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Domingo Braile

Domingo Braile: Surgical innovation

Doctor, researcher and inventor relates how he built up a business in cardiac devices in up-state São Paulo

MARLON FIGUEIREDOSurgeon Domingo Braile could be known today as an engineer, businessman, airline pilot or even as a good mechanic. His choice of medicine, however, did not prevent him from carrying out all of these activities. If he had chosen any other profession, instead, he would probably not have managed to become a surgeon. It was thanks to the influence of his father and constant visits to car workshops in Sao Jose do Rio Preto that the doctor was able to reconcile all his skills. Today,on his résumé he has performed 25,000 cardiovascular operations, set up  a company that does research and development on surgical equipment, established medical services in 21 hospitals in São Paulo and up-state and has an intense academic life, with 260 articles published in scientific journals.

Domingo Braile was a disciple of Euryclides Zerbini, the first surgeon to do heart transplants in Latin America. In the School of Medicine, of the University of São Paulo (FMUSP) he was a student and colleague of the generation that created and developed Brazilian cardiology, the center of which was São Paulo. Even so, he kept to his original plan of returning to the town where he grew up, São Jose do Rio Preto, to do there what was only done in the capital: open-heart surgery, as the procedure to open the patient’s chest to repair the heart inside is called. To do so he needed the support of an artificial heart-lung pump – or bypass machine – to stop the heart without killing the patient. Braile had already made two such pumps with Adib Jatene in the workshop of the Hospital das Clínicas. He did the same in Rio Preto and began operating. Domination of the medical, mechanical and electronic fields led him to create one of today’s successful businesses, Braile Biomédica.

In the academic area, he worked in other universities besides USP, such as the Federal University of São Paulo (Unifesp) and the State University of Campinas (Unicamp) and he was the co-founder of the Medical School of Rio Preto, Famerp. As editor of the Brazilian Journal of Cardiovascular Surgery he transformed it into the only specialized journal in the Southern Hemisphere, plus Latin American and the Caribbean, which has been on the ISI-Thomson since last year, in addition to being in PubMed / Medline and SciELO. Braille learned to fly a plane when he was 17, a skill that ended up being useful years later for moving quickly between distant cities – Rio Preto is located 450 km. from the capital and 300 km. from Campinas. At 72, the author of two books (Millennium, 2000, and Cronicas de um médico do sertão [Tales of a doctor from the backwoods], 2008) and the father of two daughters. Attorney Patricia replaced him as president of the company and cardiologist Valéria heads up the Domingo Braile Institute, the family’s own clinic. Below are the main excerpts from the interview carried out in Rio Preto.

When you graduated in 1962, there were professors at FMUSP like Zerbini and Jatene and you knew Hugo Felipozzi, who made the first by-pass machine in Brazil in 1955. Did you learn from them how to work  in the operating theater as well as in the workshop?
The school was very good; internationally it was considered level A. We could even work in the United States, with no problem at all. The students were also first class. Ricardo Brentani and Walter Colli, for example, were my classmates. Some of the doctors who were developing heart surgery in the 1950’s and 1960’s were our professors and they needed to build their own equipment if they wanted to advance. There was a certain hegemony for people who knew how to do more things.

Did Zerbini encourage this practice?
He was fundamental and always supported by Professor Alipio Correia Neto, an important figure for the School of Medicine. They had a very strong sense of “Brazilianness.” When he saw an imported bypass pump Zerbini went straight to the point; there were few digressions where he was concerned, “Dismantle this machine and see what’s inside. It must have half a dozen simple parts and they sell them to us at an absurd price.” At the time, in the late 1950’s, we only had two pumps at HC, both imported. He used to say that unless we learned how to make machines like that we’d never make any progress. And look, he knew nothing about electricity or mechanics. We started in a workshop that functioned in the basement of the hospital. It was a small room that had three employees and myself.

In any event, you started doing this because you liked doing it and not just out of necessity.
I liked it, yes. My father was from Calabria, in Italy, and graduated from the Medical School of Naples in 1923. He fought in World War I and became communal secretary, an important position that had power over a particular region. But he realized that things were not going well, fell out with the party that was on the rise in Italy and came to Brazil with only a suitcase in 1929. He had an uncle in São Carlos and he worked in upstate São Paulo while he was preparing to have his diploma revalidated. You had to write five papers and, of course, know Portuguese. He did this in the town where I was born, Nova Aliança, near São José do Rio Preto. My father had a very clear notion of what the 20th century was going to be like. When I was 10, he sent me to a car repair shop.

While you were still at school?
Exactly. There was a very good mechanic in this workshop and that was where I learned how to work with engines. By then we’d already moved to Rio Preto. During the period when I was doing scientific studies [one of the two high school courses at the time] I also frequented mechanical repair shops.

And why didn’t you become an engineer instead of a doctor?
My father’s influence was very strong. He was the doctor I never was, a family physician. He had a fantastic memory and knew the name of the client, the father, mother, children, everything. His consulting rooms were at the front of the house where we lived. He had a very interesting vision of the future. I remember he used to say to us that we’d have a TV that hung on the wall as if it was a picture. And what’s more, we’d not need to buy the paintings we see in museums because all that was needed was to put it on the TV and it would change the pictures on its own. He was already thinking this way in the 1940’s. He was also skilful at fixing everything that appeared in front of him.

So, when you went to study medicine you already had  two decisive references for your career; the influence of your father and your skill with machinery.
Both things, plus the encouragement I received from Professor Zerbini. In 1960, I was getting into an elevator at the School of Medicine when a big guy appeared, whom I didn’t know personally. He pointed his finger at me and asked if I was Braille. I nodded. He said he was Adib Jatene – who had already made a name for himself at the college – and he asked if I was I was the person making a bypass pump. I said yes. He asked me, “Can we work together?.” I was surprised and said that I would work with him, and not vice versa. Adib is a very good mechanic and an extraordinary lathe machinist, although he doesn’t know much about electronics. Once, a very important professor from Canada came to São Paulo with his wife. Adib was having lunch with the two of them when she started talking about surgeons’ hands, about how precious they were, how delicate, that they heal etc.. Adib looked at his own hands, which had one finger with half a nail missing, and part of another nail still had grease under it that he’d been unable to remove; it was all black … He slowly slid his hands under the table.

Jatene also seems to have had a great influence on you.
We were very close. Later, Adib went to the Dante Pazzanese Institute and even today he has the Adib Jatene Foundation that makes hospital machinery. He’s been working on an artificial heart with excellent engineers for a very long time.

Did he use to collaborate with the companies that manufactured medical devices?
He collaborated a lot with Macchi, the predecessor of a multinational company, Nipro, that’s now located in Sorocaba. Macchi was founded by heart surgeon, Hélio P. Magelhâes. Adib has never been an owner, but he developed products at the Dante Pazzanese Institute and passed them on to the company. He achieved a lot of progress in this process. Macchi made oxygenators, bypass pumps and a lot of medical equipment. Adib was always very keen on the countryside. He’s still riding horses even today, at the age of 81. He’s an indescribable person. He has a huge inventive capacity for surgery and in developing equipment. But he always said to me that by going into industry I’d only face hardships. In fact, he says that even today and he’s right.

When did you go back to Rio Preto?
When I graduated in 1962. I already knew quite a lot about medical instruments and heart surgery. It was funny, because while I was a student I was a monitor and gave surgical technique lessons to residents. They were very angry about this.

MARLON FIGUEIREDOWere you already operating as a student?
Only on dogs, from the third year on. After I had some very good training with Zerbini and Adib. At that time, few people dared to get involved with cardiac surgery. When we walked down the corridors in college, someone always made a comment like, “There go the killers. How many are you going to kill today?” This was because in the beginning lots of people died. Between July 1958 and April 1963 a group of 1000 patients underwent surgery using cardiopulmonary bypass; 680 at Hospital das Clinicas of the FMUSP and 320 at the Cardiology Institute of the State University of São Paulo. In the first 100 cases, mortality was 25 percent ; by the last 100, it had dropped to 7 percent . These initial figures frightened people. I always say that wherever you look, the story of heart surgery is very beautiful, not only abroad, but here too. The HC was the focus of this when InCor [FMUSP’s Heart Institute] didn’t even exist. Zerbini operated on both lungs and heart without cardiopulmonary bypass in the Beneficênça Portuguesa Hospital and the Institute of Cardiology, where Dante Pazzanese [which is the name of the institute today] worked. He trained a fantastic group that had Zerbini, Arruda, Bittencourt and Dante.

Why did you leave such an important center, where things were happening, to go back to Rio Preto?
I always thought that my place was here and that I should set up a cardiology service upstate, in which I was encouraged by Gilberto Lopes da Silva Junior, an important doctor in the city. But for quite a long time I kept a strong connection with São Paulo – I sometimes spent months there. At the time, in the early 1960’s, Rio Preto had 80,000 inhabitants and 80 doctors. The most important test done was a blood test. We didn’t even have gas measurement. When I got married, some of my wife’s uncles gave us money as a present. I used it to buy some equipment and material, already thinking about building a pump. I went to a blacksmith who made horseshoes, railings for gardens and bars for windows. There I made a machine so I could operate. I wouldn’t have had the money to buy an imported one, which is very expensive. As I’d already built pumps for the HC I made one here too.

Was it there that you started building up your own company?
No. It took a long time. It was only in 1968 that I managed to get together all the cardiologists in Rio Preto. I brought a colleague from São Paulo and we set up the Institute of Cardiovascular Diseases (IMC), which is still around today. It was at this institute that I installed a small workshop in a room. I managed to get hold of some good mechanics to work there and we started making other devices. Before this, around 1960 and 1961, the first heart valves began to appear. When a patient was operated on, either the heart valve could be repaired or he died. There was nothing that could be done. Adib Jatene managed to make the first mechanical Starr-Edwards valve, which is the one that uses a little ball. It was very interesting because the original ball was made of silicone and we didn’t know how to make it. We ended up going to a tire-repair shop and improvising. The result: all the original valves from the Americans ended up breaking. Adib’s never broke.

When did biological valves first appear?
Only some years later, but nobody knew how to make them very well. Professors Ênio Buffolo and Hugo Felipozzi, both from the Paulista School of Medicine [Unifesp], tried making some. Ênio wrote the first thesis on homologous valves, which were taken from corpses, sterilized and mounted on a support. I’d already worked with this, with an aorta graft preserved in alcohol. I’d also worked with tracheal grafts – in fact, it was the first work I published in 1960, while still a student. We took a trachea preserved in alcohol and put it in the trachea of a dog. It didn’t work very well, but it was one of the first studies of tracheal grafts ever done in the world. Here in Rio Preto, after making the bypass pump, we operated on patients for free in a private hospital, the Santa Helena, which belonged to Gilberto Lopes da Silva Junior. The problem is that we had no biological valves. In the HC in São Paulo they began making a valve from dura [the outermost layer of the meninges]. They used to take the dura from the head of a corpse and make the valve. At first, it was an international success, but it later proved to be unfeasible. The valve made from bovine pericardium started with Marion Ionescu, in Leeds, in England; the valve was called the Ionescu-Shiley; in this case the first name is the doctor’s and the second the engineer’s. These dual names are very common in the case of appliances, devices and techniques developed jointly by doctors and engineers. I went to Leeds, I talked to Ionescu, but he didn’t tell me anything. Then I went to Argentina, where there was a group that worked with valves and they knew less than I did. Finally, I talked to Ênio Buffolo, who knew a little. The fact is that no one had very clear idea of how to make them. So I dedicated myself to this and in 1973 I successfully made a bovine pericardium. By 1977 it was in the market. Today, we’ve made almost 70,000 valves.

Was it your most important creation?
It was; and it was made right here in Brazil. It has been very extensively studied. We have a pericardium analysis database that no one else in the world has. Some 200, 000 pericardia have been tested for traction, shrinkage, elasticity …We carry out very strict tests and create the parameters of what’s good and what’s not suitable. My PhD was also on the pericardium. Now there’s pressure on us to present new work on the valve. I’m saying that now there’s no way. Original work on it will only come in 15 years time. We have several types of new valves, but you have to be very careful before stating that all of them are safe. There are decellularized valves, for example, and others that undergo special treatment, all made here at Braile. When I made the first bovine pericardium valve, I wanted it to last for at least three years. After, the expectation increased to 5 years, 10 years and 15 years. Now we want it to last 20 years – or forever. But it’s very difficult. The organism’s natural valves don’t last, so imagine the artificial ones. And there are problems with mechanical valves; they are subject to thrombosis and anticoagulation is difficult to control. Macchi was interested in selling the pericardial valves when I was still in the IMC, when we were 13 partners. We concluded that this was an interesting area and we put together a laboratory and a workshop in a separate house. We started making pumps, oxygenators and products for hospitals. But after a few years I was excluded from the company. I thought we should move forward in several directions and the other partners disagreed.

I wanted to build a hospital. I had everything ready, the plans had been drawn up and the land had been bought. The partners thought it was absurd and it created a very difficult environment, so in 1991 it was easier to get rid of me. In the split up, I got the biomedical part, which at the time owed some $3 million. In other words, I got a half empty building and debts. That was when Braile Biomedica was born, which until the break-up was an arm of the IMC. All but one of the other surgeons left with me. It was a very difficult phase. I was kicked out of an institution that I’d founded and where I’d been for 25 years. And without any money, without knowing whether I’d manage to eat for the rest of the month. But we managed to go ahead and we founded Braile, which today has 50 percent of the Brazilian market.

Is everything you make at Braile made with Brazilian material?
No. But that’s not very important. I always repeat a phrase of Winston Churchill, “The emperor of the future will be an emperor of ideas.” Knowledge is disseminated throughout the world. You can have access to practically any magazine or book over the Internet. Today, you have an idea and go looking for the raw materials wherever they are in order to turn your idea into a reality. Despite buying a lot of raw materials abroad everything else is done here: the concept of the projects, the design and the injection molds. A mold for the oxygenator costs US$100,000. If we had to buy a mold we’d be dead, because we make 2000 – 3000 oxygenators a month. We make around 30,000 a year. A mold for dolls or pipes makes millions of copies. We make a few thousand. We also have a metalwork shop to make the stainless steel boxes. It’s all very expensive because it’s manual, but there’s no other way because production is small. Another example: the international market for cardiopulmonary surgical pumps is almost zero. We have 500 of our pumps being used in Brazil, most of them on consignment. In other words, we assign them to the hospital for them to use the disposable material. It’s expensive to make the pump.

PERSONAL ARCHIVES OF DOMINGO BRAILEBraile (in the background) in the workshop in the basement of the HC in 1960, still in his clothes from the surgical centerPERSONAL ARCHIVES OF DOMINGO BRAILE

But this was all known before. Why, even so, did you persist with the company?
We have to deal with the obstacles that exist in Brazil, without giving up easily. That’s why it’s so necessary to help Brazilian industry, so we don’t remain eternally dependent on technology from abroad. And look here, I’ve no problem about copying. It’s stupid to be always wanting to invent the wheel. When you copy you always modify something and it’s possible to take out a patent on the manufacturing process. You can’t patent the wheel, but you can do this with a manufacturing process for a more efficient wheel. We have some feasibility markers in Brazil – Embraer, Embrapa and Petrobras are good examples. Obviously we can’t forget that Brazilian cardiology competes on an equal footing with any country in the world in all senses. So when we talk about price, we win easily. This happens because there was an industry in this sector that developed. Macchi, Braile and DMG, which is a company from Rio, were fundamental in this. Because of them we started having quality equipment for cardiology made here. It?s common to have creative doctors visit us in the company. They bring us proposals for new machinery and devices but we have no way of attending all of them. I don’t even have enough engineers for this here. Right now I’m looking for an engineer or a doctor physicist to help develop the prosthesis area and I can’t find one.

How many patents have you taken out?
As an inventor, between patents and utility models, I have 19 [a patent is a totally new idea and a utility model is an improvement on some project that transforms it into something new].Today, we have 15 doctors and 500 employees in the company. The average number of years of study of those working in the plant is 14. It’s higher than in the average company in the United States, which is 12 years.

Has Braile managed to get   funding from Finep recently?
We finally managed to get R$5 million for four projects, with a counterpart of R$5 million, also. This is still a problem for companies that are needing money to develop projects and generally don’t have it. We have to try to develop a Brazilian industry in any way possible or we’ll end up buying everything from China. Until June this year the Brazilian manufactured goods deficit was $60 billion. Our situation is not worse only because we export a lot of soybeans and iron ore. That’s what keeps the balance of payments in the black by about $1 billion. That?s very little.

Let’s go back to talking about medicine. You were a pioneer in heart surgery in various hospitals in São Paulo and up-state. Ws it because you liked doing it or you needed to do it?
More because I liked doing it. Despite the business side, I was always more attached to academic life. In 1968 I helped found Famerp as a private non-profit foundation. We’ve been publicly-owned since 1994. In Famerp I headed up the Heart Surgery Service until my retirement, but since 1994, as the pro-dean, I’ve been head of the graduate school, with a mark of 5 from Capes, and for the time being I?m heading up research. There are 300 students in the graduate area, which we call the “umbrella”. We take in doctors, physiotherapists, nurses and engineers, all related to medicine. I was recently tutor to a lawyer, a former prosecutor, who wrote a very nice thesis on medical ethics.

You graduated in 1962 and got your PhD in 1990, 21 years later. Why?
I even enrolled to do a PhD at USP in 1965, but they canceled the enrollment without my knowledge, for no apparent reason.  I was working a lot, I was operating on a lot of patients, so I gave up. Until one day in 1980 I was invited to be on a doctoral thesis panel at FMUSP. Although I didn’t have a PhD, I was invited as having acclaimed knowledge. I met Costabile Gallucci there, who was also an important figure in the history of Brazilian heart surgery and a full professor at UNIFESP. He turned to me and asked why I hadn’t done my PhD. I told Gallucci the story and he said to me, “Then you’re going to go to the Paulista School of Medicine with me and enroll for your PhD today.” I allowed myself to be convinced and did a thesis, with Ernie Buffolo as my tutor.

What are the main challenges for medicine today?
Although we’ve already mapped out human DNA we still don’t know how to cure some of the main groups of diseases that affect us. Mental illnesses – such as schizophrenia – are an example. Another is cardiovascular disease. Fifty percent of the people who have a heart attack or cerebrovascular accident have no known risk factor. Sometimes the heart attack is the first symptom and the patient dies. The reverse is not true – i.e., anyone who has any risk factor will undoubtedly have some problem at some point in their life. Questions like these show there is still much to be discovered, despite huge advances. The other two are: arthritis, an autoimmune disease, and cancer.

You overcame cancer. How was that?
Six years ago I discovered a large tumor in my throat, which measured three by four centimeters, even though I’d never smoked or drunk. I became hoarse, but I thought it was because I was giving a lot of classes. My family pressured me and I went to a throat and nose specialist, who made the diagnosis. Then I began going backwards and forwards between Unicamp and the AC Camargo Cancer Hospital to find out whether I should operate or not. If I’d operated, I might have had to have the whole larynx removed. A friend of mine, Antonio Carlos Martins, a head and neck professor at the School of Medicine at Unicamp, advised me to go to the United States to get a another opinion. I went and stayed six months at the Sloan-Kettering Memorial Cancer Center in New York.

Were you operated on?
No. When I arrived there, the doctor concluded that I should have chemotherapy and radiotherapy in extremely high doses and gastrostomy [direct feeding into the stomach, via a tube]. I said I didn’t want that. He retorted in true American style, “Then go back to Brazil.” I ended up accepting. To get an idea of what the treatment was like, I spent a year without eating, only via a tube in the stomach, and I convinced myself of something interesting: people with cancer sometimes die of starvation.

I was using a nutrient of five thousand calories a day and even so I lost three or four kilos a month. So I invented adding curd and it was successful. The Americans didn’t believe it and came to ask me how I’d discovered that curd was so good. Well, it’s very high in calories and helps the intestine too. It worked.

Have you really carried out 25,000 cardiovascular operations?
I operated from 1962 to 2005, 43 years. I stopped when I got sick. It was common to operate on at least four patients a day. In this calculation everything is included, because surgery is a team effort. Sometimes I wasn’t the main surgeon, but I helped in every way; other times I only did the main part. In some situations there were two surgeries in different operating theaters and there were always doctors opening and closing patients. So I used to leave one and go into another… In all I participated in 25,00 of them.