The Heart Healers (21 page)

Back in Boston, I devoted two years of my life to learning every intricacy of cardiac catheter manipulation in the lab of world-renowned cardiologist Dr. Richard Gorlin. Harvard medicine captured the quintessential Boston of that era, where the Lowells talk only to the Cabots and the Cabots talk only to God. I had entered a formal society stratified by rank, with a medical history of tremendous intellectual achievements. When your medical superiors spoke, it was taken as truth. We did not imagine aggressively challenging authority. Sometime during that first frigid Boston winter, I concluded that when finished with my training in the “Sones Technique” I must return to hurly-burly Los Angeles with no tradition, no social stratification, no “establishment.” I wanted a medical environment fully open to new thinking, to challenging the old ideas, to being a misfit.

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SONES’S DISCOVERY-BY-SERENDIPITY—WHAT
his eulogist Dr. Robert Hall calls “a, if not the, most important advance in cardiology in the 20th century”—stands as an enduring lesson that chance favors the prepared mind. For the first time we had a full diagnostic tool kit. We could assess chamber structure and function with angiography, valve obstruction by pressure drops across a valve, and now we could see the coronary arteries. We could describe the number, location, and severity of coronary obstructions in each patient. We could correlate this information with a patient’s risk of a cardiac catastrophe.

Because knowledge is power, coronary angiography revolutionized our thinking. The new idea was simple enough: if we could see the obstructions that caused angina and precipitated heart attack, perhaps we could find a way to treat them.

The idea was liberating, but still, it was only a concept. Seeing the problem does not mean you can fix it. Mason Sones would need a partner. How Mason found his cardiologic soul mate, what they achieved together, and their subsequent fates is hard to believe and yet it is all true.

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WHEN THE PAMPAS CAME TO CLEVELAND

You can imprison a man, but not an idea. You can exile a man, but not an idea. You can kill a man, but not an idea.

—BENAZIR BHUTTO, PAKISTANI LEADER ASSASSINATED IN 2010 DURING HER RETURN TO HER COUNTRY

THE FULL IMPACT
of coronary angiography finally burst like July Fourth fireworks over cardiology in mid-1967 as I drove west to return to Los Angeles. As a treatment solution to CAD, coronary artery bypass graft surgery (CABG) would stand as the pinnacle achievement of surgery’s glorious century that had begun with the discovery of anesthesia. It is tempting to imagine that CABG was so obvious that surgeons only needed the proper tools. No idea is more off the mark. For two decades after Harken’s battlefield breakthrough, surgeons pursued highly innovative surgical solutions to CAD. All failed.

In Philadelphia, the indefatigable Charles Bailey found that he could strip out atheroma from the inside of large blood vessels in the leg. So he reasoned that the same procedure would work in coronary vessels. Whereas the large diameter vessels of the leg tolerated this surgical insult, the smaller diameter vessels of the heart turned out to be far less forgiving. Bailey’s results were disastrous. Tearing of a vessel’s surface almost immediately led to the formation of an obstructive blood clot in the coronary artery, and a heart attack immediately followed. Not unfamiliar with disastrous innovation, Bailey abandoned the procedure.

In Cleveland, defibrillator developer Claude Beck reasoned that he could stimulate blood flow to the heart by irritating its surface. So he cracked opened the chest, sliced a hole in the pericardium, and poured in talcum powder. Yes, talcum powder. Sure enough, his supposition was correct: in the animal lab a complex mesh of tiny new vessels soon ran from the pericardium to the surface of his dogs’ hearts. But when he performed the same surgery in humans, he discovered to his dismay that the volume of additional blood flow was trivial, and completely ineffective in relieving angina.

Beck next hypothesized that he could circumvent coronary artery obstructions by pumping in oxygenated blood through the veins. So he connected the aorta directly to the heart’s largest vein, calling the procedure “retroperfusion.” When his patient died one day after surgery, he abandoned the procedure. In modern surgery, we often use retroperfusion from a heart-lung machine to support the heart during cardiac arrest. And what solution is pumped through the heart? A chilled nutrient solution, the child of Lillehei’s hypothermia surgery, preserves the heart in hibernation during the surgical procedure. Men die, but their ideas live on.

In Canada cardiac surgeon Arthur Vineberg had a different intuition. If delivering blood to the surface of the heart was insufficient—Beck had tried with talcum powder—why not deliver it directly to the heart muscle? Why not tunnel a nearby artery to the heart muscle itself? The internal mammary artery (IMA) lies an inch or so from the heart and it runs down the inner surface of the sternum (breastbone), from the level of the collarbone to the bottom of the rib cage. There are two IMAs, one on either side of the sternum. Vineberg clamped off the left IMA at its origin, freed it up from the length of the sternum, cut off its side branches, burrowed the vessel into a dead-end tunnel within the heart muscle itself, and released the clamp on the IMA. Blood surged down the vessel and, like a garden sprinkler, spilled out of its many open side branches into the tunnel within the heart muscle. Vineberg imagined that the IMA implanted within the heart muscle would grow new side branches that would become a source of nutrient blood flow to the heart.

Vineberg’s procedure did ameliorate angina in many patients, but cardiologists were deeply skeptical. Charles Friedberg, author of the era’s leading cardiology textbook, joked of surgeons that “if the heart has a hole in it, they want to close it, if the heart doesn’t have a hole they make one.” Skeptics claimed that angina relief by the Vineberg procedure was nothing more than the placebo effect, possibly augmented by cutting nerves that carried pain sensation from the chest. But when Mason Sones reported that his own angiographic evaluation of over a thousand IMA implants showed open IMA vessels in 92% of patients and communications between the IMA and the coronary artery in 54%, the procedure was more widely accepted. I recall, however, my own experience looking at similar angiograms in our Harvard cath lab as a fellow. We would all gather around our boss, the famed Dr. Richard Gorlin, who was an enthusiastic advocate of the procedure, as he reviewed our angiographic films. “There it is boys … see the dye perfusing that heart muscle?” he would say. Standing behind him, most of the time we would look blankly at each other with raised eyebrows. We would see dye coming down the IMA, and then … nothing more. “That man is a wizard,” we would say when out of earshot, “he can see things that escape the vision of the average man.” Looking back, I believe that relief of angina after the Vineberg procedure was predominantly due to the placebo effect. Whether the Vineberg operation was effective is irrelevant today, because at that moment in time, the Canadian’s procedure stood at the base of another Cleveland avalanche.

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IN 1967, NINE
years after his first serendipitous coronary angiogram, Mason Sones’s discovery paid off on its promise. The world of cardiac surgery was turned upside down by an unknown Argentine surgeon named René Favaloro who had spent years collaborating with Sones at the Cleveland Clinic. René Favaloro reported that he had surgically restored blood flow beyond an obstructed coronary artery. Most dramatically, the patient’s disabling angina disappeared and did not return.

I admired René Favaloro. His personal story for me stands as the most inspirational in all of cardiology. He was born to Italian immigrants in a dusty rural town about thirty miles south of Buenos Aires. His father, a carpenter, was barely able to provide for the family. As Favaloro told oral historian Dr. Allen Weisse, “[My father] was really an artist … He did very fine carving with very delicately constructed pieces … I began working with my father at the age of 10. I could have made a living doing carving.” His mother supplemented their meager income working as a seamstress. With free schooling throughout the country, both René and his brother Juan José merged their genetic endowment of fine carpenter and seamstress. Both became surgeons.

René was in medical school during World War II when revolution brought fascist Juan Perón to power. Perón sent his military to train in Germany, creating Argentina’s bizarre dichotomy in which its government was pro-Axis, but its population supported the Allies. An idealistic populist, Favaloro’s opposition to Perón cost him. He was jailed twice by the government for his participation in anti-Perónist rallies. When he graduated first in his class, he refused to sign a document stating he did not oppose the Perónists. In retaliation, he was denied the coveted academic job traditionally reserved for the school’s top graduate. As he recalled, “all doors were closed to me.” When opponents of the government began to disappear by the hundreds and thousands, “I exiled myself within the country, going to the southwest, to the dry Pampas. It’s an area very similar to the southwestern United States, Texas or Arizona.” He spent twelve years there as a country surgeon.

Yet during those years in exile, Favaloro never lost his dream of what, in another time and place, might have been. His passion was to contribute something new to his society. Over his years of exile, he envisioned learning the spectacular cardiac new surgery techniques in the United States and bringing them back to his homeland. In 1962, with little money, no promise of a job, very limited English skills, and now middle-aged, thirty-nine-year-old René Favaloro traveled to Cleveland where he introduced himself to Dr. Donald Effler, the chief of thoracic surgery at the Cleveland Clinic. After interviewing Favaloro, Effler was blunt: “You don’t have the qualifications. You can only be an observer. We won’t pay you for anything.”

Favaloro replied, “Look, I saved some money. I can live on my own money. Don’t worry about it.”

What could Effler say? He took on Favaloro as an unpaid laboratory technician.

René was both intellectually and surgically gifted. Over the ensuing months, Favaloro’s dedication and technical skill shone through his fractured English. Favaloro assisted the surgeons by day, and when he finished he spent countless nights with workaholic Mason Sones, studying coronary angiograms and visualizing ways to cure CAD with surgery. Effler was deeply impressed. When Favaloro passed the U.S. Foreign Medical Graduate exam, Effler took the unprecedented step of offering him a cardiac surgery training fellowship. He dedicated those years to his new profession: “Living just across the street I was at the Clinic all the time.” Paraphrasing Gabriel García Márquez, he worked when others stopped and rose while others slept. In his training years, Favaloro emerged as Effler’s star pupil.

In 1966, four years after he arrived as an unknown immigrant, Favaloro’s transformation was complete. Effler offered him a full-time staff position in thoracic surgery. To Effler’s astonishment, Favaloro replied that he could not accept the position. He had come to Cleveland with a dream. His destiny was to create the first heart surgery program in Argentina, one that would serve the rich and poor alike. He had to return home.

At home, however, Buenos Aires sent the dreamer packing: no one was interested in supporting a country surgeon with a grand delusion. With Effler begging him to return to the Cleveland Clinic, Favaloro abandoned his quest after several months.

On his return to the Cleveland Clinic group, Favaloro and his boss, Effler, collaborating with Sones and Proudfit in cardiology, set out to find a surgical solution to coronary disease. Favaloro did not practice in the animal lab. Most animals’ coronary arteries were too small, and there were no animal models of CAD. Like the first generation of cardiac surgeons, Favaloro simply worked on intuition, and like them, he was condemned to endure the agony of a string of deaths without knowing if he would ever succeed. Initially he tried slicing open the coronary artery along the length of the obstruction, then enlarging it with a patch cut from the pericardium. It seemed like a logical idea. The pericardial patch, however, was a stimulus to blood clot formation. Favaloro logged a devastating 70% mortality rate before he admitted defeat. Self-critical like Harken before him, Favaloro talked openly about his pain as a pioneer, labeling his first outcomes “terrible” and “tragic.”

But for Favaloro, failure was fuel. Then he set rules to reduce risk until he succeeded. He would only bypass completely obstructed coronary arteries, theorizing that if a clot formed, there would be no additional loss of blood flow through the vessel. He chose the right coronary artery because it supplied less myocardium (heart muscle) than the left coronary artery. Finally, he chose patients whose Vineberg procedure had failed, and had no other options.

In early 1967, he dissected the coronary artery free from the heart, then cut out the diseased segment of the coronary artery. In its place he patched in a vein he had removed from his patient’s leg. More clots. He decided to abandon patching the vessel. Years of failure surrounded him. Retroperfusion had failed. Extracting the atheroma had failed. Replacing the vessel segment had failed. Patching it had failed. Tunneling was doubtful at best. Was there still another way? Why had not anyone thought of the highway planner’s way: when traffic on a main artery becomes congested, bypass it?

Favaloro decided to use the leg vein, but now to connect one end of the vein to the aorta and the other end to the obstructed artery just beyond the obstruction. Eureka! No clot. He had “bypassed” the coronary obstruction. His patient survived bypass of the obstruction in good condition. The miracle was complete when their patient strolled the hospital’s halls without a trace of angina. Now came the moment of truth. Sones performed a postoperative angiogram. The two men stood transfixed as they watched blood flow briskly through the vein graft directly into the coronary artery segment. It entered the heart and spread throughout the muscle. Short, irrepressible Mason and tall, serious René, as unlikely a pair as one might imagine, had restored coronary blood flow in a patient with intractable angina. It was an incomparable moment in the history of surgery. Favaloro and Sones had wandered through a maze filled with tragic blind alleys, to emerge with a stunningly simple and thus brilliant solution. They had restored blood flow to a starving heart. The year 1967 was a very good year. America had its first African American Supreme Court Justice and its first Super Bowl; cardiology had its first bypass surgery and its first heart transplant.