Ann Thorac Surg 2008;86:1676-1677. doi:10.1016/j.athoracsur.2008.04.082
© 2008 The Society of Thoracic Surgeons
Case Reports
Vineberg Operation: A Successful Case 35 Years Later
Prashanth Katrapati, MD,
Jon C. George, MD*
Division of Cardiovascular Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
Accepted for publication April 24, 2008.
* Address correspondence to Dr George, 11100 Euclid Ave, M. L. 5038, Cleveland, OH 44106-5038 (Email: jon.george{at}uhhospitals.org).
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Abstract
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The Vineberg operation was introduced by Dr Arthur Vineberg in the early 1940s for revascularization of ischemic cardiac tissue with direct implantation of the left internal mammary artery into ventricular myocardium. We report the case of an 81-year-old man who presented to the Veterans Administration Medical Center with progressive shortness of breath during the course of 1 year. The patient's history was significant for multiple cardiac interventions, the most notable of which included a Vineberg operation in 1970. The patient underwent coronary angiography showing a patent Vineberg implant with myocardial blushing approximately 35 years after initial surgery. Here we report the significance of this finding and possible implications for the future of cardiology and cardiac surgery.
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Introduction
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The Vineberg operation (VO) pioneered by Dr Arthur Vineberg [1] in the early 1940s was an experimental model for revascularization of ischemic cardiac tissue with direct implantation of the left internal mammary artery into ventricular myocardium. Initial success with animal models led to the first human operation in April 1950. The VO is believed by many to be the first successful attempt at coronary revascularization for ischemic myocardium leading to the birth of coronary artery bypass grafting. Although there were approximately 10,000 to 15,000 VOs performed in the 1950s and 1960s, there are few reports of patent Vineberg implants more than two decades after the initial surgery. We believe that our case is the only documented patent Vineberg implant beyond 3 decades after the initial surgery, as we present it here as evidence of the long-term success of one of the pioneering procedures in cardiac surgery.
The patient, an 81-year-old man, presented to the Veterans Administration Medical Center in Cleveland, Ohio, with progressive dyspnea on exertion during the course of 1 year. His symptoms occurred with minimal activity, as his functional capacity was diminished due to severe degenerative joint disease of bilateral knees. On admission, he denied any chest pain, dizziness, syncope, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema. Past medical history was significant for coronary artery disease with multiple cardiac interventions including initial coronary artery bypass grafting in 1970 with a saphenous vein graft to the right coronary artery and a VO with implant of the left internal mammary artery to the anterior left ventricular wall; and a redo coronary artery bypass grafting in 1995 with a right internal mammary artery graft to the left anterior descending coronary artery, a saphenous vein graft sequentially to the diagonal and ramus intermedius branches, and a free radial artery graft from the Vineberg implant to the posterior left ventricular branch of the left circumflex artery. Physical examination was unremarkable without evidence of fluid overload. Laboratory analysis revealed negative serial cardiac enzymes and normal brain natriuretic peptide. Electrocardiogram showed T-wave inversions in the inferolateral leads, which were unchanged from before, and an echocardiogram revealed preserved left ventricular function. Cardiac catheterization showed severe native coronary artery disease with occluded bypass grafts, except for the Vineberg implant, which was patent with good myocardial blush (Figs 1A and 1B).
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Comment
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In 1945, Vineberg [1] experimented with the internal mammary artery (IMA) implantation in dogs by dissecting the IMA, ligating the distal end, creating artificial perforations in the ligated end, and inserting it into a tunnel created in the myocardium. He based this operation on the concept of the sinusoids [2, 3], and he hoped that these sinusoids would absorb the run-off from the perforated IMA. He further theorized that the sinusoids would fortify and develop collateral communications with the native coronary circulation [4]. After various modifications to his technique, Vineberg [5] took a bold step and operated on the first human in 1950. Although his first patient only survived 62 hours after surgery, his procedure was viewed as a potential success after postmortem examination revealed a patent IMA without evidence of infarction, hemorrhage, or hematoma.
The case presented here stands as a testimony to the long-term success of VO, being, we believe, the only documented patent Vineberg implant more than 3 decades after the initial surgery. Although VO has become obsolete with the advent of coronary artery bypass grafting, the value of the IMA as an expendable artery, and its resistance to thrombosis and atherosclerosis, were both recognized by early experimentation with VO on the path toward the current gold standard of myocardial revascularization.
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References
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- Vineberg AM. Development of an anastamosis between the coronary vessels and a transplanted internal mammary artery Can Med Assoc J 1946;55:117-119.
- Wearn JT, Mettier SR, Klumpp TG, Zscthesche LJ. The nature of the vascular communications between the coronary arteries and the chambers of the heart Am Heart J 1933;9:143-164.
- Truex RC, Angulo AW. Comparative study of the arterial and venous systems of the ventricular myocardium with special reference to the coronary sinus Anat Record 1952;113:467-491.[Medline]
- Thomas JL. The Vineberg Legacy Tex Heart Inst J 1999;26:107-113.[Medline]
- Vineberg A. Coronary vascular anastomoses by internal mammary artery implantation Can Med Assoc J 1958;78:871-879.[Medline]
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Abstract
Introduction
