Ann Thorac Surg 1998;66:1440-1443
© 1998 The Society of Thoracic Surgeons
Our Surgical Heritage
Nikolai Terebinski: a pioneer of the open valve operation
Vladimir V. Alexi-Meskishvili, MD, PhDa,
Evgenij V. Potapov, MDa,
Erik A.K. Beyer, MDa,
Roland Hetzer, MD, PhDa
a German Heart Institute Berlin, Berlin, Germany
Address reprint requests to Dr Alexi-Meskishvili, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
e-mail: (alexi{at}dhzb.de)
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Abstract
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On the occasion of the hundredth anniversary of heart surgery, this article presents the remarkable work of the Russian scientist and surgeon Nikolai Terebinski. The medical world today remains largely unaware that he performed the first successful open valve operations. These experimental operations were conducted in Russia between 1926 and 1937 through the use of an extracorporeal circulation device known as the autojector. The experiments were reviewed based on Terebinski’s original articles and experimental notes. Here we present the techniques and results of his landmark open valve operations on dogs. He performed more than 250 open valve operations, which were the first of their kind. In his attempt to create and then later correct tricuspid and mitral valve stenosis and insufficiency, Terebinski developed many principles of open heart surgery that are valid today. His work represents a milestone in the history of heart surgery.
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Introduction
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Brunton, Pribram, Souttar, and other surgeons attempted, with some success, to achieve hemodynamic improvements by converting mitral stenosis to mitral insufficiency with the aid of a finger or "valvulotome" [1]. Allen, Graham, Wilson, and others used a "cardioscope," which they introduced into the left ventricle to visualize the operating field [1]. Other attempts were also undertaken to place various extracardiac shunts where a defect was present. However, these methods were either too hazardous or unsuccessful and therefore did not come into widespread use.
In 1937 Gibbon reported on experiments with extracorporeal circulation (ECC) [2], and the further development of his ideas produced a breakthrough in the advancement of heart surgery in the early 1950s. However, as early as the 1920s and 1930s, the Russian surgeon Nikolai Terebinski had successfully experimented with ECC in animals [3–5]. Unfortunately, the isolation of Soviet society at this time prevented Terebinski and other scientists in the Soviet Union from presenting their findings to an international audience. Their publications were translated rarely or only much later. For this reason, Terebinski’s series of open valve operations, the first of their kind in the world, fell into oblivion.
Despite a wide range of publications on the history of heart surgery, the international literature either makes no mention of the role and significance of Terebinski’s trail-blazing studies or fails to give them full recognition [6–8]. In this article we present his experimental work on dogs involving more than 260 operations between 1926 and 1937. In these experiments he first created and then later corrected valvular defects under direct inspection of the open heart.
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The career of Nikolai Terebinski (1880–1959)
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Nikolai Terebinski was born in 1880 and began the practice of medicine in 1904 in a surgical clinic in Moscow. Three years later, he received his doctorate after writing his dissertation on the surgical treatment of laryngeal cancer. Beginning in 1911, Terebinski served as coeditor of the journal Khirugia together with Nikolai Napalkov. In 1912, he became Chief of Medical Staff of the Pediatric Surgery Department of St. Vladimir Clinic in Moscow. During the First World War, he worked at the front. After the war, Terebinski established a university surgical clinic in Moscow and continued to direct it as professor of the Second Medical Institute. There, together with Sergei Brukhonenko, he began his experiments with a device for ECC that Brukhonenko had developed. The possibility of substituting the pumping function of the heart for a prolonged period of time gave rise in 1926 to his idea of using this time for an operation on the open heart. Terebinski continued to study this question until the Second World War, in which he served as a specialist in various field hospitals. After the war, Terebinski continued his professorship and served as Chief of Medical Staff of the government hospital in Moscow [9] (Fig 1).
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Surgical technique and methods in Terebinski’s series
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Nikolai Terebinski used an ECC device that was devised by Brukhonenko and known as the autojector [6]. The device had two diaphragm pumps that were mechanically driven and an oxygenator derived from excised homologous lung (Fig 2). In 1926 Terebinski, with the help of the autojector, operated for the first time on a "dry" heart, ie, one that had been excluded from the circulatory system. The experimental animals (dogs) were cannulated through vessels in the neck or less often in the thigh. The pumping function of the heart was interrupted by clamping the inferior and superior venae cavae and the azygos vein and replaced by the autojector.
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Fig 2. Schematic diagram of S. Brukhonenko’s autojector. (Reprinted with permission of the Meditsina Publishing House, Moscow, Russia.)
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During cardiac arrest it was possible to open the empty chambers of the heart and, for the first time in the history of surgery, the surgeon had the opportunity to manipulate the valves in an open, nonfunctioning heart under direct vision. In experiments conducted from 1929 to 1937 (Fig 3), various valvular defects (stenosis or insufficiency of the atrioventricular [A-V] valves and three operations on the pulmonary valve) were created under direct vision in 216 open heart procedures. In some of the experiments the pumping function of the heart was replaced by the autojector and in others it was replaced by occlusion of the caval veins and massive blood transfusions or infusions of Ringer’s solution into the femoral artery.
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Fig 3. During an experiment in Moscow in 1934: Nikolai Terebinski is second from the left. (Reprinted with permission of the Russian Academy of Medicine.)
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Valvular insufficiency was created by transecting the chordae tendineae, incising the leaflets under direct vision, or both. Blind manipulation of the valves or manipulation performed with poor exposure usually resulted in severe and therefore fatal insufficiency. In his monograph Terebinski describes his attempts at creating A-V stenosis: "In making stenosis of the A-V valve, in the beginning, suturing of the adjacent leaflets was attempted. This was usually possible. However, later on, because the sutures cut the tissue of the leaflets, it produced insufficiency ... An attempt was made to suture the chordae together but the results were not predictable because of rupturing of the chordae. Instead of stenosis these dogs developed insufficiency. ... In later experiments the method described by Wilson was used" [3].
In Wilson’s method for creating A-V valvular stenosis, a needle was used to advance a rolled-up strip of pericardial tissue 5 to 6 mm wide through the myocardium. The needle was inserted immediately inferior to the A-V node and valvular leaflets and then fixed to the ventricle so that it interfered with the motion of the leaflets [10]. Up to three strips could be introduced at intervals of 2 to 3 mm. Terebinski modified this method by introducing a longer strip. This procedure created a stable stenosis with only slight insufficiency.
In 16 animals, the stenotic strips placed via Wilson’s technique were removed after a few months through an open heart operation with the valves broadly exposed. Terebinski described the operation as follows [3]:
After dissecting the adhesions between the heart and the pericardium, venous inflow was excluded by the usual methods. An incision into the ventricle was made and a retractor was placed. The blood was evacuated and the stenotic strips of pericardium were identified. For this it was necessary to retract one of the valve leaflets. Then when the strip was found, it was removed by excision.
In most of these operations the pumping function of the heart was suspended for up to 5 minutes. Whenever this time limit was exceeded, blood supply to the heart was reestablished for a few minutes by reopening the superior vena cava to restore contractility, a procedure that unavoidably involved severe bleeding.
At the end of each open valve operation Terebinski stressed the importance of deairing the heart before discontinuing cardiopulmonary bypass. He concluded the following [3]:
After visualization of the interior of the ventricle and performing one or another manipulations on the leaflets or chordae, the sucker was removed and closure of the incision was begun. Prior to this it was necessary to use all measures to remove air from the atrium and ventricle. ... During the operation on the left ventricle in particular, it is necessary to take meticulous measures to remove the smallest residuals of air before the closing of the heart because there is a danger of air embolism to the coronary arteries followed by complete arrest of the heart.
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Results of the series
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In the initial experiments from 1926 to 1928, 7 of 8 dogs undergoing operation survived ECC lasting several hours. In further experiments from 1929 to 1937, a total of 298 heart operations were performed: 216 involved opening the heart and creating stenosis or insufficiency of the atrioventricular valves by various means under direct vision (three operations were also performed on the pulmonary valve). Wilson’s technique was applied in 37 animals to create mitral or tricuspid stenosis. Finally, 45 "partial procedures" were performed to develop and improve the open heart surgical technique (Table 1). Perioperative mortality for creating tricuspid and mitral valve defects were 34% and 52% respectively. Nine of 16 animals (56%) survived the procedure for correcting the previously created stenosis [3].
Early in his experiments using cardiopulmonary bypass Terebinski had drawn many conclusions. Of the seven conclusions that he lists after the first 31 procedures employing the use of ECC, the third and fourth stand out. In his monograph Terebinski wrote [3]:
3) On artificial circulation and with a contracting heart many procedures can be performed. Examples include incision of the ventricle, visualization of the valve leaflets, incision and suturing of the valve leaflets, and closing the incision of the heart.
4) The heart that was operated on in this way and then once again included into the circulation restored pump function to such a level that it was possible to switch off artificial circulation and close the pericardium and chest.
Terebinski also described several variations of thoracic and intracardiac approaches and developed completely new instrumentation for these procedures. He also considered many details such as covering the jaws of the vena cava clamps with pieces of rubber to prevent them from slipping off and causing injury. Additionally, he described the difficulties and hazards of pericardial adhesions while performing second operations [3].
His procedures for combating air embolism were crucial for a successful outcome and remain valid today. As such, he described the need for the ventricular incision to be at the highest point of the heart before closing and would use sand bags to position the animal appropriately. It was also necessary to fill the ventricle with blood by carefully opening the clamps and then to mechanically bleed the air out of the heart by turning it slightly and pressing it. Furthermore, drawing the ventricular sutures closed in a warm saline solution was helpful in reducing the risk of air embolism to the central nervous system and coronaries. Terebinski stated the following [3]:
With the retractor in the ventricle and 2 to 3 sutures through the edges of the ventriculotomy, the ventricle was filled with a warm physiologic solution. Gently manipulating the atrium and ventricle helped with removing air from the heart. At this time the retractor was removed, the sutures were tied, and the physiologic solution was removed from the pericardial and pleural space with a sucker. Additional sutures were placed. Usually after placing the deep sutures the clamps were removed from the superior and inferior vena cava. This method was most satisfactory.
One problem that Terebinski encountered often was intraoperative and perioperative ventricular fibrillation. He suspected air embolism to be the cause of fibrillation, but he was only able to document the cause as such in 3 cases.
The novel aspect of these experiments was the ability to open the chambers of the heart to expose the valves and operate on them under direct vision. Terebinski also described the excellent exposure provided through a ventriculotomy. In an article in 1938 and later in his monograph (Fig 4) on open approaches to the atrioventricular valves of the heart (1940), he concluded that several conditions had to be met to perform open valve operations: suspension of the pumping function of the heart; oxygenation to the central nervous system and myocardium; careful prophylaxis against air embolism, especially while operating on the left ventricle; and the need for a "blood stabilizer" with minimal side effects and an antidote [3, 5].
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Fig 4. Title page of the Nikolai Terebinski’s monograph of 1940: Materials on Research Into Open Approaches to the Atrioventricular Valves of the Heart. Experimental Studies. (Reprinted with permission of the Meditsina Publishing House, Moscow, Russia.)
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In the last sentence of his monograph, Terebinski writes: "The methods I have described are not complete or perfect and require further developments and improvements to make the approach to the heart less hazardous such that later one may perform these operations on human heart defects." Eleven years later, his hope became reality: On April 5, 1951, Dennis performed the first operation using extracorporeal circulation on a child [11]. Unfortunately, Terebinski was unable to put his research and techniques to practical clinical use. The Second World War interrupted his work. However, his trail-blazing experiments in heart surgery, with which the broad international readership is hardly familiar, are not merely of historical interest. They also help us to understand the origins and further development of heart surgery, and in so doing warrant our full recognition. The excellent results of his series of more than 260 open heart operations, his surgical methods, and the principles of open heart surgery he formulated represent a milestone in the development of cardiac surgery. Nikolai Terebinski’s name should take its place among the pioneers of cardiac surgery.
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Acknowledgments
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The photographic documents were made available by the friendly cooperation of the Scientific Research Center "Medical Museum" of the Russian Medical Academy. We express special thanks to Ms L. Arifulova, Deputy Director of the Center.
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References
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- Shumacker H.B. The evolution of cardiac surgery. Bloomington: Indiana University Press, 1992:31-40.
- Gibbon J. Artificial maintenance of circulation during experimental occlusion of pulmonary artery. Arch Surg 1937;34:1105-1131.
- Terebinski N. Materials on research into open approaches to the atrioventricular valves of the heart: Experimental studies. Moscow: Medgis, 1940.
- Terebinski N. About experimental modeling of failures of cardiac valves. Doklady Akademii Nauk SSSR, Isdatel’stvo Akademii Nauk SSSR, Leningrad 1930;22:601-603.
- Terebinski N. Experimental stenosis of the atrioventricular valves of the heart and their repair. Khirurgia 1938;12:36-43.
- Probert W., Melrose D. An early Russian heart-lung machine. Br Med J 1960;5178:1047-1048.
- Pantalos G. A selective history of mechanical circulatory support. In: Lewis T., Graham T., eds. Mechanical circulatory support. London: Edward Arnold, 1995:3-12.
- Stephenson L. History of cardiac surgery. In: Edmunds L., ed. Cardiac surgery in the adult. New York: McGraw-Hill, 1996:5-33.
- Doletzki S.J., Terebinski N.N. In: Petrovski B.V., ed. . The unabbreviated medical encyclopedia. Moscow: Soviet Encyclopedia Publishing House, 1985:21.
- Wilson W. Studies in experimental mitral obstruction in relation to the surgical treatment of mitral stenosis. Br J Surg 1930;18:259-274.
- Dennis C., Spreng D., Nelson G., et al. Development of a pump oxygenator to replace the heart and lung: an apparatus applicable to human patients, and application in one case. Ann Surg 1951;134:709-721.[Medline]
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Introduction
