Tuesday, 31 May 2011

Love always wins

Giancarlo Rastelli who died in 1970 at the age of 36, was a pioneer cardiac surgeon who developed a classification of atrioventricular canal (defects) and a novel surgical procedure that revolutionized the management of children with congenital heart disease.  In fact, using a new surgical technique based on the Rastelli classification from 1964, surgeons at Mayo Clinic –where he worked - obtained extraordinary results operating on the AV canal, with a reduction in mortality from 60 to 5%. Rastelli lived a short, yet fascinating life. His work was ahead of its time and laid the foundation for the treatment of complex congenital cardiac anomalies. The most extraordinary aspect of his successful research work was that it was mostly done during the five years when he was fighting his fatal illness –Hodgkin’s disease. With his intelligence, generosity, and love for life, he became an outstanding doctor and scientist.

Dr. Giancarlo Rastelli decided at a very young age that he wanted to be a doctor: a natural choice for him. He saw this as a vocation to which he was called by his faith from which he had learned to devote himself to others. He also had an inborn love for learning and scientific curiosity, cultivated at first in his family where he learned that “to stop research is to stop life,” as he used to say.

He attended medical school at the University of Parma in Italy where, on 19th July 1957, he graduated cum laude and had the honour of having his graduation thesis printed. During the third year of medical school, he had begun to visit the surgical department, and after his graduation, he continued to work there, devoting himself to his first scientific paper. During those years, he developed interest in cardiovascular surgery and experimental research, which offered, at that time, many challenges and extensive possibilities. He met his wife, Anna Anghileri, in Italy in 1959.

In the 1960s when cardiovascular surgery had only a few years of life, many difficulties were still present and many congenital heart diseases were inoperable or presented a very high rate of mortality. In 1960, Dr. Rastelli was granted a NATO scholarship which allowed him to choose between various centres in the USA: he preferred the cardiovascular surgical department of the Mayo Clinic. While in America, he continued to correspond with his wife-to-be almost daily.

In 1962 he started to operate with Dr. Kirklin, who very soon recognized and appreciated Gian’s great value as a surgeon and a scientist. At the same time, he was conquered by Dr. Rastelli’s human qualities, his moral strength, and the warmth of his friendship. Their scientific partnership was extremely profitable for both of them. Dr. Kirklin, who had been Dr. Rastelli’s master, wrote after his death: “I personally have learned many things from Dr. Rastelli. In the numerous scientific projects that we worked on together, new knowledge was developed which has been of both practical and theoretical importance to me.”

During this period of surgical work with Dr. Kirklin, Dr. Rastelli decided to study the common AV canal, one of the most difficult to repair among congenital heart diseases. As a conclusion of his research on a large series of anatomic specimens, he presented a new type of anatomical classification of complete common AV canals. This new classification explained some unclear aspects but, far more important, opened the possibilities for new surgical techniques, based on a very precise anatomical knowledge.

The results of Dr. Rastelli’s research were so new, and in some aspects even disconcerting, that only a few months later, they were officially accepted by Dr. Kirklin and the other colleagues of the Mayo Clinic and presented for publication. He will eventually settle for experimental cardiovascular research.

He got married to Anna in 1964 and a few days after their honey moon, he was diagnosed with Hodgkin’s disease (a cancer of the lymphoid cells which at that time had a very poor outcome). He was only 30 years. He never reduced or slowed his work. He was tireless, and derived a remarkable strength from his work. In 1966, they had a daughter, Antonella, who is also a doctor.

Through all those years of intense studies and research Dr. Rastelli succeeded in proving the possibilities of the repairing of another, at that time, inoperable congenital heart defect: the “Truncus arteriosus communis.” Many surgeons in various centers had repeatedly tried to separate the aorta and the pulmonary artery but without success.

Dr. Rastelli had the idea of using a homograft to connect the right ventricule to the pulmonary artery branches, detached from the Truncus, and to close the VSD leaving the original truncus to function as aorta. He experimented on this new type of intervention in the laboratory, with success. Then Dr. Dwight McGoon performed the first surgical procedure with this technique in 1967. With the same innovative technique of using the homograft to connect the right ventricle to the main pulmonary artery, and allowing the left ventricle to egress into the aorta only through the VSD, Dr. Rastelli successfully developed a new surgical procedure for complete repair of the Transposition of the great arteries associated with pulmonary stenosis and VSD. This surgical procedure, performed today in every major cardiovascular centre all over the world, is unanimously recognized by cardiologists and cardiac surgeons as “The Rastelli Procedure”.

For two consecutive years, Dr. Rastelli was awarded the Annual Golden Medal for Research of the American Medical Association: the first, for his research on AV canal, and the second, for the innovative technique used for surgical repair of the Truncus Arteriosus and transposition of the great arteries. Finally, in 1968, young as he was, the Mayo Clinic appointed Dr. Rastelli as Head of Mayo Cardiovascular Surgical Research.

Patients were always his first concern and Dr. Rastelli dedicated himself tirelessly to them. He displayed a poster with the Italian saying L'Amour Vince ("Love Always Wins") in his office. Many patients signed the poster as an expression of hope and appreciation. Being a compassionate person, he always explained to his patients the exact underlying cause of the illness, as well as the anatomy, pathology, and treatment options. He also had a passion for both classical music and mountain trekking.

The words of Dr. John Kirklin, Rastelli’s master, in a testimony he wrote to Mayovox a few days after Dr. Rastelli’s death: “Perhaps the most remarkable aspect of this man’s life was his reaction to his fatal illness. About five years ago, he walked into my office and said that he had Hodgkin’s disease. He told me this with about the same display of emotion that he would have used should he have said that our densitometer was not working properly. Somehow an unspoken agreement developed between us that neither of us would speak of this illness unless there was urgent need to do so. About a year and a half later, another recurrence developed and he told me of this in the same simple words. Dr. Rastelli was too intelligent not to realize that his disease could be fatal. Yet he worked happily, vigorously, and productively, with apparently never a thought to the fact that his life could end prematurely. Characteristically, two weeks before his death he wrote me a letter announcing with pride his receipt of several honors. In this letter, there was no hint of what he must have known, namely, that his disease had progressed greatly. It contained only enthusiasm for the work that lay ahead, and warmth for his friends. The serenity and confidence with which Dr. Rastelli faced life and death, literally, is the greatest of the many things that he taught me, and taught many of us. Dr. Rastelli’s fame as a scientist and a researcher belongs now to the historical memory of medicine, while his work is carried on every day all over the world through the surgical interventions he invented for treatment and repair of congenital heart diseases.’’

Special thanks to Umberto Squarcia and Antonella  Squarcia, Dept of Pediatrics, Pediatric Cardiology Unit, University of Parma, Italy.

Konstantinov, IE: A Tribute to Giancarlo Rastelli. Ann Thorac Surg 2005;79:1819-1823. http://ats.ctsnetjournals.org/cgi/content/full/79/5/1819
McGoon DC, McMullan MH, Mair DD, Dannielson GK: Correction of complete atrioventricular canal in infants. Mayo Clin Proc 1973;48: 769–772
Rastelli GC, Kirklin JW, Titus JL: Anatomic observations on complete form of persistent common atrioventricular canal with special reference to atrioventricular valves. Mayo Clin Proc 1966; 41: 296–308
U Squarcia and A Squarcia: Giancarlo Rastelli: The Scientist, the Man. Clin. Cardiol. 30, 485–487 (2007).Dept of Pediatrics, Pediatric Cardiology Unit, University of Parma, Parma, Italy