He put the arteries back where they belong

Fifty years ago, in September 1976, a surgeon in São Paulo told the world how to repair a newborn heart built the wrong way round. He was the son of Lebanese immigrants who had gone to live in the Amazon, and the operation still carries his name.

In September 1976 the Journal of Thoracic and Cardiovascular Surgery printed a short paper from Brazil. It was seven pages long and its title was plain: Anatomic correction of transposition of the great vessels. The lead author was Adib Domingos Jatene.

The paper described two babies. One was three months old and weighed 4,200 grams. The other was forty days old and weighed 3,700 grams. Both had been born with the two great arteries of the heart in each other’s place. The team cooled them deeply, stopped their circulation, and rebuilt the outflow of the heart so that each artery came from the chamber it should.

The first baby, a girl, recovered from the operation itself with a heart that was working well. Her kidneys failed and she died on the third day. The second, a boy, made an uneventful recovery. Twenty days after surgery the tests showed the malformation completely corrected. Five and a half months later he weighed 7,500 grams and, the paper said, was developing very well.

Surgeons around the world now call it the arterial switch, or simply the Jatene operation.

The condition is called transposition of the great arteries. The United States Centers for Disease Control and Prevention describes it simply. The aorta and the pulmonary artery, the two large vessels that carry blood out of the heart, are swapped. Blood that comes back from the body short of oxygen is pumped straight back out to the body. Blood that has collected oxygen in the lungs is sent back to the lungs. Two loops, running side by side.

Some blood can cross between the loops through a hole in the heart or a vessel that has not yet closed, and how ill the baby is depends largely on how much does. The CDC says every baby born with it needs surgery, and estimates that about one in 3,846 babies in the United States is born with it, about 920 a year.

There was already a way to keep these children alive. In the atrial switch, the surgeon leaves the arteries where they are and builds a channel inside the upper chambers to reroute the blood. The CDC notes the cost: the right ventricle is left pumping to the whole body, which can cause problems later in life. The obvious answer was to swap the arteries themselves. The difficulty was the two coronary arteries. When the great arteries are switched, they have to be moved too, and reattached to the aorta.

The Embryo Project Encyclopedia at Arizona State University sets out what came before. In 1952 and 1953 Charles Bailey, in Philadelphia, switched the great arteries but left the coronary arteries behind. All of his patients died. In 1954 Harold Albert, in New Orleans, proposed that the operation would work if both coronary arteries were moved across. The same year William Mustard, in Toronto, tried it moving only the left one. All three of his patients died.

Jatene prepared for a long time. An editorial in the Brazilian Journal of Cardiovascular Surgery by two Mayo Clinic surgeons, Elizabeth Stephens and Joseph Dearani, records that he examined 62 pathology specimens of this and related defects held at the Dante Pazzanese Institute of Cardiology in São Paulo before he operated. His method, as the 1976 paper describes it, was to cut out both coronary arteries with a small piece of the aortic wall attached, move them to the artery at the back, patch the holes they left, then divide the two great arteries and join each to the other’s stump.

He reported the surviving case first in the journal of the Brazilian Society of Cardiology, in August 1975, under the title of a preliminary report. The fuller paper followed in the American journal the next year. He later said that the first case, the baby who died, had convinced him the operation could be done.

He was born on 4 June 1929 in Xapuri, in the state of Acre, a town in the far west of Brazil near the borders with Peru and Bolivia. Domingo Braile, the editor in chief of the Brazilian Journal of Cardiovascular Surgery, and Enio Buffolo wrote in their tribute after his death that Adib was the son of Lebanese immigrants who had crossed into the unknown early in the twentieth century and gone to live in the jungle. Wikipedia gives his parents’ names as Domingos Antonio Jatene and Anice Adib Jatene.

His father traded in rubber, the latex tapped from wild trees in the forest. On one trip into the forest he came home with a high fever and jaundice, and within a few days he was dead. Adib was two.

The family stayed in Xapuri until he was about ten. Then his mother took the children to Uberlândia, in Minas Gerais, where she set up in business. The Mayo editorial says she moved them so that they could get a better education. In 1947 he went to São Paulo, thinking of engineering or medicine, and in 1948 he entered the medical school of the University of São Paulo.

He meant to study public health and go back to Acre. In 1951, in his fourth year, he joined the team of Euryclides de Jesus Zerbini, and scrubbed in for the operation that opened a narrowed mitral valve at the university hospital. He did not go back to Acre. He graduated in 1953, aged twenty three.

In 1955 he moved to Uberaba, in Minas Gerais, to teach anatomy and operate. There was no heart lung machine. So he built one. The Embryo Project says he did it with the help of an auto repair and engine reconditioning shop. Braile and Buffolo add that he built a disc oxygenator as well, and used both for experimental heart surgery on dogs.

Zerbini called him back to the university hospital in São Paulo, where a workshop for making surgical equipment had been set up. Braile and Buffolo say he built improved bypass machines, oxygenators, heat exchangers and thermometers there, used in Brazil and in other South American countries, with some models shipped to Europe.

In 1961 he moved to the young Institute of Cardiology of the State of São Paulo, now named after Dante Pazzanese. In 1962 he set up another workshop there. According to his biographers it made artificial heart valves of the Starr Edwards type two years after the original was developed, along with defibrillators, pacemakers and oxygenators, and later a tilting disc valve that earned an international patent. Braile and Buffolo make the larger point themselves: where most developing countries imported this equipment, Brazil learned to make it.

The Embryo Project says that by 1998 his operation had replaced the Mustard operation as the standard treatment. The CDC today calls the arterial switch the most common repair, usually done in the first month of life. Braile and Buffolo write that it gave rise to a new subspecialty, heart surgery in newborns, with its own surgeons and its own intensive care.

His own career kept going in several directions at once. In 1983 he became professor of cardiovascular surgery at the University of São Paulo, at the Heart Institute known as InCor, and he retired from there in 1999 as professor emeritus. He served twice as Brazil’s minister of health. A Folhapress report on his death notes that he never joined a political party. He went on operating at the Hospital do Coração in São Paulo, and Braile and Buffolo put the number of patients he operated on personally at more than 20,000.

Two of his sons, Fábio and Marcelo, became heart surgeons at InCor, Marcelo in charge of children’s heart surgery. His daughter Ieda became a paediatric cardiologist.

He died at the Hospital do Coração in São Paulo on 14 November 2014. He was eighty five.

The date. Braile and Buffolo say that on 8 May 1975 he operated on the first patient with the new technique. The Embryo Project calls 8 May 1975 the date of the first successful arterial switch. The 1976 paper and the Mayo editorial agree that the first of the two babies died and the second lived. Since the sources we read do not say which baby was operated on that day, we give the date and not the claim attached to it.

His father’s trade. Braile and Buffolo and the Mayo editorial call him a rubber trader. Wikipedia says he was a merchant selling goods to the rubber tappers. The Embryo Project calls him a rubber tapper, and so does the Folhapress report. We say he traded in rubber.

The return to São Paulo. Braile and Buffolo say Zerbini called him back in 1957. The Embryo Project says 1958.

His years as minister. The Embryo Project says 1990 for eight months, then 1995 to 1997. Braile and Buffolo say 1992, then 1996 to 1998. Folhapress says eight months in 1992, then twenty two months in 1995 and 1996. We say twice, and leave the years to the record.

His papers. Wikipedia says more than 270 scientific studies. Folhapress says about 700. Braile and Buffolo say about 800. We print none of them.

The earlier Lubnan pieces keep finding the diaspora in places nobody thinks to look: a consulate ledger in Beirut, business directories in Argentina, a chemistry laboratory in Massachusetts. This one starts on a rubber frontier in the Amazon, where a Lebanese trader died of a fever and left a widow with young children.

Her son did not have the machine he needed, so he built it in a mechanic’s shop. He did not have an operation for the babies he wanted to save, so he studied 62 hearts until he could design one, and lost a patient before it worked. Then he wrote it down so that anyone could do it.

That is what excellence looks like when it travels. It did not stay in São Paulo. By one account it became the standard treatment within about twenty years, and the CDC calls it the most common repair today.

So it goes on the record. With the dates, the disagreements and the name of the town where he was born.