this presentation traces the early reports of angina, when it was thought to be a disease of the breast, goes on to describe the stepping stones leading to myocardial revascularisation.

1. A Brief History of
Coronary Artery Bypass
Grafting - The Holy
Grail of Cardiac Surgery

2. around 1500 BC, describes chest pain radiating down the
arm and warns that the symptom often betokens imminent
death.5 A thousand years later a famous Indian surgeon,
Sushruta, discussed a symptom which he called ‘hritshoola’,
pain above the heart aggravated by exertion and eased by
rest.
The doctor who called it angina pectoris (literally, ‘choking
of the breast’) was William Heberden. In 1772 he described
‘a disorder of the breast marked with strong and peculiar
symptoms’, which he had observed in over a hundred
patients:They who are afflicted with it, are seized while they
are walking (more especially if it be up hill, and soon after
eating) with a painful and most disagreeable sensation in
the breast, which seems as if it would extinguish life, if it
were to increase or to continue; but the moment they stand
still, all this uneasiness vanishes.

3. relation of angina to the coronaries was in fact a
contribution of Edward Jenner, who associated
these symptoms, and later on even predicted post
mortem findings, with “ossification” of the
coronaries.

4. initial surgeries
sympathectomy for pain relief
thyroidectomy

5. Claude Beck,
Cleveland
• one of the first to attempt
myocardial revascularisation.
• the first to use a defibrillator
(1947).
• Beck’s triad - tamponade

6. Dr. Beck was working on Pick’s disease - constrictive
pericarditis in dogs and the effect of compression on
the heart, when his associate, Dr. Moritz pointed out
the vascularity in the cardio-pericardial adhesions.
Moritz, Hudson and Orgain,' not only demonstrated
anatomically the presence of blood vessels in
cardiac adhesions by the injection of carbon particles
into the coronary arteries but also Doctor Moritz
believed that under certain conditions these blood
vessels might function and become an important
source of blood supply to the heart.
This became the basis of Beck’s attempts at
myocardial revascularisation : COLLATERALS

8. 13/2/1935
after a series of
experiments on dogs, the
first operation on a human
was performed on a coal
miner from Ohio, 48yr old
Joseph Krchmar.

13. later, Beck tried the 2 stage surgery was also a method to
increase collateral circulation. in this procedure, a short vein
graft, harvested mostly from the forearm, was anastomosed
to the coronary sinus.
first stage : partial ligation of the coronary sinus, methods to
increase pericardial adhesions - asbestos.
second stage : few weeks later: arterialisation using vein
graft : descending aorta to the coronary sinus.
this procedure increased inter-coronary anastomoses
He performed 124 of these operations from 1948 to 1954.
From 1954 on, given the technical difficulties of the Beck II
operation, he returned to the simpler Beck I and treated
more than 1000 patients with coronary heart disease.

16. Arthur
Vineberg,
Montreal
the first intervention
documented to increase
myocardial perfusion.
the first to recognise the
internal mammary artery as
a handy conduit.

17. The Vineberg operation was based on the then
prevalent concept of myocardial sinusoids -
endothelium-lined lakes and spaces with a
discontinuous basement membrane, like a blind end
of an arteriole.
these sinusoids were thought to drain directly into the
cardiac chambers, separate from the Thebesian Veins

18. the Vineberg surgery involved direct implantation of
the LIMA in the myocardium , with the hope of
reperfusing the myocardium through these sinusoids,
which provided the run-off

20. after about 4 months of
surgery, the dog’s heart
was harvested, solution
was injected in the
mammary and this
solution came out
through a cannula in the
LCA. this was thought of
as a proof of the
myocardial sinusoid
concept.
bear in mind, we still
didn’t have coronary
angiograms.

21. Vineberg’s 1st human subject died 62 hrs after
surgery, however at autopsy the graft was
functional.
however Vineberg’s second attempt, six months
later, was far more positive. His patient was a fifty-
four-year-old oil worker who was living on a liquid
diet because solid food resulted in intolerable
angina. By the time he left hospital in December
he was eating normally, completely free of pain
and back at work. Three years later his recovery
was startling: previously able to walk only a few
yards, he could now hike ten miles over rough
terrain.

22. however, surgeons were skeptical of the surgery.
Meanwhile, another method to treat angina
surgically gained popularity briefly : it was a
simplistic procedure which involved tying off
both internal mammary arteries! there seemed to
be no plausible reason for it to work, and it was
put to the test.
this was perhaps the first double blind trial in
surgery. (university of Washington)

23. It involved seventeen patients with angina, randomly
divided into two groups. The first group were given the
genuine operation: under local anaesthetic, a surgeon
made a skin incision and then tied the mammary arteries.
The second went through a sham operation, a procedure
in which the surgeon merely opened an incision and then
closed it again. Crucially, not even the patient’s own
doctors knew whether they had received a genuine or a
fake operation. The researchers were stunned to discover
that there was no difference between the two groups. Of
the nine patients who underwent the sham operation, five
noted significant improvement, and two who had been
severely disabled before their ‘surgery’ were once again
able to engage in strenuous exercise. The artery-tying
operation was obviously worthless. Rarely has there been
a more striking demonstration of the placebo effect.

24. Donald Effler (Cleveland Clinic) put it, ‘The patient
with coronary artery disease gets initial relief of
angina from almost anything: this includes walking
into the reception room of the surgeon’s office.’
It was a dramatic indication that clinicians needed
to find physical proof of improvement rather than
rely on the patient’s impressions.
And then came Mason Sones, Effler’s colleague
from The Cleveland Clinic.

25. 30/10/1958

27. the Vineberg operation
was put to the test
After studying X-rays of the grafts, Sones found
that Vineberg’s claims were entirely accurate: the
mammary artery implanted into the heart had
formed new branches which communicated with
the coronaries, providing a new source of blood for
the myocardium.
Vineberg’s operation was widely adopted after this
emphatic vindication.

28. but, there was a catch
later on , pathologists revealed that the concept of
myocardial sinusoids proposed by Wearns was
indeed flawed, there were no blind ended
arterioles…
hence the question, what provided the run-off for
the LIMA graft? and how did this surgery really
work/how did the graft not get thrombosed?

29. The "lakes of sinusoidal space" demonstrated by
the digestion casts were in fact casts of the
interstitial space! The earlier investigators using
digestion cast technique could not tell whether such
space was lined by endothelium or not, because the
endothelial cells were digested away by the strong
alkaline solution used to prepare the cast.
the implanted IMA does not occlude even though it
has virtually no run-off when measured with flow
probes, because of the squeezing action of the
muscle. This causes to-and-fro motion of the blood
within the IMA, resulting in defibrination, thus
preventing thrombosis.

30. Ischemic myocardium is now known to liberate
factors for the development of collaterals [28].
When this is supplemented by blood-borne
angiogenic factors, the process is amplified [29].
Recently, it has been shown that an IMA implant
will indeed collateralize to a nearby left anterior
descending artery when stimulated by platelet-
derived growth factor. These anastomoses are
able to maintain myocardial vascularity when the
left anterior descending artery is subsequently
ligated.
Hence the delay in alleviating symptoms…

31. The Vineberg operation continued to be
performed till the mid ‘70s; one patient operated
in 1969, had 21 symptom free years!

32. –But till now, these sacred pipes of life, were untouched.
Soon , this was to change, as the era of direct myocardial
resvascularisation would be ushered in.
“The tragedies of life are largely arterial. —
Sir William Osler, Diseases of the
Circulatory System (1908).”

33. Walton Lillehei had shown that this was possible in
experiments on cadavers in 1956, slitting open the
affected vessels, removing the plaque and then stitching
them back together.
Later that year Charles Bailey successfully used this
technique – known as coronary endarterectomy – on a
patient, inserting a fine cannula through an incision in
the artery to remove a 7-millimetre plug of fatty deposit.
Unlike the Vineberg operation, which took months to
establish a new circulation, endarterectomy restored
blood flow immediately.

34. But scraping the delicate vessels with a metal
instrument was likely to damage them, and a less
traumatic method of endarterectomy was also
developed, using a high-pressure jet of carbon
dioxide gas to blast obstructions out of the diseased
arteries. Both approaches suffered from the same
shortcoming: the coronary arteries tended to become
constricted where they had been incised and sutured,
once again reducing the diameter of the vessel.
Åke Senning found a way round this difficulty, using
a strip of artery taken from elsewhere in the body to
cover the incision - endarterectomy and patch
grafting

35. René Favaloro

36. In 1962 a young Argentinian called René Favaloro joined Effler’s department at the Cleveland Clinic.
Born in 1923 in La Plata in eastern Argentina, Favaloro studied medicine at the city’s university, intending
to become a surgeon, but his early career was blighted by the oppressive political climate of the time. In
1949 he was offered a prestigious training post, on condition that he first signed a piece of paper affirming
the policies of President Juan Perón’s regime.This he refused to do, choosing instead to live in self-
imposed exile in Jacinto Aráuz, a small and impoverished town more than 400 miles away.
He was eventually joined there by his brother, and from nothing the two men built up a small but well-
equipped hospital with its own laboratory and operating theatre. Favaloro performed thousands of
operations, accumulating experience which ranged from childbirth to major abdominal surgery. Despite his
isolation he kept abreast of the rapid development of cardiac surgery, and after twelve years decided to
move to America to be trained in the new speciality.
When Favaloro arrived in Cleveland he spoke English poorly and knew nobody. Although he was thirty-
nine and vastly experienced he was also unlicensed to work as a surgeon, so was obliged to study for the
relevant qualifications. But his boss Donald Effler was willing to overlook this detail, allowing him to assist
in the operating theatre.
In his spare time Favaloro spent hours watching Mason Sones’s large archive of X-ray films, learning how
to interpret them and trying to identify the recurring features of coronary disease. Favaloro was fascinated
by the success of the Cleveland Clinic’s vascular surgeons, who had been doing innovative work in the
reconstruction of diseased blood vessels.They used sections of vein taken from the patient’s own leg to
replace the arteries supplying the kidneys, or to provide a detour around an obstructed vessel in the limbs.

37. This was not quite a new idea, since a similar scheme had been
proposed by Alexis Carrel more than half a century earlier. In a
famous paper on experimental heart surgery published in 1910,
Carrel wrote: ‘In certain cases of angina pectoris, when the mouth
of the coronary arteries is calcified, it would be useful to establish
a complementary circulation for the useful part of the arteries.’
This was prophetic in the extreme, especially if one considers that
it was written at a time when many experts believed angina to be a
stomach disorder. Carrel even managed to attach a portion of
preserved artery between the descending aorta and the left
coronary artery of a dog, but the animal died: he had no heart-
lung machine, and the operation interrupted the circulation for
too long for the heart to recover.
in 1953,Vladimir Demikhov, a maverick researcher at the Institute
of Surgery in Moscow , succeeded in performing bypass
operations on a series of dogs, some of which survived for over
two years.

38. In the 1960s no fewer than five surgeons
independently devised a procedure
recognisable as a CABG and applied it
to a human patient; and the man
generally acknowledged as its inventor,
René Favaloro, was the last to do so.
Robert Goetz, a little-known surgeon in
New York, who on 2 May 1960 attached a
patient’s internal mammary artery to his
right coronary artery. four surgeons all
taking a role as the two arteries were
stitched together in a breathtaking
seventeen seconds, however, the
anastomosis was accidentally ripped
apart in the confusion, and it took a
further ninety seconds to repair the
damage.The patient survived for a year.
All trace of the operation mysteriously
disappeared from hospital records, and
he was never allowed to repeat it.

39. In November 1964 Edward Garrett, a junior colleague
of Michael DeBakey’s in Houston, was operating on a
forty-two-year-old truck driver whose coronary
arteries were 85 per cent obstructed by fatty deposits.
His attempts to scrape them out failed when the
vessels disintegrated, and in desperation Garrett
decided to employ a technique he had only practised
in animals. An incision was hurriedly made in the
patient’s leg, saphenous vein was removed, then used
to bypass the coronary blockage. Although this was a
notable surgical achievement, Garrett seems to have
overlooked its significance. He did not make any
public report of the case until seven years later, when
the patient was still alive and without symptoms.

40. Vasilii Ivanovich Kolesov
On 25 February 1964,V.I. Kolesov successfully performed the first
anastomosis between the left ITA and the left circumflex artery.
Kolesov developed an interest in the subject, when he
became aware of Demikhov’s work he resolved to turn
it into a procedure which could be used on humans.
The patient was followed up for three years and did
well, and Kolesov continued to perform the procedure
on a regular basis – the only surgeon in the world to
do so for the next three years. But it was not until 1967,
when one of his articles was translated into English
and published that. experts outside Russia knew
anything of his consistent success.

42. Favaloro’s first attempt, on a
middle-aged woman, used a
slightly different technique
from those tried before. Rather
than attach a new blood supply
to the coronaries he simply
used a short length of
saphenous vein to bypass the
obstruction, cutting out the
blocked section of artery and
then using the graft to bridge
the gap.Though he
subsequently used the
technique on more than fifty
patients, it was fiddly in the
extreme, and he eventually
abandoned it.

43. on 19 October 1967 a vein
from Pottenger’s upper
thigh was extracted and
used as a bypass graft from
his aorta to the right
coronary artery, restoring
blood flow to his starved
myocardium. Given the state
of his arteries before that
first operation, it is nothing
less than astonishing that he
lived for another twenty-six
years.

44. Mason Sones, urged him to withhold judgment
until he knew whether the grafts were still
functioning months later.The outcomes were
excellent, however, and within two years they were
able to present the long-term results of their first
100 operations, of more than 300 already
performed.
the mortality rate for his new procedure and
revealed that he had already performed it on over
1,000 patients, of whom fewer than 5 per cent had
died.

45. In June 1971, Favaloro decided to leave the
Cleveland Clinic and return to Argentina, where he
created a medical center, a teaching unit, a research
department, and, finally, an Institute of Cardiology
and Cardiovascular Surgery.

47. Drs. Favaloro (at right) and Effler in the operating room. Dr.
Effler donated this photograph to Dr. Favaloro after the
latter submitted his resignation from Cleveland Clinic in
1971. He added a dedication to the photo, which read, “We
have taught each other many things.”

48. The Favaloro retractor was
designed to lift the left side of
the sternum, giving good
exposure of the left mammary
artery

49. Dr. Favaloro was welcomed warmly in Argentina as a famous
surgeon and soon became a local hero. He initially worked as Chief
of Cardiac Surgery at Clinica Güemes, a general surgical clinic.
René and his brother had together created the Favaloro Foundation
in 1975, thereby achieving the 3 goals listed in the resignation letter
to Dr. Effler: those of providing medical care, generating scientific
knowledge, and educating health professionals.
In 1980, Favaloro and his team carried out the 1st heart
transplantation in Argentina, and in the same year he also
succeeded in establishing a medical center and a teaching unit,
both located in the Hospital Güemes.
Institute of Cardiology and Cardiovascular Surgery on a site
adjacent to the research building: the culmination of his dream. 6
The building was inaugurated on 2 June 1992 with the motto:
“Advanced technology at the service of medical humanism,”

50. By 1999, no fewer than 400 cardiologists and cardiovascular surgeons
had been trained at the Favaloro Foundation and were scattered all
over Latin America and beyond, witnesses to the enormous bravery
and generosity of this 1 man
In order to maintain itself, a great institution like the Favaloro
Foundation required a budget equal in greatness. In the midst of a
good economy this was of little concern; however, in the late 1990s,
when Argentina's economic standing turned sour, the magnitude of the
problem became all too clear. At the age of 77, René was faced with
tremendous losses due to defaults in payments from other hospitals
and the government, 6 estimated at around $18 million. In the last years
of his life, at a time when he ought to have begun reaping the benefits
of decades of relentless work, he was instead compelled to vie for
additional financial help. He tried desperately to rectify the situation
and salvage the Foundation, which had become his very soul. A week
before his death, he wrote a letter to the President of Argentina,
pleading for the payment of government debts to his institute, 6 but it
was to no avail.

51. -These are the poignant words on Rene Favaloro’s epitaph,
which he himself wrote before he shot himself, in The
Heart.
“Do not talk of weakness or courage; the
surgeon lives with Death, his inseparable
companion – I walk hand in hand with
him.”