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Congenital Heart Surgery
World Journal for Pediatric and
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DOI: 10.1177/2150135110387622
2011 2: 104 World Journal for Pediatric and Congenital Heart Surgery
Horacio Capelli, Christian Kreutzer and Guillermo Kreutzer
Development of Pediatric Cardiology in Latin America : Accomplishments and Remaining Challenges

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Historical Review
Development of Pediatric Cardiology
in Latin America: Accomplishments
and Remaining Challenges
Horacio Capelli, MD
1
, Christian Kreutzer, MD
2
, and
Guillermo Kreutzer, MD
3
Abstract
Until the first quarter of the 20th century, most physicians were more than happy to differentiate congenital heart lesions from
rheumatic heart disease, which then was rampant. As early as 1932, Dr Rodolfo Kreutzer, from Buenos Aires, Argentina, was
already involved in the study of congenital heart defects. He started off assessing children with a stethoscope and with
Einthoven electrocardiography equipment. The cardiac unit at the Buenos Aires Childrens Hospital was created in 1936. It
established the onset of pediatric cardiology in Argentina and fueled its development in South America. Nearly at the same
time, Agustin Castellanos from Cuba also became a pioneer in the assessment of congenital heart disease. He described the
clinical applications of intravenous angiocardiography in 1937. Meanwhile in Mexico, Dr Ignacio Chavez founded the National
Institute of Cardiology in 1944 in Mexico City. It was the first center in the world to be exclusively devoted to cardiology.
From this center, Victor Rubio and Hugo Limon performed the first therapeutic cardiac catheterization in 1953. Meanwhile,
Professor Euriclydes Zerbini from Sao Paulo, Brazil, built the largest and most important school of cardiac surgeons in South
America. In Santiago, Chile, the Calvo Makenna Hospital was the center where Helmut Jaegger operated on the first infant
with extracorporeal circulation in Latin America in 1956. The patient was a 1-month-old baby, with complete transposition of
the great arteries, who underwent an Albert procedure. Currently, there are many fully equipped centers all over the region,
capable of dealing with most lesions and of providing excellent medical, interventional, and surgical treatment. Outcomes have
improved substantially over the last 20 years. These achievements have gone beyond our pioneers dreams. However, many neo-
nates and young infants die prior to surgery because referral centers are overburdened and have long surgical waiting lists. Clearly,
we still have to mastermind and establish sustainable public health policies to overcome these challenges.
Keywords
congenital heart disease, pediatric cardiology, pediatric cardiac surgery, history of pediatric cardiology, pioneers of pediatric
cardiology, development of pediatric cardiology in Latin America, achievements and drawbacks of pediatric cardiology in Latin
America
Submitted September 13, 2010; Accepted September 23, 2010.
Presented at the Multi-Societal Joint Meeting of the World Society for Pediatric and Congenital Heart Surgery (WSPCHS) dedicated to
Aldo R. Castaneda; July 15-17, 2010; Antigua, Guatemala.
In order to put in perspective the origin and growth of pediatric
cardiology in Latin America, we will highlight some early mile-
stones in the history of pediatric cardiology. Until the first quarter
of the 20th century, cardiology as a medical specialty arose from
early anatomical descriptions of congenital cardiac defects. Only
a few clinical diagnoses were made during life.
1
Most physicians
were more than happy to differentiate congenital heart lesions
from rheumatic heart disease, which then was rampant. Those
few pediatricians interested in cardiology taught themselves.
Physicians and Centers
Actually, the number of relevant people who have contributed
to the growth and development of pediatric cardiology in Latin
America is really large. Only a few of the most prominent will
be mentioned here. As early as 1932, Dr Rodolfo Kreutzer
(1900-1978) from Buenos Aires, Argentina, was already
concerned with the impact rheumatic fever had on the morbidity
1
Hospital de Pediatr a J. P. Garrahan, Buenos Aires, Argentina
2
Pediatric Cardiovascular Surgery, Hospital Nacional Alejandro Posadas,
Buenos Aires, Argentina
3
Hospital de Ninos Ricardo Gutierrez, Buenos Aires, Argentina
Corresponding Author:
Horacio Capelli MD, Hospital de Pediatria J. P. Garrahan, Pichincha 1850,
Buenos Aires, 1245, Argentina
Email: Horaciocapelli027@hotmail.com
World Journal for Pediatric and
Congenital Heart Surgery
2(1) 104-110
The Author(s) 2011
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and mortality of children.
2,3
At the time, 7 of 10 children with a
heart ailment had rheumatic heart disease. He was also deeply
involved in the clinical diagnosis of congenital heart defects.
4-6
So, he began assessing children with a stethoscope and with
Einthoven electrocardiography (ECG) equipment, which had
only 3 leads. Then, the cardiac unit at the Childrens Hospital was
created in 1936.
Among Kreutzers associates were Gustavo Berri, who later
would run the cardiac department from 1968 for over 20 years;
Juan Alberto Caprile, trained at Johns Hopkins; Juan Marletta;
and Gonzalez Parente, who would develop the catheter labora-
tory in the mid-1950s. They established pediatric cardiology in
Argentina, and subsequently, fueled its development in South
America. Actually, they were all pediatricians who needed some
guidance from cardiologists. They received a great deal of help
and advice from Pedro Cossio (1900-1986), an emblematic fig-
ure of Argentine cardiology, who became consultant at the Chil-
drens Hospital. Pedro Cossio, jointly with Tiburcio Padilla and
Isaac Berconsky, performed in 1932 the first cardiac catheteriza-
tion in the Americas and the fourth in the world.
7-10
Agustin Castellanos (1902-2000) from Havana, Cuba, also
became a pioneer in the assessment of congenital heart defects.
He was convinced that an appropriate contrast substance
could be used for the in vivo visualization of the cardiac cham-
bers. In 1937, Castellanos and his coworkers published a land-
mark paper on the clinical applications of intravenous
angiocardiography.
11
He described the normal patterns of car-
diac chambers and great vessels and also those in ventricular
septal defects (VSDs) and pulmonary stenosis. Subsequently,
in 1940, his team reported the method of retrograde injection
of dye into the aorta.
12
This aortography was mainly used
to evaluate aortic coarctation and a patent arterial duct.
Castellanoss work quickly achieved recognition among physi-
cians, mainly from Spanish-speaking countries. After reading
his innovative papers, Rodolfo Kreutzer immediately wrote
to Castellanos to find out the exact dose of substance to be used
in children, according to age and weight. Castellanos promptly
answered and generously provided all the details for a success-
ful procedure, and at the end of the letter, he added the follow-
ing: It is a truly revolutionary diagnostic method. . . . It is like
performing a cardiovascular necropsy in a living child. The
content of this letter was disclosed by Kreutzer in his first pub-
lication on angiocardiography in children in 1943 (Figure 1).
13
Mexico honored Castellanos by including his image in
Diego Riveras mural Great Men of Cardiology, which
stands at the National Institute of Cardiology in Mexico City.
It was a special request of Dr Ignacio Chavez (Figure 2). On the
upper left side of this beautiful mural, painted in 1943, 2 rele-
vant people related to the history of congenital heart disease
were portrayed: Karl Rokitansky (1804-1878), an anatomist
and pathologist from Vienna who first described the anatomy
of the congenitally corrected transposition, and Maude Abbott
(1869-1940), a renowned Canadian physician who published
the famous atlas of 1000 anatomical specimens of heart defects.
She was the only woman scientist depicted in the mural. Just on
the middle right side of it, Castellanos is portrayed near to the
fields of radiology and angiocardiography.
In 1944, Dr Ignacio Chavez (1897-1979), considered to
be the master of Mexican cardiology, founded the National
Institute of Cardiology in Mexico City. It was the first
center in the world to be exclusively devoted to cardiology.
El Maestro Chavez, as he was called by his disciples and
colleagues, was the director of the Institute from 1944 until
1961.
Figure 1. (A) Rodolfo Kreutzer (Buenos Aires, 1900-1978) performing retrograde arterial angiocardiography in an infant with aortic coarctation in
1951. (B) Aortogram.
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A large number of Spanish-speaking cardiologists, both
pediatric and adult, were trained in this famous institute.
Chavez had learned the skills of the French school of cardiol-
ogy in Paris and had a particular interest in congenital heart
disease. Among his many scientific contributions, he published
an excellent paper on selective angiocardiography in congeni-
tal and acquired heart disease in 1947.
14
From this institution,
many relevant contributions to ECG were made by the
Mexican school of electrocardiography led by Demetrio Sodi
Pallares, Jorge Espino Vela, and Enrique Cabrera. Their
remarkable studies and description of systolic and diastolic
overload patterns of both ventricles, as well as the ECG pat-
terns in several congenital heart lesions, have stood the test
of time and remain as relevant information in todays clinical
practice.
15,16
In addressing the field of ECG, it is of note that
the first description in the world of a congenital atrioventricular
block was reported by a smart pediatrician from Uruguay, Luis
Morquio, as early as 1901.
17
Sao Paulo, Brazil, was another important center for pediatric
cardiology in South America. This group was initially formed
by Radi Macruz, Munir Ebaid, Rachel Snitcovsky, Ademar
Atik, and others. They initially worked with Hugo Felipozzi,
a talented surgeon from Sao Paulo, who performed Brazils
first operation with extracorporeal circulation at Sabaddo
DAngelo Institute of Sao Paulo. Later, Professor Zerbini
(1912-1993) at Hospital de Clinicas started the most important
cardiovascular surgery program for the surgical treatment of
congenital heart defects. He will be remembered for building
the most important school for cardiac surgeons in South
America, where hundreds of excellent cardiovascular surgeons
were trained (Figure 3).
The Calvo Makenna Hospital in Santiago, Chile, was
another distinguished South American cardiology center.
Fernando Eimbcke, a pioneer of Chilean pediatric cardiology,
and his colleagues worked jointly with Helmut Jaegger, an
outstanding Chilean cardiovascular surgeon who operated on
the first infant in Latin America in 1956. The patient was a
1-month-old baby with transposition of the great arteries (TGA)
who underwent an Albert procedure, similar to a Mustard oper-
ation (F. Eimbcke, personal communication).
Cardiovascular Pathologists
In the 1950s, 2 eminent pathologists profoundly contributed
to the understanding of embryology and morphology of
simple and complex heart lesions: Maria Victoria de la Cruz
(Sancti-Spiritus, Cuba, 1916-1999) from the Institute of Cardi-
ology in Mexico City and Luis Becu (Buenos Aires, Argentina,
1927-1997) from the Buenos Aires Childrens Hospital. De la
Cruzs unique and smart investigation on living chicks
embryos was summarized in 2 important books: Development
of the Chick Heart and Living Morphogenesis of the Heart.
18,19
Reading both is a must for students and practitioners to
decipher the development of the early stages of the fetal heart
and particularly of the conotruncal abnormalities.
Luis Becu trained with Jesse Edwards at the Mayo Clinic.
He arrived at a propitious time and so had the privilege of
Figure 2. Diego Riveras mural Great Men of Cardiology, which
stands at the National Institute of Cardiology in Mexico City. On the
middle right side, Castellanos is depicted near to the fields of radiology
and angiocardiography.
Figure 3. Euryclides Zerbini (left) (Sao Paulo, 1912-1993) with his
distinguished disciple Guillermo Kreutzer (right).
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joining John Kirklins surgical group when they performed the
first open heart operation in 1955. Not infrequently, in those
early days, he used to be required in the operating room to unra-
vel the anatomical mysteries of hearts undergoing repair. He
was an outstanding cardiovascular pathologist with a brilliant
mind, which enabled him to take a new look at old matters usu-
ally not perceived by others. The term higgledy-piggledy to
describe the myocardial disarray often found in some forms of
diffuse cardiovascular disease shows his provocative and
humorous style in reporting his anatomical findings.
20,21
Becus anatomical classification of VSDs in the mid-1950s still
is currently used in many surgical reports.
22
Besides, it was the
guide and main source of anatomical information for one of us
to report, in the early 1980s, a 2-dimensional echocardio-
graphic classification of VSD.
23
Interventional Cardiac Catheterization
William Rashkind and William Miller described the first bal-
loon atrial septostomy in patients with TGA in 1966, and it was
the beginning of interventional cardiac catheterization in the
world.
24
Alberto Rodriguez Coronel, who had trained with
Miller in Chicago, performed the first atrial septostomy in a
neonate with TGA at the Buenos Aires Childrens Hospital in
1967. Likewise, in the same year, Alfredo Vizcaino Alarcon
also did a Rashkind procedure at the Childrens Hospital in
Mexico City. The first balloon pulmonary valvuloplasty in
Latin America was performed by Valmir Fontes at the Dante
Pazzanese Institute in Sao Paulo in 1982.
25
However, it should
be mentioned that the first therapeutic cardiac catheterization
procedure in the world was performed by Victor Rubio and
Hugo Limon in 1953 in Mexico.
26,27
They opened the pulmon-
ary valve by pulling a wire mounted at the tip of an arced cathe-
ter across the valve. It was published almost 30 years before the
landmark report by Kan et al,
28
which described balloon pul-
monary valvuloplasty. The procedure had not been repeated
by others, and thus, it was unfortunately forgotten.
Meetings and Societies
The Fourth Panamerican Congress of Cardiology was held in
Buenos Aires in 1952. A significant number (over 200) of
closed surgical procedures had been successfully performed
and reported by Alfonso Albanese (1906-2009) from Buenos
Aires (Figure 4).
29
Helen Taussig (1898-1986) attended the
meeting and was impressed with this large surgical series and
excellent results. Thus, she decided to visit the Buenos Aires
Childrens Hospital, where she shared her vast knowledge and
experience with the local colleagues (Figure 5). In 1953, the
VII International Congress of Pediatrics was held in La Habana.
The scientific program included a roundtable on surgery of con-
genital heart defects. The participants were Helen Taussig, John
Lind from Sweden, and 3 big guns from Latin America:
Agustin Castellanos, Ignacio Chavez, and Rodolfo Kreutzer.
Figure 4. Professor Alfonso Albanese (1906-2009) at age 97 years teaching anatomy at the School of Medicine of Buenos Aires University.
Capelli et al 107
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Many years later, in 1974, the idea of creating a Latin
Society of Pediatric Cardiology and Cardiac Surgery was first
conceived. It was in Caracas at the time of the Latin American
Congress of Cardiology. It was masterminded and put forward
by some prominent Latin American pediatric cardiologists
and surgeons, jointly with Manuel Quero Gimenez and Pedro
Antonio Sanchez from Spain. The late Manuel Quero Gimenez
(1941-2003) was an outstanding Spanish pediatric cardiologist
with a vast knowledge of cardiac morphology. The first Congress
of the Society, however, was held in Oaxtepec, Mexico, in 1982.
It was hosted by Carlos Perez Trevino and Alfredo Vizca no
Alarcon. Since 1982, the Congress has been staged successfully,
every other year, in different Latin countries, either in Europe or
in America. In 2005, the Congress of the Latin Society was held
jointly with the Fourth World Congress of Pediatric Cardiology
and Cardiac Surgery in Buenos Aires. It gathered 3000
delegatesthe largest attendance ever. Many Latin Americans
were able to attend a World Congress for the first time.
Current Situation: Achievements and
Drawbacks
We have tried to summarize how and where all these endeavors
started in our region. Latin America has been characterized as
having endured a long-standing deep social crisis. There has
always been a big gap between the haves and the
have-nots. Nevertheless, despite the ups and downs of our
emerging economies and somewhat unpredictable govern-
ments, we have come a long way until todays reality. Defi-
nitely, our achievements have gone beyond our pioneers
dreams. We count now a large number of fully equipped
centers, all over the region, capable of dealing with the whole
spectrum of heart lesions and of providing excellent medical,
interventional, and surgical treatment. A good example of the
latter is the Garrahans childrens hospital in Buenos Aires. It
runs the largest pediatric cardiology program in Argentina.
Over 800 children are operated on every year with an overall
mortality less than 5%. Certainly, our outcomes have improved
substantially over the last 20 years.
There is still plenty of room for improvement. Certain flaws
and drawbacks have to be recognized and confronted. The vast
majority of the population with congenital heart disease in Latin
America depends on the public health system.
30,31
This results in
overburdened referral centers, long surgical waiting lists,
delayed hospital admissions, and probably higher morbidity and
mortality rates. Furthermore, many patients are unable to get
access to treatment. The following example will provide insight-
ful information on this thorny issue: In Argentina, around 3500
children need cardiac surgery each year. However, only 2500
reach the opportunity to get access to treatment. Regarding this,
we have documented, with death certificates, that around 1000
children per year, most of them neonates and young infants, die
with an untreated congenital cardiac defect.
32
It should be
emphasized that these are preventable deaths that have a signif-
icant impact on the global childrens mortality rate.
Future Prospects
Clearly, we still have to mastermind and establish public health
policies to tackle our deficits and flaws. Only setting up sus-
tainable national programs will allow most children born with
a heart defect to get access to treatment. In order to succeed in
Figure 5. Helen Taussig (1898-1986) assessing a patient at the Buenos Aires Childrens Hospital in 1952.
108 World Journal for Pediatric and Congenital Heart Surgery 2(1)
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this serious issue, we must take some steps in the right direc-
tion. These will have to include, among others, the following:
increasing the number of centers able to cope with high com-
plexity procedures, improving the diagnostic facilities and
transportation from distant geographical regions, and addres-
sing the long surgical waiting lists. Other remaining challenges
for Latin America include the following: improving the devel-
opment of prenatal diagnosis, organizing effective follow-up
after surgery, and creating specialized centers to deal with the
increasing community and new problems of adult congenital
heart disease, particularly with their surgical treatment.
33
Finally, we must also devote time and effort to the development
of research in basic sciences.
We wish to round off this report with some acknowledg-
ments. We owe special recognition to some Latin American
surgeons who work or have worked in the United States and
have made significant contributions to our specialty for a
great deal of time: Aldo Castaneda, Francisco Puga, Eduardo
Arciniegas, and Pedro del Nido, among many.
Also, we feel a genuine indebtedness to 2 people who have
had a long-standing love affair with Latin American countries.
We refer to the late and great Bob Freedom (1941-2005) and to
our dear friend Jane Somerville. Their commitment, support,
and innovative thinking strongly influenced the development
of pediatric cardiology in the whole region. Although not born
in Latin America, both are Latin at heart.
Finally, we wish to express our gratitude to Aldo Castaneda,
an outstanding pediatric cardiac surgeon. Clearly, he has been
an inspiring figure to all of us. Nearly all Latin American sur-
geons have visited him in Boston, looking for training, valuable
information, or some piece of advice. He has always been eager
and willing to help and keeps showing a deep interest and com-
mitment to our problems and needs. His multiple scientific con-
tributions to pediatric cardiac surgery have earned the
admiration of contemporary pediatric cardiologists and cardiac
surgeons alike. Definitely, he belongs to a special breed of sur-
geons, and that is why the tribute to him by organizing a
Special Joint Symposium in Antigua, Guatemala, was an unfor-
gettable and moving experience.
Acknowledgments
The authors are truly indebted to the following colleagues and friends
for providing information and data referred to in this report: Gustavo
Berri from Argentina; Ademar Atik, Valmir Fontes, and Carlos Pedra
from Brazil; Alfredo Vizcaino Alarcon and Alfonso Buendia from
Mexico; Pedro Antonio Sanchez from Spain; Fernando Eimbcke from
Chile; Ruben Leone from Uruguay; Carlos Carcia Morejon from
Cuba; and Nestor Sandoval from Colombia.
Declaration of Conflicting Interests
The author(s) declared no conflicts of interest with respect to the
authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research and/or
authorship of this article.
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