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.
my aortic surgery presentation in Solo as an introduction for general practitioner and cardiology resident
Cover the basic diagram of surgical procedures of aorta.
definitely not for surgeon.
Although the risks of coronary angiography have declined over the years by increased clinical experience and advanced technologies, it still requires attention, knowledge and experience due to being an interventional diagnostic method. A safe coronary angiography begins with the selection of the appropriate catheter for the anatomical structure of the patient and the evaluation of the pressure when the catheter is placed in the coronary ostium. Coronary pressure waves are complementary requirements of angiography. The recognition, evaluation and precautions to be taken for abnormal pressure waves directly affect the mortality of the patient. One of the first clues to the presence of stenosis in the left main coronary artery (LMCA) is abnormal changes in pressure when the catheter is seated in the ostial LMCA. This often occurs as a “ventricularization” or “damping”. For decades, ventricularization was mostly experienced as a stenosis by invasive cardiologists [1]. Recognition of abnormal changes in pressure and precautions to be taken prevent catastrophic outcomes in patients
https://crimsonpublishers.com/ojchd/fulltext/OJCHD.000518.pdf
For more open access journals in Crimson Publishers
please click on https://crimsonpublishers.com/
For more articles in open journal of Cardiology & Heart Diseases
please click on https://crimsonpublishers.com/ojchd/
EMBOLISM AND FILTERS USED IN CARDIOPULMONARY BYPASSGLORY MINI MOL. A
FILTERS USED IN CARDIOPULMONARY BYPASS
EMBOLISM
DEFINITION: obstruction of an artery, by a clot of blood or an air bubble.
This emboli is categorized to
Biological emboli
Foreign emboli
Gaseous emboli
There are current technologies to decrease this embolic event delivered to patient
Membrane oxygenators
FILTER
Blood surface coating
Bubble traps
Emboli detection system
Blood Filters
Depth filters
Consist of packed fibers of Dacron wool or
polyurethane foam .
No defined pore size
These filters have large wetted surface
areas to filter the blood by absorption , they are effective in
trapping gross bubbles.
Screen filters
composed of a woven
mesh of polyester fibers
defined pore sizes
From 20 -40 μm
(all of the arterial line filters used are the screen type)
my aortic surgery presentation in Solo as an introduction for general practitioner and cardiology resident
Cover the basic diagram of surgical procedures of aorta.
definitely not for surgeon.
Although the risks of coronary angiography have declined over the years by increased clinical experience and advanced technologies, it still requires attention, knowledge and experience due to being an interventional diagnostic method. A safe coronary angiography begins with the selection of the appropriate catheter for the anatomical structure of the patient and the evaluation of the pressure when the catheter is placed in the coronary ostium. Coronary pressure waves are complementary requirements of angiography. The recognition, evaluation and precautions to be taken for abnormal pressure waves directly affect the mortality of the patient. One of the first clues to the presence of stenosis in the left main coronary artery (LMCA) is abnormal changes in pressure when the catheter is seated in the ostial LMCA. This often occurs as a “ventricularization” or “damping”. For decades, ventricularization was mostly experienced as a stenosis by invasive cardiologists [1]. Recognition of abnormal changes in pressure and precautions to be taken prevent catastrophic outcomes in patients
https://crimsonpublishers.com/ojchd/fulltext/OJCHD.000518.pdf
For more open access journals in Crimson Publishers
please click on https://crimsonpublishers.com/
For more articles in open journal of Cardiology & Heart Diseases
please click on https://crimsonpublishers.com/ojchd/
EMBOLISM AND FILTERS USED IN CARDIOPULMONARY BYPASSGLORY MINI MOL. A
FILTERS USED IN CARDIOPULMONARY BYPASS
EMBOLISM
DEFINITION: obstruction of an artery, by a clot of blood or an air bubble.
This emboli is categorized to
Biological emboli
Foreign emboli
Gaseous emboli
There are current technologies to decrease this embolic event delivered to patient
Membrane oxygenators
FILTER
Blood surface coating
Bubble traps
Emboli detection system
Blood Filters
Depth filters
Consist of packed fibers of Dacron wool or
polyurethane foam .
No defined pore size
These filters have large wetted surface
areas to filter the blood by absorption , they are effective in
trapping gross bubbles.
Screen filters
composed of a woven
mesh of polyester fibers
defined pore sizes
From 20 -40 μm
(all of the arterial line filters used are the screen type)
A beautiful paper published by Eugene Braunwald
European Heart Journal, Volume 42, Issue 24, 21 June 2021, Pages 2327–2328, https://doi.org/10.1093/eurheartj/ehab264
Heberden meticulously described a symptom, but he did not understand the disease. Edward Jenner noticed thickened coronary arteries at autopsy of his colleague John Hunter who had died suddenly after an angina attack in 1793,2 but it took decades for a first remedy for angina pectoris and even longer for a true understanding of the underlying disease
Surgery for atrial fibrillation abhijit presentationAbhijit Joshi
this presentation starts with the description of atrial fibrillation and goes on to describe the basis of it's surgical cure, viz. The Maze procedure. I then describe the technical aspects of Maze 1,2,3,4...
This presentation starts with a description of what is MRI and how it generates an image. I feel that MRI is the investigation of our era and the applications will only grow, perhaps in some cases will drastically alter treatment protocols, being ignorant about the physics of MRI would be a crime!
I then introduce the concepts behind the common cardiac use cases. Cardiac MRI by itself is a huge topic, this presentation aims to prepare a base to understand this huge pandora's box.
This presentation covers the methodology of evaluating CTEPH (chronic thromboembolic pulmonary hypertension) case. It starts from the basic concepts of Pulmonary hypertension.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
A brief History of Coronary Artery Bypass Grafting (CABG)
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.
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
7.
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.
9.
10.
11.
12.
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.
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
19.
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.
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
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.
41.
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.
46.
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.”