Earl C. Smith
Mount Sinai Hospital, Chicago, Illinois, United States (Spring 2013)
Dr. René Favaloro pioneered a new era in the management of coronary artery disease. Up to the 1960s the primary focus of cardiology was valvular heart disease. However with the introduction of penicillin the incidence of valvular heart disease was diminishing, and the cardiologists’ attention was turning to acute myocardial infarction and coronary artery disease. The diagnosis of these conditions was at times mystical, the only objective evidence of myocardial infarction being the EKG abnormalities. The diagnosis of angina was subjective, as was its management. Although cardiac catheterization was being performed for valvular and congenital heart diseases, there was a belief that visualization of coronary arteries should not be performed because it could lead to cardiac arrest.
In 1958 a serendipitous event in the cardiac catheterization laboratory at the Cleveland Clinic changed the diagnosis and management of coronary artery disease. Dr. Mason Sones, a pediatric interventional cardiologist, was evaluating the aortic valve on a patient with aortic stenosis and the tip of the catheter accidentally slipped into the right coronary artery at the time of the contrast injection. He recognized at once that the contrast had entered the coronary artery and stopped the injection. The patient had a cardiac standstill but quickly recovered. When Dr. Sones examined the images he realized that he had obtained a complete visualization of the right coronary artery. He also recognized the potential such a study would have for accurately diagnosing coronary artery disease and over the next several months perfected the technique to allow routine catheterization of the coronary arteries.
Around this time cardiovascular surgeons were trying to develop methods to re-vascularize the myocardium. One method was to dissect out the mammary artery and tunnel it into the myocardium in the hope that it would sprout new blood vessels to the muscle (Vineberg Procedure). Additionally, they also attempted to place patch grafts in areas of narrowing of the coronary artery. However follow up angiography after these procedures showed that these efforts were mostly unsuccessful in restoring blood flow to the cardiac muscle because the arterial implant or patch graft usually thrombosed.
In 1962 Dr. Favaloro joined the Department of Cardiac Surgery at the Cleveland Clinic, first as an observer, then as a fellow, and eventually as an attending. Dr. Favaloro was born on July 14, 1923, and raised in Argentina to a hardworking Sicilian immigrant family; his father was a carpenter and his mother a seamstress. René had an uncle who was the local physician, and at an early age he decided that he also wanted to become a physician. He attended medical school in his home town of La Plata, Argentina, and completed a surgical residency there. He remained on the staff of the hospital after finishing his residency and traveled weekly to Buenos Aries to learn how to do esophageal and lung resections. At La Plata he was able to assist with many thoracic surgery cases and had decided that his future was in academic surgery. In 1950 one of the requirements for his appointment at the university hospital was to sign a declaration supporting the “National Doctrine.” He did not believe physicians should sign such a political document and so resigned his position at the hospital and set up a medical clinic in the small rural town of Jacinto Aráuz, La Pampa, using his own resources. During this period he became convinced of the need for universal health care and spoke out in favor of social justice.
He discussed with his former mentor at La Plata his desire to travel to the United States to learn cardiovascular surgery, and his mentor arranged for him to go to the Cleveland Clinic in 1962. At that time the surgeons were doing mammary artery implants into the myocardium based on the findings of the coronary artery angiographs done by Dr. Sones. Dr. Favaloro became interested in the anatomy demonstrated in the angiographic studies and spent his evenings reviewing the coronary angiograms of the patients scheduled for operations. He recognized that there were two main patterns of abnormalities. Some patients had diffuse coronary artery disease with good collaterals; others had localized obstructions with usually good distal runoff. Because of the poor results with the mammary artery implants and patch grafts and the good results the vascular surgeons were having with saphenous vein grafts in renal and peripheral arteries, he wondered if this might be a suitable technique to use in those patients with localized coronary artery occlusions.
In May 1967 he performed the first saphenous vein bypass graft from the aorta to the distal right coronary artery, bypassing an obstruction in the artery. Dr. Sones studied the patient one week later and showed that the graft was patent. On a follow-up angiograph three months later the graft was still patent. Thus began the era of coronary bypass surgery. Over the next few years he perfected the technique for bypassing occlusions in the coronary arteries as well as for managing diffuse coronary artery disease. The cardiology program at the Cleveland Clinic became world renowned, and Dr. Favaloro received much deserved recognition for his work in coronary artery revascularization.
However he still maintained the strong sense of social justice that had caused him to refuse to sign the National Declaration, and he continued to believe that everyone in Argentina should receive the best medical care. In October 1970, to the surprise of everyone in Cleveland, he resigned from the staff to return to Argentina. He gave as his reason the lack of any sophisticated cardiovascular surgery in Argentina or for that matter in all of Latin America and that the poor in South America could not travel elsewhere to receive care. His ambitions were to set up a foundation in Buenos Aries to perform cardiac surgery in all who needed it regardless of their ability to pay, to set up a training program to allow his procedures to be performed throughout South American, and to develop a cardiovascular research institute. He returned to Buenos Aries and with government support was able to establish the Favaloro Foundation to fulfill these dreams. At the time of his return to Argentina the medical system was supported heavily by the government and union health programs, and they enthusiastically supported his Foundation. It flourished and succeeded in modernizing cardiovascular surgery throughout South America.
In 1998 changes in the government in Argentina caused many people to lose coverage for payment of their medical care, the unions were no longer supporting health insurance, and the government programs frequently involved kickbacks and poor payment for services. Dr. Favaloro refused to become involved in the various kickback schemes but continued to treat all patients at his foundation regardless of their ability to pay. His foundation amassed large debts because of delays in payment and its refusal to be involved in kickback schemes. Despite pleas to the government by Dr. Favaloro the debts of his clinic mounted and the government also requested back tax payment on equipment that the foundation owned (he had been given exemption from this tax in the past). He also continued to speak out on social justice issues and the need for universal healthcare. He frequently gave speeches attacking globalization and the free market system as the cause of unavailability of healthcare to all. On July 17, 2002, shortly after lunch he shot himself in the heart and left notes indicating that he was doing this as a statement of the need for social justice and universal health care for all.
EARL C. SMITH, MD, is Professor of Medicine at the Chicago Medical School, Rosalind Franklin University and Chief of Nephrology, Department of Medicine at Mount Sinai Hospital in Chicago, Illinois.
Highlighted in Frontispiece Spring 2013 – Volume 5, Issue 2