his days in the Pampas, he made certain that those who could not pay were not turned away. Despite the cost of bypass surgery, Favaloro operated on indigents on a daily basis. When I met him on my trips to lecture in South America, he struck me as a person of such genuine integrity and goodness that he might have arrived directly from having delivered the benediction from his window in St. Peter’s Square
Ten years after Favaloro left Cleveland to build his foundation into one of South America’s leading medical institutions, chain-smoking Mason Sones fell ill with metastatic lung cancer. Four months before Sones’s death, Favaloro and his wife made a special trip back to say good-bye to Mason, whom Favaloro loved like a brother. “Finally we embraced and said goodbye for the last time in this world … I will always thank God for giving me the opportunity to share with Mason many years of common work, understanding and deep friendship,” Favaloro recalled.
Of Sones and Favaloro, we can say each needed the other, and together their work constitutes one of the greatest milestones in our story.
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A YEAR BEFORE
his death, René Favaloro spoke about his pride in the Favaloro Foundation’s accomplishments to author Dr. Allen Weisse. “We have over two hundred full-time members on our staff.… We have published over one hundred peer-reviewed papers in international journals. Our people are [collaborating with investigators in Germany, Italy, France, Poland, Canada, Belgium, and the United States]. Latin America was once far behind the rest of the world in cardiovascular research. I don’t think that anyone could say that this is true today.”
But within a year Argentina’s economy collapsed amid projections that it might default on its public debt and that the currency would be devalued. In December 1999 Fernando de la Rúa was elected president, campaigning on the promise to save the Argentine economy and end the corrupt ten-year rule of President Carlos Menem. Six months later, La Rúa announced massive spending cuts. Two days later 20,000 protesters took to the streets.
The Favaloro Foundation, dependent on government support, fell progressively into debt, reaching $75 million (USD). As the foundation appeared to teeter on bankruptcy, federal subsidies cut off completely. Favaloro desperately sought relief. Every door was closed. In a note to President de la Rúa, he expressed his dismay at “being a beggar in his own country.” As his foundation’s default and collapse became imminent he wrote seven letters, recalling his dream and recounting his foundation’s accomplishments. In one, he said: “We insisted on the admittance of a number of beds for the poor. This meant that hundreds of patients were treated completely free of charge … At this moment and at my age, it is incredibly difficult to break off with the ethical principles that I got from my parents, my teachers and my professors. I can’t change; I would rather disappear.” Letters written, the beloved idealist who had performed bypass surgery on over 13,000 patients closed his bathroom door forever, and in a final symbolic act, shot himself through the heart. It was July 29, 2000. Remarkably, the foundation weathered the storm and remains a beacon of hope today. I can only fathom the tragic, operatic denouement of René Favaloro’s illustrious career in the context of his mission, as the final poignant expression of his soaring idealism. I must believe this, and so I do. I am not alone.
The United States had provided the fertile ground for invention, and a country doctor from Argentina possessed by a vision had found the solution. His nephew Roberto Favaloro, director of the Favaloro Foundation, summed up his uncle’s life: “Despite his greatness he had humility … He was a great man who was able to be charming and be a normal person. In the end he always carried on being a country doctor in his way of life.” Favaloro was a man of a different generation, a different time, with values rooted in a bygone era that no longer exists, and perhaps never did. A decade after his death, in
The Argentina Independent
article “Shot Through the Heart: The Life and Death of René Favaloro,” reporter Hannah Vinter summarizes his vision by quoting from one of his speeches: “I have always believed that in the future, reality will be constructed on the foundations of ideals and utopias.” René Favaloro, the Don Quixote of the Pampas, lived and died that dream.
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THE EVOLUTION OF
CABG from the early days has been dramatic. Today we have surgical alternatives. The surgical incision may be made through the breastbone or the ribs. The latter, called minimally invasive surgery, is more technically challenging but often has more rapid postoperative recovery. A third alternative is beating heart surgery, which is even more technically challenging but eliminates the need for a heart-lung machine. Robotic surgery, in which devices are inserted through small incisions in the chest wall, is also being tested in some institutions.
During my years as chief of cardiology the cost of bypass surgery escalated. To counter rising costs, we initiated a sea change in the concept of postoperative care. Our emphasis went from gradual recovery to early ambulation. We were successful beyond our imagination. Not only did we reduce costs, but our patients’ recovery was less eventful. In the earlier years, patients were hospitalized for two to three weeks; today we discharge most patients in three to seven days. Our patients typically resume driving at two to three weeks, and return to work by one to two months.
The risks and benefits of bypass surgery are very well defined. The risk of serious complications during hospitalization is small: heart attack 1%, stroke 3%, and mortality 2%. CABG relieves angina chest pain in about 95% of patients, and postoperative survival is 90% five years after the procedure.
Don’t be afraid of new ideas. Be afraid of old ideas. They keep you where you are and stop you from growing and moving forward. Concentrate on where you want to go, not on what you fear.
—ANTHONY ROBBINS, AMERICAN MOTIVATIONAL SPEAKER
AS MASON SONES
and René Favaloro pursued surgical solutions to CAD, surgeons cast their eyes on heart failure (severe reduction in the heart’s pumping function). The two most common causes of heart failure in adults are diseases of the heart valves and scarring of the heart muscle after a heart attack.
Today it is hard to imagine the era before the spectacular developments in surgical treatment of heart failure. Cardiologists relied on digitalis, a foxglove-derivative handed down from the prior century, which sometimes provided a spectacular relief of symptoms. One of the toxic effects of digitalis is distortion of visual shape and color. Vincent Van Gogh’s obsession with yellow and his distortion of perspective has been alleged to be the result of digitalis intoxication. Even if the story is apocryphal, his paintings do capture how digitalis’s toxicity affects vision. In 1785, English physician William Withering first described giving foxglove to a forty-year-old lady, a “Mrs. H. of A. near N” who was “nearly in a state of suffocation, her pulse extremely weak and irregular, her breath very short and laborious, her countenance sunk, and her arms of a leaden color. She could not lie down in bed and had neither strength nor appetite, but was extremely thirsty. Her stomach, legs, and thighs were greatly swollen.” Within a week these signs disappeared. A century later the father of pharmacology, German chemist Oswald Schmiedeberg, isolated the first pure digitalis crystal from foxglove, launching the modern pharmaceutical industry. Despite its efficacy in relieving symptoms, however, digitalis had little effect on the progressive downhill course of the heart failure. Could surgeons offer a better solution?