The Three Muskateers
1- Coronary Arteriography by Accident
F. Mason Sones, Jr. (1918 - 1985). He was the head of Pediatric Cardiology
in Cleveland Clinic. On October 1958, while working in the cath-lab on a patient
with rheumatic heart disease, they planned to inject contrast above the aortic
valve to assess the severity of aortic incompetence. The catheter whiplashed
into the ostia of the right coronary artery, and an estimated 30 cc of 90%
Hypaque (Nicomed) was selectively delivered as a bolus into the coronary artery
before the injection could be aborted. The patient went into asystole and Sones
shouted at him to cough which successfully restarted the heart beating (1, 2,
3).
Dr. Julio Sosa, who attended the event, described the anguish Sones felt as he
witnessed this inadvertent injection and blurted out “We’ve killed him!” (3).
From this experience, Sones realized that smaller amounts of contrast dye could
safely be injected directly into coronary arteries. In 1967, Sones' Cleveland
Clinic colleague, Dr. René Favaloro performed the world's first coronary bypass
surgery. Dr. Favaloro called Sones, "The most important contributor to modern
cardiology", and said that without his work, "All our efforts in myocardial
revascularization would have been fruitless".
Yet within a decade, Sones and his team had performed over 8000 coronary
angiograms, and cardiology has never looked back. However, the Sone’s technique
of coronary arteriography which utilizes the brachial artery as an avenue for
catheter introduction is nowadays not used and was replaced by Seldinger
percutaneous technique described by two radiologists, Drs. Judkins and Amplatz
(4, 5).
Lastly, Sones the first musketeer died without his sword in Cleveland from lung
cancer at the age of 66.
2- The Saint of Coronary Bypass Surgery
Dr. René Gerónimo Favaloro (1923–2000), was an Argentine cardiac surgeon who
created the technique for coronary bypass surgery.
His biography (6-8) is very interesting, his father was a carpenter and his
parents were Sicilian immigrants. When he took his degree in medicine he was the
only doctor in a small rural town in Argentina. As a rural physician he took
major steps to improve the general level of health by training and educating the
general public, teachers and nurses.
In 1962, he traveled to Cleveland Clinic to continue his medical training. In
the beginning, the major part of his work related to valvular and congenital
diseases. Later on, Favaloro spent most of his time there with Mason Sones
reviewing coronary angiograms and studying coronary arteries and their relation
with the cardiac muscle.
At the beginning of 1967, Favaloro began to consider the possibility of using
the saphenous vein in coronary surgery. The basic principle was to bypass an
obstructed segment in a coronary artery in order to deliver blood flow distally.
Within one year from the first operation, 171 bypasses had been performed at the
Cleveland Clinic. In 1970 he published a book called Surgical Treatment on
Coronary Arteriosclerosis.
In 1971, Favaloro left Cleveland to return to Argentina. By 1980 he was able to
establish a center for cardiovascular surgery, training surgeons and
cardiologists on his methods and ideas. This institute offered highly
specialized services of cardiology, cardiovascular surgery and heart, lung,
cardiopulmonary, liver, kidney and bone marrow transplants. He trained more than
450 residents from all over Argentina and the Americas.
Favaloro did not limit himself to print media. He developed a television program
called "The Great Medical Issues", offering medical information on prevention
and treatment of diseases.
By the year 2000, Argentina was in an economic and political crisis and the
Favaloro Foundation was US $ 75 million in debt. Favaloro, on repeated occasions
requested the Argentine government to aid the Foundation, but he never received
an official response. It was quoted from Favaloro, writing that "I am going
through the saddest period of my life. In the most recent times, I have been
turned into a beggar". On July 29 of that year, Favaloro took the tragic
decision of committing suicide, and shot himself to death.
The second musketeer died gracefully like a Samurai by his own weapon.
3- A Balloon Catheter on the kitchen table.
Andreas Roland Grüntzig (1939–1985), was a German cardiologist who was the
first to develop successful balloon angioplasty for opening narrowed arteries.
He joined the Angiology Division of the University Hospital, in Zurich,
Switzerland, in 1969.
Few years before working on peripheral arterial narrowing, Charles Dotter, 1964,
published an article in Circulation journal (9), describing a new technique for
dilatation of ilio-femoral occlusions non-surgically. The technique was simply,
crossing the obstruction with an ordinary catheter of about 0.05 inch diameter.
Their success depended on, more or less forceful manipulation at the blocked
area. The next step was by using another 0.1 inch catheter and slipping it over
the guide and advanced until it, too, has traversed the block. Grüntzig,
performed the Dotter procedure on 50 patients in the angiology division (10). In
the meantime, Charles Dotter was forced to abandon the procedure because of the
opposition of prominent vascular surgeons.
Grüntzig, believed that the previous method could not reach a reasonable
arterial dilatation for the difficulty of introducing larger rigid catheters. He
tried to dilate with Fogarty's balloon catheter used for embolectomy (11), but
it was too weak for dilatations at high balloon pressures. Other available
balloons at that time, were not convenient to use or harmful to the arterial
wall.
After many experiments, including animal studies, Grüntzig built prototypes on
the kitchen table of his apartment. The balloons were fixed on angiographic
catheters; it resisted 5 atmospheres pressures on inflation and had the shape of
sausages. In 1974, Grüntzig used his first handmade catheter on a patient with
femoral artery stenosis. During the first two years, each balloon catheter was
made by hand on the kitchen table (12, 13).
In 1975, the first double-lumen catheter was designed and introduced to his lab.
After some time he could convince Cook and Schneider companies to produce these
catheters by industrial means.
In 1976, Grüntzig presented the results of his animal and his first human
balloon angioplasties on leg arteries at the American Heart Association (AHA)
annual scientific sessions, telling the audience that he would soon take his
method into the human heart. On the next year, he presented 3 cases of
successful coronary angioplasty at the AHA meeting (11).
In 1980, Grüntzig went to Emory University Hospital, Atlanta. A few months
later, he held his first American courses with live demonstrations to an
audience of some 200 doctors during several days (11-13).
By about 1990, coronary angioplasty technique was more performed than coronary
bypass surgery. This treatment approach is now referred to as POBA (Plain old
balloon angioplasty).
In 1985, while Grüntzig was flying by his own aircraft (He was the pilot), he at
the age of 46 years old and his 27 year-old physician wife died in an airplane
crash in a remote area near Atlanta,Georgia.
Our third musketeer was a genius who died in a tragic accident that shocked the
hearts of the whole medical community.
Corresponding author:
Adel M. Zaki, MD
Professor of Cardiology department, Cairo University
E-mail: adel@heartmirror.com
References