The term heart bypass surgery is not new to people today, but its establishment process is quite tortuous, from the initial exploration to the classic coronary artery bypass graft (also known as heart bypass surgery) officially recognized by the medical community, it took more than 40 years. Although physicians recognized the symptoms of angina as early as 1759, there was no cure but symptomatic relief for a long time, and the exploration of surgical treatment for coronary heart disease began more than 160 years later. The story of this time, especially the initial failures that brought shame to the surgical community, is a little-known history because it is rarely mentioned in textbooks. In the 1920s, some surgeons believed that sympathectomy of the neck and chest would relieve angina attacks. The result was that patients felt that their angina was relieved, not realizing that the pathology of coronary artery disease had not improved significantly and that myocardial ischemia would still occur. However, even if myocardial ischemia occurs, since the nerve concerned has been cut, the pain sensation is not so obvious, and the patient mistakenly thinks that the condition has improved, and will unconsciously increase the amount of activity, so that myocardial ischemia will be worse than before the operation, and if a serious myocardial infarction occurs, the patient may die. If this surgery had not been done, when angina attacked, the patient would at least be forced to reduce activity and lie quietly in bed, so that the oxygen consumption of the whole body would be reduced, and the myocardial ischemia would be relatively reduced. Therefore, this procedure, which seems to reduce the painful attacks, is in fact a life charm for the patient. Another procedure that emerged a little later was almost as notorious. The theory at the time was that by reducing the body’s metabolism, there would be fewer episodes of angina. This argument was valid to some extent, but the partial thyroidectomy performed by some surgeons based on this theory caused great pain to the patient. Because the thyroid gland is an important endocrine organ of the human body, and thyroid hormones are related to most of the metabolic activities of the human body, when the surgeon removes part of the patient’s thyroid gland, the frequency of angina attacks is certainly reduced, but the effect of thyroid hormones is so wide that the consequence of throwing the bath water out with the children is that the human body will present a serious state of thyroid hormone secretion deficiency after surgery. It is like climbing out of the fire and falling into the ice, which is worse than death. When some scholars mentioned these attempts back then, they evaluated them as “having little effect”, which I think is too kind. For this kind of blind exploration, it is meaningless to overdo it, and failure is failure. But we need to know that the main reason for this mistake is that it was limited by the theoretical level at that time. But when I dug into the pile of old papers to examine the state of medical knowledge about angina pectoris at that time, I found out that someone had already made an insightful observation a decade earlier! He described the signs and symptoms of myocardial infarction and demonstrated that infarction occurs due to coronary thrombosis secondary to myocardial ischemic injury. Unfortunately, at that time, his report did not attract much attention, and many people still regarded the clinical manifestation of acute heart attack as a stroke or gastrointestinal problem, and it was only after the widespread use of electrocardiography that the medical community gradually accepted this theory. The truth is not always accepted by most people in the first place, and human beings always have to pay one price or another in their quest to conquer diseases. Perhaps the founders of the two aforementioned procedures may not have been unaware of Herrick’s theory, but before the use of heart-lung machines was established, surgery on the heart was still incredibly taboo, which is probably the main reason why they went off the rails. To be fair, before coronary artery bypass surgery became a classic procedure, there were some procedures based on the correct theories of the time that, although far from perfect, were positive for the patients themselves and for the advancement of the discipline, at least in the sense that they didn’t go “off the rails”. For example, Claude Beck of Cleveland believed that improving the blood supply to the myocardium would relieve angina attacks, so at the time he performed a series of creative procedures, including regenerating the surface vessels of the heart by mechanically rubbing or flushing the pericardial cavity with chemicals, causing adhesions between the dirty and walled pericardium; transferring the pectoralis major muscle to the pericardium with a vascular tip; narrowing the coronary sinus to increase the perfusion pressure of the coronary arteries. Although these procedures were used to some extent, doctors at this time were still guessing what was going on with coronary artery disease because the level of diagnosis at the time was not able to determine the extent of coronary stenosis and the location of the blockage. Fortunately, the patient’s angina did improve through indirect revascularization procedures. This part of the procedure was intended to improve the blood supply to the myocardium, and it did, which is why I believe these attempts were not “off the mark”. After World War II, Vineberg at McGill University in Canada designed a procedure that was already somewhat of a prototype for coronary artery bypass grafting. He envisioned freeing the internal mammary artery from the chest wall, grafting this vessel into the myocardial conduit, and using its collateral flow to improve blood flow to the heart. After repeated animal experiments, Vineberg applied it clinically in 1950 with good results. The mortality rate for this procedure was 6% at the time, and because Vineberg did not have strong evidence to convince his colleagues that it would improve symptoms, it was not adopted by other physicians until the mid-1960s. Up to this time, coronary artery disease was evaluated mainly on the basis of the patient’s history, complaints, ECG and relevant laboratory tests, i.e. diagnostic measures were not significantly advanced compared to the pre-World War II era of the Beck procedure. Under these conditions, the Vineberg procedure was probably the highest level that could be achieved at that time. But a blind cat incident greatly advanced the level of understanding of coronary artery disease and led directly to the emergence of coronary artery bypass surgery as a possibility. In the 1950s, peripheral arteriography had become quite popular, but no one dared to perform imaging of the coronary arteries, believing that direct injection of contrast into the coronary arteries would lead to cardiac arrest or myocardial infarction. At that time, cardiac angiography was available, but only catheters that could access the root of the aorta, even if a large amount of contrast was injected, how much of it could enter the coronary arteries? After all, the internal diameter of the coronary artery trunk was only 3 to 4 mm, and the coronary artery was naturally poorly visualized, which certainly did not provide the clinician with effective information about the pathological changes in the coronary arteries. One day in 1958, Frank Mason Sones, a cardiologist at Cleveland Hospital, was preparing to perform a cardiogram on a 27-year-old patient when the catheter entered the patient’s aortic root. The uninformed Sones started to push the contrast agent as usual, resulting in a 30 ml dose being injected directly into the patient’s right coronary artery. …… When Sones realized that things were not going well and realized that the patient might suffer a cardiac arrest or infarction, he immediately started to prepare for resuscitation. However, surprisingly, nothing happened and the patient was unharmed, with a normal heart rhythm and normal enzymatic parameters. The patient was happy that nothing had happened to him, and that his heart rhythm was normal and his enzymes were normal. Sones was surprised by the results of the subsequent radiographs, which clearly showed the condition of the patient’s right coronary artery, which was unprecedented. The shock was followed by ecstasy as the gods of fate thrust Sones into the portal of a new era. After Sones repeated the procedure on a second patient, he was convinced that coronary angiography was safe and feasible. He spent nearly three years perfecting all the details of this test, performing hundreds of coronary angiograms, and taking the medical community’s understanding of coronary artery disease a significant step forward. Since then, people finally have reliable and objective indicators for coronary heart disease evaluation and criteria for judging the effectiveness of coronary heart disease surgery. In medicine, using symptoms and signs as the main indicators to estimate the condition is more accurate in some cases. In appendicitis, for example, the pain in the right lower abdomen is gradually aggravated with the severity of the appendicitis lesion. However, the symptom of angina pectoris, by itself, does not fully reflect the severity of coronary artery disease. In some cases, a patient may have a subjective feeling of severe symptoms, but if the stenosis is confined to the right coronary artery, the risk of sudden death may be minimal; conversely, a patient with very mild symptoms may be at great risk if the major lesion is concentrated in the anterior descending branch of the left coronary artery (which innervates the largest area of blood supplying myocardium). More importantly, in nearly 20% of patients, the first episode can be a fatal major infarction without any warning. The advent of coronary angiography was undoubtedly a landmark event in the development of coronary surgery, which led to a new level of understanding of coronary artery disease and created the basic conditions for the creation of coronary artery bypass grafting, because only when the surgeon knew where the coronary stenosis was located, it was possible to cross the stenosis by means of a vascular bridge. In 1963, Sones performed coronary angiography on two patients from Canada, both of whom had previously undergone the Vineberg procedure. The first patient had no specific findings, while the second patient had extensive collateralization of the graft with the left anterior descending branch, a finding that certainly confirmed the value of the Vineberg procedure. Donald Effler at the hospital therefore began to apply the procedure and evaluated the patient postoperatively with coronary angiography, reporting good results. It was only after this that the procedure devised by Vineberg was introduced in the mid-1960s. Among the colleagues who worked with Sones was the Argentinean surgeon René Gerónimo Favaloro, whose legendary story stands out, even in the history of the development of cardiac surgery, which has been characterized by a great number of masters, and it is thanks to the combined contribution of Sones and Favaloro that the great era of coronary surgery in medical history was truly begun. The great era of coronary artery surgery. On July 14, 1923, René Gerónimo Favaloro was born in La Plata, Argentina, to a carpenter father and a tailor mother. Before entering medical school, he was deeply influenced by altruistic ideas that probably played a great role in the development of his later career. 1948, after graduating from the National University of La Plata with honors, he wanted to be a thoracic surgeon. At that time, Argentina was ruled by the Partido de Justicia del Perón (a third way different from capitalism and communism) and he had to sign his allegiance to the Partido de Justicia del Perón if he wanted to study thoracic surgery in a major hospital. This was almost a routine procedure at the time, and was required to work in a university hospital or many other places. But for some reason, this guy was so disgusted with this form that after 24 hours of consideration, he actually approached the dean and said, “Since you know that I study hard, work hard and am first in my class, why do I have to sign this crap? The dean said, if you refuse to sign, we can not give you this opportunity. At this point in the conversation, the atmosphere was naturally unpleasant, and Favaloro decided not to sign. In a 1998 article, he said, “My destiny led me to become a village doctor in a small village in the southwestern part of the Pampas in May 1950”. Favaloro’s personal and unconscious choice made it possible for the inhabitants of the Pampas to benefit. He established a clinic in Pampas, and two years later his brother graduated and came to help. Together, the two brothers worked very hard to build an operating room and laboratory from scratch, and acquired the best X-ray equipment available at the time. …… It is impossible to imagine how the two brothers spent those 12 busy years under those difficult circumstances, inside and outside women and children, and they became true general practitioners. In addition to diagnostic and treatment activities, he also vigorously educated the local population on health, popularized prenatal checkups, trained midwives, and popularized basic health care knowledge. In Latin America at that time, medical conditions were relatively backward, and the mortality rate of pediatric diarrhea alone was as high as about 200 per 1,000. Through the efforts of the two brothers, the health of the local population was greatly improved. But the eagle was destined to fly, and Favaloro’s dream was still alive, so he could not be a village doctor for the rest of his life. Favaloro quickly overcame the language barrier and passed the U.S. medical licensing exam. Although there were many fine young men studying cardiothoracic surgery together in the operating room, Favaloro was, after all, a doctor with many years of clinical experience, so he quickly proved himself and became close friends with many doctors. When Favaloro finished his day’s work, he would take home a stack of coronary arteriograms and continue to look at them, asking Sones for advice the next morning if he couldn’t understand them, and Sones was happy to help. In 1966, Favaloro successfully performed the world’s first coronary artery bypass surgery using the saphenous vein (a superficial vein in the leg) at Cleveland Hospital (Dr. Sabiston performed the world’s first saphenous coronary artery bypass in 1962, but the patient died three days after the surgery due to acute thrombosis of the proximal segment of the anastomosis), and established the technical details of median opening and lateral anastomosis of the vessel. In 1970, when the World Heart Association was held in London, Favaloro’s presentation overwhelmed most of the scholars and physicians present and they began to believe that coronary artery bypass surgery could prevent sudden cardiac death in coronary patients and prolong their lives. After the meeting, one doctor jokingly said, “I can’t believe you guys have such a low mortality rate for coronary artery surgery,” and Favaloro said seriously, “I can’t accept anyone doubting our data. In fact, many scholars did go to Cleveland Hospital later, but of course, they went to study. As coronary artery bypass surgery was performed worldwide, the theory and routine of the procedure matured, and a new era in the era of coronary surgery officially began. The contributions of Favaloro and Sones during this period revolutionized the understanding of coronary artery disease and profoundly influenced the treatment of coronary artery disease, including medical and surgical approaches. The successful placement of stents in the coronary arteries by Dr. Sigwart in 1987 was in fact the same as the coronary angiography technique invented by Sones. The advent of interventional stenting started a 20-year-long competition between cardiac surgery and cardiology in the field of cardiac revascularization, something that the two best friends in the history of coronary artery disease treatment could not have anticipated. The story of coronary artery bypass can actually end here, more technical details on the update and controversy, or left to the medical community to discuss. However, I cannot resist giving an account of how Favaloro ended up. The 1970 academic meeting brought Favaloro’s career to a peak, but just when everyone thought he would continue his career in the United States, he suddenly decided to return to Argentina, to the place where he was needed more. In 1971, returning to Argentina, he entered a private hospital, eventually building it into a medical powerhouse in South America and establishing the Favaloro Foundation to aid the poor who could not afford to see a doctor. His goal was that no one would be prevented from seeing a doctor because they couldn’t afford it, and in a 1997 autobiography, he mentioned that our society had become money-oriented, that power money and pleasure had become the most important thing, and that the medical profession had followed suit, with most doctors doing excellent work but many being burdened by materialism. Sometimes when I participate in academic arguments, I can’t figure out if some people are arguing for the truth in medicine or defending their wallets or defending the company they work for, and it saddens me to say this, but it’s true. …… Some things are more important than money, I have operated on many people who couldn’t afford it, I wasted nothing more than a little time in the operating room and didn’t take a penny directly out of my wallet, there is nothing to be proud of about such things. In medicine we should be competing to help people, not to see who makes more money. …… On July 29, 2000, at the age of 77, Favaloro said goodbye to the world. Denton A. Cooley wrote with affection: “We have lost one of the best and most respected doctors, although he himself refused the title of the father of coronary artery bypass surgery. …… The people of Argentina have lost a fervent patriot, a talented surgeon and a compassionate hero (and to the people of Argentina who have lost a fervent patriot, a talented surgeon and a compassionate hero). talented surgeon and a compassionate hero.). Favaloro, a surgeon who had saved countless lives through heart surgery, ended his life by breaking his own heart with a pistol. In his suicide note, he wrote: “Being tired of being a beggar in his own country in front of his own government is enough for me. By this time his fund was$75 million in debt, and his several appeals to the government went unanswered. I suspect that his heart was already broken the moment before he pulled the trigger. In 2010, ten years after Favaloro’s death and 40 years after heart bypass surgery was established, more than one million heart surgeries are performed each year worldwide, more than 70% of which are for coronary artery disease, and tens of millions of people benefit from coronary artery surgery. Even so, it seems that Favaloro cannot smile because there are still many people in the world who are deprived of surgical treatment because of poverty. 3. Small right anterolateral incision. This is a small incision between the ribs in the anterior parasternal area to perform a procedure that includes simple precordial disease correction and valve replacement. This incision is smaller than the median mini-incision, so the lesions that can be treated are more limited, and requires another incision in the groin for femoral arterial cannulation to establish extracorporeal circulation. In other words, although there is only one small incision in the chest, there is actually another incision in the groin that is invisible to others. It has the advantage of being aesthetically pleasing, but the difficulty of the operation is simply unbearable. As the saying goes, “the patient is minimally invasive, the doctor is heavily invasive”, so it is only a matter of time before this minimally invasive approach is eliminated. 4. Thoracoscopic surgery. Thoracoscopy was first popularized in thoracic surgery, from the earliest alveolar resection and partial lobectomy to the radical treatment of esophageal cancer, and its application is becoming more and more widespread. However, the application of thoracoscopy in cardiac surgery still has a relatively short history. The procedures that can be done at present include simple precordial correction, mitral valvuloplasty, mitral valve replacement, tricuspid valvuloplasty, aortic valve replacement (which is more difficult), atrial mucosal aneurysm removal, and radiofrequency ablation of atrial fibrillation. Its advantage is that the incision is further reduced, with only two 1-2 cm eyes and a 4 cm incision, but the surgical field of view is very well revealed, and due to the application of the camera, it is often possible to obtain a clearer operative field than the naked eye during direct intracardiac view; another advantage is that the closing after the operation is very rapid, without the extremely difficult process of closing the chest in traditional open-heart surgery, with very little bleeding, which is very beneficial for postoperative management, and This is very beneficial for postoperative management and patient recovery. Its disadvantage is that the surgical field is two-dimensional, which requires some training for the surgeon to adapt to, and has a longer learning curve than traditional surgery; in addition, the surgical instruments are specially designed, unlike the instruments held directly by traditional surgery, and it is more difficult and slower to operate microscopic sutures and knots than traditional surgery, so it is not suitable for microsurgery like coronary artery bypass grafting, which requires precise sutures. Although some units have tried to perform thoracoscopic coronary artery bypass surgery, it is limited to the anastomosis of a single lesion such as the left internal mammary artery-anterior descending branch, and it is not yet possible to complete the anastomosis of more vessels, and the long-term results are still unknown, so there is still a long way to go in the future of thoracoscopic surgery in the field of coronary artery bypass. Another disadvantage of thoracoscopic surgery is that it requires no history of surgery in the patient’s lungs (mainly the right lung) and good lung function, because if there is a history of surgery in the right lung, there are adhesions in the pleural cavity, and it is impossible to place thoracoscopic instruments, and during surgery, the right lung needs to collapse to provide visual field exposure, so it requires one-lung ventilation through the left lung only, and patients with poor lung function who cannot tolerate one-lung ventilation are not eligible for this surgery. Patients with poor lung function who cannot tolerate one-lung ventilation are not eligible for this procedure. In addition, thoracoscopic surgery also requires an incision in the groin to establish extracorporeal circulation through a femoral arterial cannula. Although the total time for thoracoscopic surgery is comparable to that of conventional surgery after proficiency, the two most important times in cardiac surgery: extracorporeal circulation time and aortic block time are significantly longer than conventional surgery, which means that your heart needs to stop beating for a longer period of time during the procedure, which is somehow contrary to the concept of the concept of minimally invasive. But overall, thoracoscopy is still the most cost-effective (why cost-effective?) procedure at this stage. Because it is a high-functioning technique that will be mentioned later) and has the best future in minimally invasive cardiac surgery. 5. Robot-assisted cardiac surgery. The robot here is the da Vinci surgical robot system, which is the product of American research in space technology, and is now widely used in urology, obstetrics and gynecology, general surgery, cardiac surgery can be used for simple precordial disease correction, mitral valvuloplasty and replacement, aortic valve replacement, tricuspid valvuloplasty and replacement, atrial mucinous tumor removal, radiofrequency ablation of atrial fibrillation, coronary artery bypass surgery, etc., so to speak. The da Vinci system is a more advanced thoracoscope. All procedures that can be done under the thoracoscope can be done through the da Vinci system, and procedures that are difficult to operate under the thoracoscope can often be done easily with the da Vinci system. This is because the da Vinci system provides a three-dimensional surgical field of view, which is the same as the three-dimensional effect of the surgeon’s direct vision with the naked eye, and also has a magnification effect, making the surgical field clearer; in addition, the robotic arm of the da Vinci system is more flexible than a human hand and has greater freedom, which can achieve difficult movements that cannot be completed by a human hand, providing great convenience to surgical operations. It can be said that the da Vinci system is the perfect application of modern high technology in medicine, and it is the top level of minimally invasive cardiac surgery at this stage. So, is the da Vinci System so perfect that it can replace traditional surgical procedures? Unfortunately, the answer is no. First of all, the da Vinci system is the only one in the world, there is no other branch, want to install the machine, 20 million yuan acquisition costs, and maintenance costs later, is a considerable investment, the general hospital can not afford, and can not be popularized on a large scale, while the mechanical arm belongs to the medical supplies, after 10 times will automatically lock up, can only buy new (capitalists really black ah), this part of the cost can only be passed on to the patient to This part of the cost can only be passed on to the patient to bear, expensive surgery costs will certainly exceed the ability of most people to pay and the national health insurance payment capacity. Secondly, the intervention of the robot makes the surgeon and the patient no longer in direct contact, but through the role of the machine, the surgeon’s operating instructions to the robot arm for surgery, and the machine must have a failure, the United States has had machine failure in the course of surgery, resulting in adverse events for patients reported. Finally, the da Vinci system is still a lumpectomy and still needs to be selected for the right patient population, some patients with complex lesions are not destined to have access to it. The contraindications for thoracoscopic surgery are basically the same as it, and the force is also half-hearted, for example, it is still only suitable to complete the left internal mammary artery-anterior descending branch anastomosis for a single lesion in the anterior descending branch, and still not good enough to complete coronary artery bypass grafting for multiple vessels. 6. Endoluminal intervention. Aren’t we talking about cardiac surgery? How did we move to interventional therapy? Yes, the brutal growth of endoluminal interventions is eating away at the viability of cardiac surgery. Let’s rewind the clock 40 years, in the 70s when coronary artery bypass surgery first appeared, the treatment of coronary heart disease is mainly led by surgeons, then interventional technology, coronary stents gradually shake the dominant position of coronary artery bypass, today if you suffer from coronary heart disease, unless the brain burned confused, it is impossible to come directly to the surgeon to do bypass surgery, must first go to internal medicine to see if interventional The first step is to go to internal medicine to see if intervention is possible. So far, the treatment of coronary artery disease is still a three-legged battle between drug therapy, interventional therapy and coronary artery bypass, but the suitable population for coronary artery bypass already belongs to the high-risk patients who have been screened by drug therapy and interventional therapy. Will there come a day when interventional therapy is so advanced that all coronary heart diseases can be treated satisfactorily with interventional therapy? It is entirely possible. Another major disease area where interventional techniques have made a big splash in the last decade is transcatheter aortic valve implantation (TAVI), which is called implantation rather than replacement because the original valve is not removed, but rather the newly implanted prosthetic valve is squeezed aside with brute force. Even so, there is a high rate of complications as well as mortality, so it is currently used only in patients with aortic valve lesions who are at high risk, elderly, and not candidates for surgical valve replacement. Younger patients with aortic valve lesions are better and safer candidates for traditional surgery. Transcatheter mitral valvuloplasty is also a treatment for mitral valve insufficiency, and this technique is more “simple and brutal,” using a special “clip” to enter the heart cavity under ultrasound guidance and clip the anterior and posterior mitral valve leaflets where the regurgitation is heaviest. The regurgitation is reduced and the patient will be able to get by for a few years, and then consider surgical valve replacement in the future when the regurgitation is aggravated again. This approach is indeed less invasive and quicker to recover, but it completely eliminates the possibility of mitral valvuloplasty (repair), and it is worthwhile for everyone to ponder whether this minimally invasive concept is right or wrong. In precordial disease, basically 99% of arteriovenous ductus arteriosus can be satisfactorily treated by interventional occlusion, and a significant proportion of atrial septal defects can be occluded by interventional occlusion. Interventional occlusion of ventricular septal defects is not recommended at present, because interventional occlusion of perimembranous septal defects is likely to damage the conduction technique and lead to third-degree AV block, requiring a permanent pacemaker; interventional occlusion of subdural septal defects is likely to damage the aortic valve and lead to incomplete aortic valve closure, which may require replacement of the aortic valve in the long term, and both of these risks are also present in traditional open-heart surgery, but the chances are very low. More complex precordial diseases can only be treated by open-heart surgery, and interventional techniques are currently completely incompetent and powerless. To summarize, minimally invasive is an ideal that every surgeon should pursue throughout his life. When we start to cut the appendix as a young surgeon, we may make a relatively large incision in order to reveal it more clearly. But no matter how small the incision is, a basic principle is that you have to have enough confidence to complete the surgery safely, because heart surgery is a high-risk surgery, and if intraoperative accidents happen, the condition deteriorates very fast and the outcome is often very tragic. When choosing a minimally invasive procedure, you must combine the resources you can control, the characteristics of the patient’s condition, and the severity of the condition to make the procedure that is most beneficial to the patient’s safety, without blindly pursuing a small incision. Patients also need to be careful to listen to their doctor’s advice. Everyone’s condition is not exactly the same, and his condition may be suitable for minimally invasive surgery while yours may not be, and future treatment technology and philosophy must be individualized, so never be superstitious and blind.