Rene Favaloro developed the coronary bypass operation, in which a vein from the leg was used to transport blood around a clogged artery. The operation developed into the most widely used surgical procedure of its type and saved countless lives.
In the mid-1960’s, the leading cause of death in the United States was coronary artery disease, claiming nearly 250 deaths per 100,000 population. Since a large proportion of these deaths were from coronary artery disease, there was much research being conducted on the heart. Most of the public’s attention was focused on heart transplants performed separately by the famous surgeons Dr. Christiaan Barnard and Dr. Michael DeBakey, but other, less dramatic procedures were being developed and studied.
A major problem with coronary artery disease, besides the threat of death, is chest pain or angina
In the late 1950’s and early 1960’s, a team of physicians in Cleveland was studying surgical procedures that would eliminate angina. The team was composed of Dr. Rene Favaloro, Dr. Donald B. Effler, Dr. F. Mason Sones, and Dr. Laurence Groves
Before bypass surgery (top), the blockage in the artery threatens to cut off blood flow; after surgeons graft a piece of vein, the blood can flow around the blockage.
In order to make Vineberg’s proposed operation successful, better diagnostic tools were needed. This was accomplished by the work of Dr. Sones. He developed a diagnostic procedure, called arteriography, whereby a catheter was inserted into an artery in the arm, which he ran into the heart. He then injected a dye into the coronary arteries and photographed it with a high-speed motion-picture camera. This provided an image of the heart, which made it easy to determine where the blockages were in the coronary arteries. Since this procedure identified precisely where the repairs were needed, heart surgery was able to move ahead quickly. The Cleveland Clinic team used Sones’s procedure and expanded on the work by William H. Sewell
The surgical procedure developed by the Cleveland Clinic team was effective and appropriate for treating individuals with severe coronary artery disease. Many patients, however, had blockages in a small portion of one or more vessels that would not warrant such dramatic surgery. Therefore, the team of physicians attempted to find more appropriate procedures. Several techniques were attempted. First, the surgeons tried to ream out the deposits found in the narrow portion of the artery. They found, however, that this actually reduced blood flow. Second, they tried slitting the length of the blocked area of the artery and suturing in a strip of tissue that would increase the diameter of the opening. This procedure was also ineffective because it frequently resulted in turbulent blood flow. Finally, the team attempted to reroute the flow of blood around the blockage by suturing in other tissue. This method proved to work well.
The new method of rerouting blood flow was introduced in 1967 by Dr. Favaloro. He and a team of physicians removed the entire blocked portion of the coronary artery. Then, a vein from the upper leg (saphenous vein) was removed from the patient and a portion of it was sutured to the ends of the artery. In summary, this procedure removed part of the vessel that was clogged and replaced it with a clear vessel, thereby restoring blood flow through the artery.
Although this new procedure proposed by Favaloro was a major step forward for open-heart surgery, it had its limitations. The major problem with the procedure was its flexibility to be used in many areas of the heart. The coronary artery anatomy had many arteries located in areas that made it impossible for the surgeon to expose the artery in order to complete the surgery. Therefore, this bypass surgery was limited primarily to the right coronary artery, which supplies blood to the right side and back side of the heart. It was not effective in the other major arteries, such as the left main, left anterior descending, and circumflex. These vessels supply blood to the front, left side, and portions of the back of the heart; this procedure was unable to restore blood flow to these areas.
In order for Favaloro and other heart surgeons to perform coronary artery surgery successfully, several other medical techniques had to be developed. These included arteriography, extracorporeal circulation, and microsurgical techniques. The significance of the arteriography procedure developed by Sones was previously discussed. The other two techniques are discussed below.
Extracorporeal circulation is the process of diverting the patient’s blood flow from the heart and into a heart-lung machine
Another critical development necessary for Favaloro’s work was microsurgery. Some of the coronary arteries are less than 1.5 millimeters in diameter. Since these arteries had to be sutured, optical magnification, spring-handled needle holders, and fine sutures were required. The use of these materials made grafting coronary arteries possible. Although Favaloro and his associates successfully performed coronary artery bypass surgery in 1967, the work of many other physicians and researchers was critical to their success.
After performing this surgery on numerous patients, follow-up studies were necessary to determine the surgery’s effectiveness. These studies took several years to complete. Only then was the value of coronary artery bypass surgery recognized as an effective procedure for reducing angina in heart patients. Also, during the period these studies were conducted, improvements were made on the techniques of bypass surgery, which rendered the previous research obsolete.
In 1968, the year after Favaloro developed his coronary artery bypass technique, there was a wide research interest in that type of surgery. Improvements were needed in order to use the technique on other arteries of the heart besides the right coronary artery. The preferred approach was the aortocoronary bypass graft. In this surgery, a portion of the saphenous vein was grafted from the aorta to the coronary artery instead of grafting it from one portion of the coronary artery to another portion of the same artery. Basically, a new source of blood from the aorta was created from the bypass graft rather than rerouting the same source. The fundamental benefit of this approach was that it could be performed on almost any coronary artery.
Three teams of physicians began work on the aortocoronary bypass, besides Favaloro and his team in Cleveland. In San Francisco, a surgical team headed by William J. Kerth
The growth of aortocoronary bypass surgery was rapid. Surgeons successfully performed the surgery on a wide basis for the first time in 1968. By 1970, many physicians across the country were performing bypass surgery on a regular basis. Its use, however, was slowed and overshadowed initially by the interest in heart transplant surgery developed at the same time. Critics of heart transplants believed that bypass surgery was a much better option because it was a less dramatic surgery with less risk, it did not require a donor, and it did not have the problems with rejection. Ultimately, bypass surgery was found to be much more feasible, and its use spread quickly.
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Effler, Donald B. “Surgery for Coronary Disease.” Scientific American 219 (October, 1967): 36-43. This article was written by one of the members of the research team that included Dr. Favaloro. The three main surgeries for coronary artery disease at that time are discussed. It provides a historical perspective leading up to Favloro’s bypass graft surgery in 1967. -
Johnson, Stephen L. The History of Cardiac Surgery, 1896-1955. Baltimore: Johns Hopkins University Press, 1970. Detailed history of open-heart surgery before the development of coronary artery bypass surgery. It provides a good discussion of the many contributions made by individual physicians that made bypass surgery possible. A list of references is also included. -
Miller, Donald W., Jr. The Practice of Coronary Artery Bypass Surgery. New York: Plenum Medical Book, 1977. Although this textbook is very technical, the first chapter provides a good overview of the history behind the development of bypass surgery. This chapter is easy to understand and includes the earliest research (from the 1910’s) that contributed to the development of the surgery. It follows the procedure to its wide acceptance in the 1970’s. -
Neugeboren, Jay. Open Heart: A Patient’s Story of Life-Saving Medicine and Life-Giving Friendship. Boston: Houghton Mifflin, 2003. A detailed account of the coronary artery bypass surgery from a patient’s point of view. Bibliographic references and index. -
Ochsner, John L., and Noel L. Mills. Coronary Artery Surgery. Philadelphia: Lea & Febiger, 1978. This resource is a textbook primarily composed of technical material. Yet, chapter 2 contains the history of surgery developed to relieve angina and is understandable to the nonmedical person. It begins with the surgeries used in 1916 and concludes with aortocoronary bypass surgery in the 1960’s. Although technical in nature, it also has excellent diagrams of how the surgeries are performed, which may be of interest to the nonmedical person. -
“Surgery.” Time 91 (January 19, 1968): 50-51. This article summarizes some of the heart transplants that took place in 1967. It provides information about the transplant recipients, donors, and surgeons. The conclusion is devoted to debate about the premature increase in the use of heart transplants. This leads to the discussion of some alternative surgeries, including the bypass graft developed by Favaloro. This article provides good information about the advantages and disadvantages of the heart surgery options of the time.
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