Archivos Peruanos de Cardiología y Cirugía Cardiovascular

Arch Peru Cardiol Cir Cardiovasc. 2021;2(2):77-85. Editorial Cardiology and Cardiovascular Surgery in Peru: A Brief History Breve historia de la Cardiología y Cirugía Cardiovascular en el Perú

Bertha Gonzales Álvarez 1,a; Aida Rotta Rotta 1,b; Ofelia Aráoz Tarco 1,c*; Gian Huamán Benancio 2,c ; Vitalia Pisfil Farro 3,c; Daysi Diaz Seijas 3,c; Carlos Pereda-Joh 1,c; Manuel Chacón-Diaz 1,c

Received: June 25, 2021 s we commemorate the Bicentennial of Peru’s Independence this year, we cannot fail to Accepted: June 26, 20211 mention aspects of the history of cardiology and cardiovascular surgery in the country Authors’ affiliation 1 Cardiologist. and the contributions that these specialties have made to society. 2 Pediatric cardiologist. A 3 Nurse. a Clínica Padre Luis Tezza, Lima, Perú. Research from pre-Inca times has shown us, that members of the Sechin culture, for example, b Nacional Cayetano Here- dia, MINSA, Lima, Perú. knew the anatomy of the human body through dissection and vivisection, as reflected in the petroglyphs c Instituto Nacional Cardiovascular INCOR, EsSalud, Lima, Perú. that they left us as legacy, one of them seems to correspond to the representation of the heart, lungs and (1,2) Correspondence diaphragm (Figure 1) . The chronicler Guamán Poma de Ayala, refers in his writings to the knowledge Calle Coronel Zegarra 417, Jesús María, Lima, Perú. of chest pain as a symptom, referred to as “tight heart”, also evoking aspects that could correspond to the (3) E- mail knowledge of cardiovascular risk factors . [email protected]

Financial sources The oldest data about the first Peruvian doctors dedicated to the study of the heart go back None to declare to the year 1888, when Dr. Ernesto Odriozola (Figure 2) describes the heart in his doctoral thesis in Disclosures None to declare Paris: «Lesions of the heart following atheroma of the coronaries ». In 1904 he published his “Clinical

DOI: 10.47487/apcyccv.v2i2.141 Lessons” with semiological, pathophysiological and clinical data on cases of aortic valve disease, in 1920 he published a case of complete atrio-ventricular block, cited by Dr. Paul White in his work “Heart diseases” as the most severe bradycardia case published in the literature for that date (4). Dr. Julián Arce, professor at Universidad Nacional Mayor de San Marcos (UNMSM) and head of the San Roque ward of the Dos de Mayo Hospital, in 1918 published the first case in Peru of a patient with atrial fibrillation treated successfully with quinidine. Dr. Maximiliano Gonzales would follow the path of the cardiology study in the famous San José ward in Dos de Mayo´s Hospital, where the seed of what would become the Peruvian

Figure 1. Sechin petroglyph

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the San José ward from 1931; Likewise, he was the first Peruvian doctor dedicated exclusively to the practice of cardiology and formed the first cardiology school with doctors Eduardo Perez Aranibar, Aurelio Peralta, Augusto Mispireta, Pedro Moyano, Pedro Roggero, Carlos Guibovich, Roberto Delgado and Marcos Roitman, becoming thus in the first visionary of the creation of a National Institute of Cardiology (1957) (4).

Around the year 1940, the scientific spirit of many Peruvian doctors led to the investigation of the physiology of the “Andes people”, so there are important contributions related to cardiac and pulmonary function at high altitude, data recognized worldwide and reflected in research articles such as that on pulmonary circulation at sea level and at high altitude (4). It is known that, in those years, diagnostic cardiac catheterizations were performed as part of the investigation.

The teaching of Cardiology within the course of Internal Medicine at the Faculty of Medicine of the University of San Marcos in the 1940s, was based on clinical procedures of the French school, prior to World War II (4). The exploratory arsenal Figure 2. Dr. Ernesto Odriozola included the stethoscope, the aneroid sphygmomanometer, the http://historiamedicinaperuana.blogspot.com/2012/05/ernesto-odriozola- 150-anos-de-su.html , the chest X-ray in three positions and the Eithoven electrocardiogram, in its three classic leads (4). Therapeutics consisted in the use of digitalis leaf powders, mercurials that were cardiology school was sown, and whose first exponent would used as diuretics, antiarrhythmic drugs such as quinidine, and be Dr. Rafael M. Alzamora Freundt (Figure 3). Dr. Alzamora antihypertensives such as rauwolfia and reserpine(4) . acquired the first electrocardiograph in Peru (1921) and took over The of the Public Charity (Hospital Arzobispo Loayza) and hospitals of Ministerio de Salud (4) were in operation at that time, and many Peruvian cardiologists recently trained abroad began their work in the country, such as Dr. Matías Ferradas at the Arzobispo Loayza Hospital and Dr. Víctor Alzamora Castro at Dos de Mayo, who brought to Peru the electrocardiographic record of precordial derivations, and generalized its use since 1944 (5). Likewise, the classic cardiology schools of Loayza hospital, Dos de Mayo hospital, Military hospital, Naval hospital, Aeronáutic hospital, Socialsecurity worker hospital and San Juan del Callao hospital were stablished, where important figures of Peruvian cardiology are highlighted such as the Doctors Augusto Mispireta, Carlos Roitman, Enrique Arnaez, Andrés Rotta, Carlos Rubio, Teobaldo Pinzas, Matias Ferradas and Jorge Luis de Somocurcio.

In 1945 the Cardiology Service of the Hospital del Niño was inaugurated, its first head was Dr. Augusto Mispireta Dibarbout (Figure 4), who together with doctors Guido Cornejo, Carlos Guibovich, Carlos Solís and Carlos Ruíz began the care of the pediatric population with cardiovascular disease. Dr. Ricardo Tole was a pioneer of pediatric Cardiovascular Surgery, since 1945 he performed ligation of the ductus arteriosus, and the first Blalock- Figure 3. Dr. Rafael Alzamora Freundt Taussig anastomosis in 1951, in a patient with tetralogy of Fallot.

http://cecraf.blogspot.com/p/jrss05.html Likewise, it is in this hospital where Dr. José Bocanegra and Dr. Jesús Bendezú carried out the first hemodynamic study in 1954.

78 | EsSalud Arch Peru Cardiol Cir Cardiovasc. 2021;2(2):77-85.

Figure 5. Dr. Carlos Peschiera Figure 4. Dr. Augusto Mispireta http://repebis.upch.edu.pe/articulos/acta.hered/v49/a29.pdf

In the Obrero hospital from the Social Security System, a directed by Dr. Carlos Peschiera (Figure 5), who in 1946 performed Cardiovascular Surgery Service was created at those time and was the first cardiac surgery in Peru (ligation of ductus arteriosus).

Figure 6. Sociedad Peruana de Cardiología´s founding act https://sopecard.org/pdf/historia-sociedad-peruana-cardiologia.pdf

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president, and due to this event, March 12 was considered the Peruvian Cardiology Day years later, by Ministerial Resolution 397-2001 (5, 6).

The Department of Cardiology of the Arzobispo Loayza Hospital, with the support of the Public charitable institute and the Faculty of Medicine of the UNMSM, was inaugurated in 1956. Its first head was Dr. Andrés Rotta (Figure 7), together with Drs. Ruiz de Somocurcio and Dr. Pinzas performed electrocardiographic, vectocardiography, phonocardiography, ballistocardiography recordings and cardiac catheterization studies (Figure 8). Dr. Dante Peñaloza (Figure 9) joined the team promoting cardiological research, especially in the study of the heart and circulation in high altitudes (5,6), activities that were carried out at the Institute of Andean Biology from the UNMSM and then at the Altitude Institute of the Cayetano Heredia Peruvian University.

In 1953, the first intracardiac surgery was performed at the Hospital Obrero: mitral valvotomy by Dr. Marino Molina Scippa with the assistance of Dr. José Valencia and Justiniano Figure 7. Dr. Andrés Rotta Murphy. The following year, Drs. Molina, Valencia, and Carlos https://medicina.unmsm.edu.pe/index.php/en/home/2013-09-24-08-36- 52/2013-10-02-07-13-20 Alcántara performed the first surgical correction of an interatrial communication. The surgical team formed at this hospital, supported the development of cardiovascular surgery in other In the Inter-American Congress of Cardiology held in La hospitals, for example: Dr. Peschiera at the Dos de Mayo Hospital Habana in 1947, Peru was not represented because it did not have operated the first cases of coarctation of aorta (1956) and Dr. a cardiology society. For this reason, Dr. Rafael Alzamora, together Molina’s team in Loayza Hospital. In 1956, in the Cardiology with Dr. Andrés Rotta and other 22 leading cardiologists of the Service of Dos de Mayo Hospital, the hemodynamic laboratory time, formed the Peruvian Society of Cardiology on March activities began under the charge of Dr. Ricardo Abugattas. 12, 1947 (Figure 6), with the aim of promoting the progress of cardiology, the activity and the formation of the Peruvian The Cardiology Service of Hospital Obrero, was created Cardiology Institute. Dr. Rafael Alzamora Freundt was its first in October 1958, headed by Dr. David Cánepa, who was joined

Figure 8. Dr. Andrés Rotta. Andean biology service. Arzobispo Loayza Hospital.

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Montesinos (the latter formed at the Cleveland Clinic where Dr. René Favaloro created the surgical technique) (Figure 10). In 1971, electrophysiological studies were carried out for the first with intracavitary recording of the sinus node, atrium, bundle of His and branch potentials, with the help of Dr. Edgar Sowton from the London Institute of Cardiology. Likewise, computerized thermodilution started to be used to determine cardiac output thanks to Dr. Marco Romero, which facilitated the monitoring of patients in the coronary unit and in the postoperative period of cardiac surgery. Numerous studies have been published as a result of these advances, among which are the reports of the first cases of catheterization in patients with myocardial rupture during infarction. Furthermore, Dr. W. Fernández describes the «Hemodynamic alterations in myocardial infarction. Clinical correlation and therapeutic implications” in line with the results published by Forrester the same year.

On March 27, 1972, Dr Marino Molina (Figure 11) and Dr Carlos Alcántara, at the Hospital del Empleado, performed the first Figure 9. Dr. Dante Peñaloza heart transplant in Peru in a 29-year-old patient, unfortunately https://sopecard.org/la-sociedad-peruana-de-cardiologia-entrega-la- medalla-a-su-presidente-honorario/ the patient died 37 hours after intervention for “acute rejection.”

In the 1980s, Dr. Waldo Fernández Durán (Figure 12)

by Drs. Ruiz de Somocurcio, Esperanza Mestas, Waldo Fernandez and Emilio Tafur. This group managed to give a very significant impulse in Peruvian cardiology, generating an important development that allowed the introduction of new techniques and concepts, such as the determination of stimulation thresholds in patients with pacemakers in 1966, allowing pacemakers implantation on demand by Dr. Waldo Fernandez since 1967. On August 12, 1968, the country’s first Coronary Unit was inaugurated with Dr. José Ruiz de Somocurcio as head and Drs. Armando Estremadoyro, Aurelio Sánchez and Rodolfo Leon as residents. That same year, the Hospital del Empleado also began its care activity with Dr. Ricardo Álvarez and Dr. Hugo Dejo, concomitantly Dr. Marino Molina began the activity in the Cardiovascular Surgery Service, pacemaker implantation began in 1964 and cardiac catheterization studies began in 1966. The Cayetano Heredia Hospital inaugurated its Cardiology Service in 1968, founded by Dr. Fernando Tapia. In the 1950s, Dr. Félix Lazo Taboada, being president of the Public Welfare Society of Arequipa and a Cardiologist at the Goyeneche Hospital, managed to equip the cardiology office in that hospital, acquiring the first electrocardiograph in the city of Arequipa.

In the 1970s, coronary arteriography began at the Obrero Figure 10. Dr. Efraín Montesinos Hospital and, as a result of this, in 1971 the first myocardial https://docplayer.es/97026793-La-cirugia-toracica-y-cardiovascular-en-el-peru. revascularization with coronary aorto bypass with saphenous html vein was performed by Dr. Carlos Peschiera Carrillo and Dr. Efraín

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Figure 12. Dr. Waldo Fernández

Figure 11. Dr. Marino Molina https://docplayer.es/97026793-La-cirugia-toracica-y-cardiovascular-en-el-peru. html After many efforts, a dream came true, the Instituto Nacional del Corazón- INCOR (Figure 13), was created on August 12, 1992, by Executive Presidency Resolution 075-IPSS-92, with the purpose that the Social Health Security have a highly began the study of coronary in patients with acute specialized healthcare center with the greatest technological coronary insufficiency and Drs. Chiong, Álvarez and Mazuelos on resources in accordance with scientific advances. Its first director cardiac surgery in patients with myocardial infarction. In 1983, it was Dr. Waldo Fernández, who together with a group of specialists began the use of intracoronary fibrinolysis for the management managed to keep up with the advances in percutaneous and of acute myocardial infarction. In 1985, the transluminal coronary highly specialized surgical interventions for that date. Also angioplasty was started by Dr. Waldo Fernández, and made the peripheral arterial intervention was added (carotid stent 1999) cardiological group of the Guillermo Almenara Hospital (former and aorta stent implantation (1999). Obrero Hospital) the one with the highest activity and productivity in interventional cardiology. In 1987, pulmonary and aortic At Dos de Mayo Hospital, Dr. Efraín Montesinos valvotomy was introduced using balloon catheter. After many Mosqueira - who had practiced cardiovascular surgery in Ohio years of the first heart transplant, the transplant activity began at (USA) - together with The Medical Association of Peruvians the San Borja Clinic under the charge of Dr. Bracamonte, thus, in Residents in the USA (PAMS) participated and collaborated 1991 a heart transplant was performed on a 59-year-old patient with about 70 humanitarian medical missions in different with dilated cardiomyopathy. In 1993 a new heart transplant was departments of Peru. Once retired, they decided altruistically performed at the Almenara Hospital by Dr. Primo Pacheco. to re-establish themselve in Peru to give his experience, so together with cardiologist from the hospital organized a Thorax The development of cardiology as a medical specialty and Cardiovascular Surgery Program in order to to support the has been strongly linked to the way in which the national health poor people. From November 1998 to 2007, Dr. Montesinos was system has evolved, so that for many years only large public director of the Thorax and Cardiovascular Surgery Program of hospitals (MINSA) and social security could have cardiology Dos de Mayo National Hospital, dedicated to free cardiothoracic services properly prepared. However, at present, thanks in surgery for the benefit of the poor and the population indigent of part to private initiative and in part to the improvement of the Peru; likewise, the service was equipped with modern technology. national economy, despite not having an adequate increase in the budget for health, many lower-level hospitals have been able The following years have consolidated the cardiology to implement cardiologic services that can provide quality care (7). services of public and private hospitals at national level with

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Figure 13. Current building of Instituto Nacional Cardiovascular- INCOR in Lima.

the advancement of technology and the sub-specialization of four beds located in Pavilion 2BE was implemented under the medical personnel in centres of international prestige. Thus, leadership of Luisa Picasso, so the specialization of a group of since 2010 the heart transplant program at INCOR was restarted, nurses began. With the passing of the years, the aforementioned which to date has transplanted 87 patients; in this way, the first services became a great schol for the teaching of cardiology pediatric heart transplant was performed in 2011. As a necessary and cardiovascular surgery. Initially small continuing education and complementary part in the management of these patients, courses were held in which the knowledge of heart diseases since 2015 the use of the extracorporeal membrane oxygenation was deepened, in order to give adequate nursing care, later the system (ECMO) has been incorporated; to date, there have been specialization has been formalized through the universities. implanted a total of 47 devices. Also, since 2017, mechanical On April 27, 1999, the Universidad Nacional Mayor de ventricular assist devices have given new lease of life to 15 San Marcos, through the Postgraduate Unit, began the creation patients. The implantation of the transcatheter aortic valve (TAVI), of specialties in nursing. The nursing residency modality is the endovascular repair of the thoracic aortic aneurysm (TEVAR) created with Rectoral Resolution 04410-R-18, in compliance in the Interventional Cardiology area, and percutaneous ablations with DS 031-2015-SA of September 25, 2015, which responded with three-dimensional maps in electrophysiology, together with the advent of new imaging techniques such as tomography and to the country demand for nursing specialists and whose cardiac magnetic resonance imaging, allow us to contribute to purpose was to improve the care provided in health services the well-being of our population we serve. through specialized care. The Sociedad peruana de enfermería en el cuidado cardiológico y cardiovascular (SPECCYC) was created, on July Cardiovascular nursing 10, 2006 by a group of nurses specializing in cardiovascular surgery The training of nursing professionals in the care of patients and cardiology. The SPECCYC is a non-profit scientific society in the specialty of cardiovascular surgery in Peru dates back whose purpose is to encourage and promote scientific progress to 1965 at the Guillermo Almenara National Hospital, being in in Nursing, enhance quality care and promote professional charge of Lic. Enf. Doris Dolores. Cardiology nursing has its origin development through continuous education, promoting the on August 12, 1969 when the first Coronary Unit was created at scientific production and the formulation of policies in specialized Guillermo Almenara Irigoyen National Hospital. This unit with care to achieve hierarchical professionals in constant renewal and

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Cover art: “Retablo cardiovascular”

development for the benefit of the community and the Lex Artis system and the lack of public policies on the subject, are a threat of the profession. to the adequate diagnosis and treatment of several potentially fatal diseases (characteristic of cardiovascular diseases). The In 2015 the College of Nurses of Peru with Resolution proper organization of the community (patient associations), 357-15 CN / CEP recognizes the specialties of cardiology health centers and scientific societies, will allow coordinated nursing with a mention in cardiac rehabilitation; nursing in work among all those who make up the cardiovascular health cardiovascular surgery and extracorporeal perfusion, cardiac system in the country, so we can first know our reality to be able surgery and vascular surgery. This was notified to the entities that to propose solutions according to our needs and to improve the train specialists for their mandatory application and respective management of our patients as in the best places in the world, as issuance of the specialist registry. it should be, as they deserve.

This month marks the 200th anniversary of Peru’s In the bicentennial year... declaration of independence and we are still far from being Currently, cardiovascular is the second leading the ideal country to which all Peruvians surely aspire; but from cause of death in Peru and there is still a wide gap for adequate where we are witnesses of this bicentennial, let us at least try to access to health services for the population. The lack of equipment continue making Peruvian cardiology and cardiovascular surgery and qualified human resources, the fragmentation of the health an example of teamwork, of humanization in the treatment

84 | EsSalud Arch Peru Cardiol Cir Cardiovasc. 2021;2(2):77-85. of patients, of accurate diagnosis and treatment, and of always being at the forefront of advances in our specialty. Acknowlegments: The members of the editorial team of Archivos Peruanos de Cardiología y Cirugía Cardiovascular hope that the articles in We thank doctors Jorge Mispireta, Walter Alarco León and this issue will be of your interest. Nurse Blanca Contreras for their selfless collaboration.

References

1. Moscol Gonzales J. El conocimiento anatómico en el Perú preincaico. 5. Peñaloza D, Gamboa R, Dyer J, Echevanía M, Marticorena E. The Revista de la Asociación Médica Argentina. 2018; 131(4): 4-11. influence of high altitudes on the electrical activity of the heart. 2. Dejo Bustíos H. El corazón y pulmones en el petroglifo de Sechin. Acta Electrocardiographic and vectorcardiographic observations in the Med Per. 2009; 26(2): 141-43. newborn, infants and children. Am Heart J. 1960; 59:111-28. 3. Dejo Bustíos H. Historia de la Medicina. El Dolor Torácico en la época 6. Peñaloza D, Del Río C, Luy G, Cruz J, Gamboa R, Marticorena E, Dyer incaica. Revista Horizonte Médico. 2008; 8(2): 53-5. J, Sime F. Relationship between AQRS and the level of altitude. ln ProgressReport. USPHS Research Grant HE-06910. Cardiovasculary 4. Fernández W. Cardiología. En: Salaverry O. Historia de la Medicina laboratory of High-Altitude Research lnstitute, Peruvian University Peruana en el siglo XX (Tomo I). 1ra edición. Lima: Fondo Editorial UNMSM; 2000. 305-32. Cayetano Heredia, 1965.

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