by Rob Dunn
Favaloro did what he could and built the old house into a clinic. He figured out how to make operating rooms, a sort of lab, and even x-ray equipment. In his spare time, he helped care for his brother Juan Jose, who had lost his leg in a car accident. Two years later, his brother, also a doctor, was rehabilitated enough to join him in the clinic. Side by side, for twelve years, the two brothers worked with great success. They dramatically reduced the rate of infant mortality in the region. Meanwhile, Favaloro kept reading and learning about the rest of the world. The rest of the world was leaving Argentina behind in science, in medicine, in everything, especially surgery. Favaloro told his brother and his wife, over wine at the table in their village clinic, that what they were doing was medicine that was already accepted rather than the cutting-edge treatments yet to be discovered. Argentina deserved more! René Favaloro wanted his country to progress, but he could not lead his country out of its past while Perón was still in power. Much as it pained him, he would need to leave, to go somewhere. One of Favaloro’s mentors, Professor José María Mainetti at the Universidad Nacional de La Plata, advised him to look to the Cleveland Clinic in Cleveland, Ohio, in the United States, where, he said, they were making progress. Mainetti told Favaloro that he would write his friend George Crile Jr. at the Cleveland Clinic to put in a good word.
As much as Favaloro was a successful surgeon and a hopeful idealist, he was not a practical man. Impractical men who succeed are called visionaries. Impractical men who fail are called failures. The jury was still out on Favaloro, and so, without any assurance from Cleveland that he would have a job there or even that anyone had received Mainetti’s letter, he decided, at the age of forty, to uproot himself and his wife and go. He would go to the place where the greatest surgeries were happening. He would go there to do work and maybe someday bring his successes back to Argentina once the Peróns and their legacy were gone. He would do all of this, and so, in 1962, he bought tickets for himself and his wife.
When the two arrived in Cleveland, Ohio, Favaloro dropped his wife and luggage at the hotel and showed up at the office of the medical center’s chief of surgery, George Crile. Favaloro was used to leading. He’d earned it. He’d built and run a successful clinic. But in Cleveland, he had to explain that he had just gotten off the plane from Argentina and that he would like a job. This would be presumptuous anywhere, but Favaloro was asking for a surgery job. He could start the next day, he said. What, he asked the chief, should he do first? Crile resisted laughing. He had never gotten a letter from Favaloro’s mentor; this was the first he had heard of Favaloro. He politely sent Favaloro down the hall the way you might invite someone to take a long walk off a short pier.
Favaloro was sent to another door, and then another, until he finally made his way to the door of a man who could make sense of what was going on: Don Effler, a close colleague and frequent adversary of Sones. Effler was an accomplished heart surgeon and was fully aware of the layers of ridiculousness in what Favaloro was trying to do. Effler took the time to tell Favaloro what Crile could not be bothered to say, that one needed a U.S. medical degree to do surgery in the U.S. Favaloro appeared not to have known this (or anything else about the place he had landed). He went back to his hotel, where he joined his wife, defeated. What had he done?
The next day he went back to the clinic. He told Effler that he would “immediately start studying for the exam and… work for free” on whatever Effler would have him do. Amazingly, Effler consented to this plan and got Favaloro started doing the most menial of tasks. Favaloro worked hard, and from those tasks, he would rise, rapidly, earning his U.S. medical certification by night. Before anyone knew it, he was, once again, a surgeon, a surgeon with grand ideas, and the only man who was able to work with both Effler and Sones. With Sones, Favaloro studied coronary angiograms, thousands of them, hour after hour. With Effler, Favaloro dreamed up ways to mend the problems that he and Sones had seen.
When Favaloro was getting started in Cleveland, there were still no direct treatments for most heart diseases, including the most common set of problems, those observed by Sones, those due to the blockage of the coronary arteries. In the early 1900s, the main symptom of a temporarily blocked coronary artery, angina, had been treated by covering up the pain.2 The nerves that conveyed the pain from the heart were removed in many thousands of patients in a treatment akin to pulling out wires in your car radio to hide the sounds of the static. Alternatively, the thyroid was destroyed, which slowed metabolism and blood flow and reduced the chance that the heart would clog, at least in theory.3 Still other treatments called for irradiating the heart or injecting alcohol into the vertebral column. These methods were crude and yet still in practice in the 1960s even as bold surgeons had begun to contemplate heart transplants.
But some surgeons had the idea to graft or redirect wider, less constricted arteries from elsewhere in the body onto or into the heart, to replace or add to the function of the afflicted coronary artery. It was an idea akin to the heart transplant but with key advantages. This kind of surgery did not require a donor, so surgeons did not have to find a way to get past the response of the immune system to foreign tissue.
Transplants of arteries had been discussed for decades. In 1910, Alexis Carrel wrote that “an arterial wall can be patched with a piece of artery, or vein… these operations present very little danger, and their results, observed many months after the graft, were excellent.”4 Some had followed up, hesitantly, on Carrel’s work. Several surgeons had tried to redirect arteries and veins so that they might spill blood into the area between the pericardium and the heart, thinking that it might be absorbed. In 1946, Dr. Arthur Vineberg at McGill University had another idea. He cut the mammary artery and redirected it to the heart, where he sewed it into the ventricle wall. One group reported on angiographies of eleven hundred cases in which patients had been treated with “the Vineberg method.” In almost half the cases, blood flow to the heart muscle from the mammary artery appeared to have been achieved.5 This was success, and yet, because the cases in which the procedure did not work were often fatalities, modest success.
Favaloro thought he could improve on these approaches by following up on Carrel’s suggestion to transplant an artery or a vein rather than just redirect one. In 1954, Gordon Murray at the University of Toronto reported on successful transplants of three different arteries (subclavian, carotid, and mammary) into the hearts of dogs, with auspicious results.6 Other dog surgeries had followed in other labs with similar positive results. After looking at the details of these studies and of the many angiograms Sones had done, Favaloro thought he was ready to try to transplant the saphenous vein (a large vein from the thigh) into a human heart.7
He knew he could sew almost anything. This was not a skill possessed by all; it was what made him special, and he needed to take advantage of this gift. Favaloro would cut a section of saphenous vein from a patient’s thigh. He would then turn it into a bypass by sewing one end of it to the aorta and the other end to the coronary artery just beyond the area of the blockage. Other people had tried to do this, but they’d done it in emergencies rather than as part of a reliable solution to clogged coronary arteries. One attempt, in 1964, by three surgeons at Methodist Hospital in Texas was successful, but it was not reported until 1973.8 Favaloro would do it with his own artful simplicity and, because he was working with Sones, with Sones’s vision of a repeatable, common solution. If such a thing could be done, it would mean not only that this specific procedure—a bypass, as it would come to be called—was possible, but also that many other things were possible.
Favaloro talked to Sones about the procedure, and the two agreed that it should be done only on a patient whose right coronary artery was totally blocked in one section but open in others.9 One day Favaloro found himself with a patient that he could not fix using any standard approaches. The patient, a fifty-one-year-old woman, had a nearly completely blocked right coronary artery. If sewn back up after having been investi
gated, she would almost certainly die. The vessel would become entirely blocked, her heart would stop, and the blood would fail to reach her brain. Favaloro thought he could do something using his magic hands, and so he hesitantly began.
Favaloro cut open the woman’s chest. He did not yet have a heart-lung bypass machine (although one was present at the hospital) and so he would have to work quickly. He cut a section of saphenous vein out of the woman’s groin and then cut out the woman’s right coronary artery. The latter was every bit as clogged as he had imagined it would be, a thin tube filled with plaque. Then he began to sew, as only he could, like a seamstress of flesh: carefully, delicately, his small fingers pushing the tissue in and out, holding it just right. A poor stitch, and blood would pour out into the body. A missed stitch, and nothing would work. Favaloro did not breathe while he sewed; he held his breath so that his hands were in his control—he owned their motions. Then it was done. He exhaled. The blood was allowed to flow back into the heart. The woman was sewed shut and brought into a room, where a catheter was run up through one of her vessels and into her heart. Dye was released into her heart, and an x-ray was taken. What Favaloro hoped to see was a black space indicating that blood was moving from the heart through the new artery. None of his colleagues believed it would be there. The object of the quest was remote and improbable. There had been no way to know if it would work. If it didn’t, this woman was about to die.
Then Favaloro and his colleagues turned on the x-ray and saw the blood moving through the heart and flowing through the artery. They saw it! Mason Sones, the de facto adviser to Favaloro, ran out into the hall and announced, “We have made medical history.” He had yelled it before; he would yell it again. In that moment, for Favaloro, everything became worth it: the exile to the pampas, the trip to Cleveland, the time spent working as a helper for free, the long hours, all of it.
There would be improvements.10 Favaloro soon realized he did not have to cut out the old artery from the heart. He could just leave it in place and run a new artery alongside it, as a bypass. This is what would give the surgery its modern name, coronary artery bypass graft, or CABG. He also tried the left coronary artery. He then grew even bolder. He performed the bypass during and even after a heart attack (an acute myocardial infarction). In December of 1968, just one year after the first surgery, Favaloro was able to publish a report of 171 patients on whom he had conducted bypass surgeries. Half of those patients had received double bypasses with mammary artery implants. Just two years later, 1,086 bypasses had been performed by Favaloro and others he inspired. To see this growth in the rate of bypasses, one might suspect Favaloro of too much ambition, but the mortality rate of his patients was just 4.2 percent.
Favaloro had achieved success most can only dream of. Favaloro, the son of an Argentinean seamstress, was even invited to come on talk shows along with Sones and Effler.11 He was saving people nearly every day (or at least every day he wasn’t on a talk show). This man from a poor neighborhood in La Plata was mending real, beating hearts, and yet this was not enough for him; he was dissatisfied. Four years after the first coronary artery bypass, Favaloro decided to move back to Argentina. He had, in a few years, brought greatness to the United States, and now he wanted to return to Argentina to bring greatness back to his own country. He would go on to start a Cleveland Clinic for Argentina.
Even as Favaloro was traveling to Argentina, another story was unfolding, one that would ultimately change the place of Favaloro’s work in the story of the heart. More than that, it would plant the seed that would lead to the decline of heart surgery itself.
Adolph Bachman came into the Medical Policlinic Hospital in Zurich, Switzerland. He was near death, though he did not know it initially. The thirty-seven-year-old came in complaining of chest pain, angina. The doctors performed an angiogram on him to see his heart. A three-centimeter stretch of one of Bachman’s coronary arteries was nearly entirely blocked. Most of the artery looked fine; the angiogram showed a black river of blood where one should be, but then that river narrowed so much that whatever stream was present was invisible and obscured by collapsing riverbanks of plaque. Had he understood the angiogram, Bachman might have been worried, but the doctors did not look upset, so he would be strong. In fact, they smiled over him, like a flock of vultures.
Initially, the doctors told Bachman he would require a bypass, Favaloro’s new surgery—but at the last minute, an alternative possibility emerged. One of those doctors standing over Bachman was Andreas Gruentzig, who had invented something he really wanted to try out. A typical angiogram catheter has a narrow tip at its end through which dye is released. But Gruentzig had produced something unique after spending the last ten years experimenting and tinkering. At the end of his catheter, he had fastened a sort of sturdy balloon.
Gruentzig had tinkered anywhere he could, but the fortuitous last tweaks occurred in his apartment, where he and his assistant, Maria Schlumpf, did the work on his kitchen table. A picture still records the event. Scattered around them were the bits and pieces necessary for the endeavor—plastic, Krazy Glue, a bottle of wine, and balloons. A balloon on the end of a catheter seems like an invention one might see at a high-school science fair. It took thousands of tries to get it right, but the fundamental technology was ridiculously simple: a balloon would be inserted into the artery and inflated, the pressure of the inflation would make the narrow artery wider, the balloon would be removed, and more blood would flow through the vessel as a consequence. But it was one thing to test such a device in a kitchen and quite another to expand it inside the most intimate stretch of a man. Bachman would be that man; at least, he would be if Gruentzig could persuade Bachman to let him try the new invention.
Although Gruentzig had spent long hours working on his device and perfecting it, he had tested it during bypass surgeries only in arteries that did not need strong blood flow and would be either bypassed or clipped out. Bachman was the perfect candidate for a real attempt. Gruentzig explained the device to Bachman; he then told him something that would be said repeatedly by cardiologists to their patients: This approach will be much easier and will require less recovery time. We don’t even have to open up your chest.
Bachman was convinced. He signed the necessary forms, and, almost before Bachman lifted his pen off the paper, Gruentzig had inserted a catheter into his right coronary artery. He then pushed it up until it arrived in the heart. Once there, Gruentzig inflated the balloon, and as he did, he held his breath. Everyone could see the balloon begin to push the artery outward. That the result would be a success was not obvious. The artery could rupture. Or it might snap back in place once the balloon was removed, just as narrow as it had been.
Miraculously, the procedure worked. The balloon expanded the artery, and blood flowed freely again. It was as simple as unclogging a drain. It was just the tools that took ingenuity. The patent for this procedure would quickly make Gruentzig millions of dollars and would lead to hundreds of other devices; once Gruentzig had shown that the arteries could be successfully manipulated, a small army of tricks and tools for the ends of catheters emerged. Among the most significant of these new tools was the stent, which was to be used following angioplasty. It was a small metal-mesh tube that could be left behind and used to hold the artery open more predictably once the balloon was extracted. It was a sort of permanent angioplasty. From Gruentzig’s lead, an entirely new type of cardiologist has emerged, a specialist who never cuts open a heart but instead, like a spelunker, explores its caves.
In addition to its apparent success, angioplasty, which later included the placing of stents, had other things going for it. It made sense. The balloons and stents are biophysically intuitive medicine. You take a pipe that is clogged and push the clog out of the way. You take a pipe that won’t stay open and you reinforce it. These were the sorts of solutions plumbers might use, and so it was easy for the procedures to catch on. They spread rapidly, eventually at the expense of bypasses. Coronary artery bypas
s surgery had become ever more common in the seventies. Then, on its heels, angioplasty and then stents became ever more common. All of this happened with very little consideration of what an optimal solution would look like. Initially, it happened without a single study comparing the fate of patients who underwent bypass surgery with that of patients who had stent treatment. Such comparisons would come, but only much later.
With time, Gruentzig’s method has been elaborated upon. There are now many kinds of stents, some of which, in addition to holding open the artery, can release (elute, the doctors say) drugs. In other words, without ever opening up the chest, doctors can widen an artery, reinforce it, and implant a device that releases drugs directly where the artery seems most blocked.
While Gruentzig’s methods were proliferating, Favaloro was back in Argentina. He had decided to return just as his creativity as a researcher and doctor was at its maximum, at forty-seven years old. He could have stayed in the United States and found wealth and fame. It was a hard decision, but he had begun practicing medicine to help the people of Argentina, and he needed to return. He handed in his letter of resignation at the Cleveland Clinic and left a note on his boss’s desk: “As you know, there is no real cardiovascular surgery in Buenos Aires… Believe me, I would be the happiest fellow in the world if I could see in the coming years a new generation of Argentineans working in different centers all over the country able to solve the problems of the communities with high-quality medical knowledge and skill.”
Back in Argentina, Favaloro began to take the steps to establish a major clinic. In 1980, he created the Favaloro Foundation (which would later become Favaloro University). There, he taught more than four hundred residents from Argentina and elsewhere in Latin America. They were trained in heart surgeries, like Favaloro’s cardiac bypass, and in other techniques, including, eventually, angioplasty and stents, as well as in approaches for dealing with liver, kidney, and other organs’ problems. Again, Favaloro found success—greatness, even. This humble, ambitious man was sewing hearts back together all over Latin America, and he was inspiring others who were mending even more. And then tragedy struck.