SPECIAL CORRESPONDENCE
Fantastic VoyageA Patient's Journey Through Cardiology From 1969 to 2008
Harvey S. Hecht, MD, FACC* and
Marc Colmer, MD, FACC
Lenox Hill Heart and Vascular Institute, New York, New York
* Reprint requests and correspondence: Dr. Harvey S. Hecht, Lenox Hill Heart and Vascular Institute, 130 East 77th Street, New York, New York 10021 (Email: hhecht{at}aol.com).
Key Words: Vineberg • CTA • PCI
Two generations of cardiology can rarely be encompassed in a single patient. In this Special Correspondence, the early era of coronary angiography with Mason Sones, of bypass surgery presaged by the Vineberg procedure, through multimodality imaging, followed by implantation of an implantable cardioverter-defibrillator (ICD), and culminating in placement of a drug-eluting stent, is presented in historical text, images, and videos. Through this rare perspective of 40 years encapsulated in a single still living individual, the extent of progress can be appreciated.
 |
Case Report
|
|---|
The patient is an 84-year-old man who was referred to the Cleveland Clinic in 1969 at age 45 for treatment of severe exertional angina. Coronary angiography by Dr. Mason Sones (Fig. 1) revealed severe triple-vessel disease. He underwent double internal mammary implant (Vineberg procedure) by Dr. Donald Effler (Fig. 2) on February 27, 1969.
At age 61 he developed recurrent angina; angiography revealed patency of both mammaries and severe right coronary artery (RCA) disease. Medical management was successful until symptoms of syncope and recurrent angina, and discovery of a heart murmur in 2006 led to carotid ultrasound, which revealed 60% to 79% right and 40% to 59% left internal carotid stenoses, and transthoracic echocardiography that demonstrated 3+ mitral regurgitation and a 32% ejection fraction. Myocardial perfusion imaging revealed a fixed inferior defect. An ICD was inserted (Fig. 3). Anginal symptoms persisted, and 64-detector computed tomographic angiography (CTA) was performed, the first CTA imaging of a Vineberg procedure (Fig. 4).
View larger version (65K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4 64-Detector CTA Images Obtained After ICD Placement in 2007
(Left) Curved multiplanar reconstruction of the patent left internal mammary artery (LIMA) implanted in the posterolateral wall. (Right) Curved multiplanar reconstruction of the patent right internal mammary artery (RIMA) implanted in the anterior wall. (Center) Three-dimensional volume-rendered image of the LIMA and RIMA. CTA = computed tomographic angiography; ICD = implantable cardioverter-defibrillator.
|
|
Patency of the mammaries was demonstrated, as well as the intramyocardial insertion of the left mammary into the lateral wall and the right mammary into the anterior wall. Severe RCA stenosis was noted as well as normal left ventriculography. Persistent symptoms despite aggressive medical therapy resulted in invasive coronary angiography that confirmed the CTA findings, revealing connection of the left mammary to the posterolateral branch of the circumflex coronary artery (Fig. 5A) and the right mammary to the diagonal branch of the left anterior descending coronary artery (Fig. 5B).
View larger version (77K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5 Selective Coronary Angiography of the Internal Mammary Arteries
(A) Selective coronary angiogram of the left internal mammary implant connecting to a posterolateral branch of the circumflex coronary artery. (B) Selective coronary angiogram of the right internal mammary implant connecting to the diagonal branch of the left anterior descending coronary artery. See accompanying Online Videos 1 and 2.
|
|
The severe proximal RCA narrowing was easily identified on CTA (Fig. 6A) despite heavy calcification, and was confirmed by coronary angiography (Fig. 6B). A drug-eluting stent was successfully implanted in the RCA (Figs. 6C and 6D), and symptoms disappeared.
View larger version (120K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6 Right Coronary Artery Imaging by Computed Tomographic Angiography and Selective Coronary Angiography
Curved multiplanar reconstruction of the right coronary artery (A) revealing the severe proximal stenosis (arrow), confirmed by invasive coronary angiography (B, arrow), followed by revascularization (C, arrow) by implantation of a drug-eluting stent (C and D, arrows).
|
|
|
Discussion
|
|---|
The introduction of selective coronary angiography by Dr. Mason Sones in 1958 (1) heralded a new era in cardiology. Direct visualization of the coronary arteries provided the blueprint for surgical and, eventually, percutaneous intervention. Before conventional bypass graft surgery with full cardiopulmonary support, the Vineberg procedure, introduced in 1950, utilized internal mammary conduits, but with direct myocardial implantation rather than coronary anastomosis. Success depended on developing connections to the distal native coronaries, which was noted in 54% of patients, accompanied by 92% patency in an evaluation of 1,100 internal mammary implants (2,3). Between 1958 and 1975, 10,000 to 15,000 procedures were performed (2,4). It was replaced in 1967 by conventional bypass surgery (5) with saphenous vein and, finally, internal mammary conduits. The next few decades marked the development of noninvasive ultrasonic imaging of the heart by echocardiography and carotid arteries by carotid ultrasound, followed by myocardial perfusion imaging. Most recently, the "holy grail" of coronary imaging (i.e., the ability to image the coronary arteries noninvasively) has been accomplished by multidetector coronary angiography. Concurrently, pacemakers, defibrillators, and a combination thereof (ICD) were developed to treat electrical sequelae commonly associated with coronary artery disease. Percutaneous coronary intervention with angioplasty, bare-metal, and, finally, drug-eluting stents provided the extension of revascularization to the nonsurgical arena.
The journey was successfully negotiated by this patient, with stops at all the invasive and noninvasive way stations. The historical, personal involvement of Mason Sones and Donald Effler, the remarkable longevity of the pioneering surgery, the use of multiple noninvasive imaging modalities, as well as ICD and drug-eluting stent insertion in the possible sole survivor of a double Vineberg procedure combine to anthologize many of the major accomplishments of the last 2 generations of cardiology.
|
Appendix
|
|---|
For accompanying videos, please see the online version of this article.
|
Appendix
|
|---|
|
References
|
|---|
1. Sones Jr. FM, Shirey EK, Proudfit WL, Westcott RN. Cine-coronary arteriography Circulation 1959;20:773-774.2. Shrager JB. The Vineberg procedure: the immediate forerunner of coronary artery bypass grafting Ann Thorac Surg 1994;57:1354-1364.[Abstract] 3. Fergusson DJ, Shirey EK, Sheldon WC, Effler DB, Sones Jr FM. Left internal mammary artery implant-postoperative assessment Circulation 1968;38(Suppl 4):1124-1126. 4. Preston TA. Coronary Artery Surgery: A Critical ReviewNew York, NY: Raven Press; 1977. pp. 7-26. 5. Favoloro RG. Saphenous vein autograft replacement of severe segmental coronary artery occlusion: operative technique Ann Thorac Surg 1968;5:334-339.[Medline]
Related Article
-
Inside This Issue of JACC
J. Am. Coll. Cardiol. 2008 52: A26.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
G. A. Mensah
Fantastic voyage through cardiology: from 1969 to 2008.
J. Am. Coll. Cardiol.,
June 9, 2009;
53(23):
2197 - 2197.
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. S. Hecht and M. Colmer
Reply.
J. Am. Coll. Cardiol.,
June 9, 2009;
53(23):
2197 - 2198.
[Full Text]
[PDF]
|
|
|
|
Top
Case Report
Discussion
