Yustin Y. Djanelidze and the First Successful Repair of an Injured Ascending Aorta

Abstract

Yustin Y. Djanelidze is one of the little-known pioneers of cardiac surgery in the 20th century. He successfully sutured a penetrating injury of the ascending aorta in St. Petersburg, Russia, on 27 October 1913. To the best of our knowledge, this was the 1st case of ascending aorta repair described in the world medical literature.

Ludwig Rehn performed the 1st successful repair of a cardiac injury on 9 September 1896 in Frankfurt. ¹ He repaired an injury of the right ventricle. In Rome on 19 April 1897, Parrozzani successfully repaired the left ventricle. ² The time when surgeons washed their hands only after operating had long since passed, and the worldwide acceptance of aseptic technique was beginning to pave the way for cardiovascular surgery.

Despite the many advances that had been made in knowledge and technique, however, injury of the aorta was still regarded as universally fatal. It was not until Yustin Y. Djanelidze in St. Petersburg, Russia, sutured the ascending aorta that the era of aortic surgery began. ^3,4 In the recent textbook Cardiothoracic Trauma, the pioneering contribution of Djanelidze is briefly acknowledged. ⁵ Although a number of biographical articles about Djanelidze's career have been published in Russia, virtually no information on this distinguished surgeon is available to anyone who does not read Russian.

Biographical Notes

Yustin Y. Djanelidze was born on 2 August 1883 in the village of Samtredia, Georgia, in the Russian Empire. In 1900, he began his studies at the Medical Faculty of the University of Kharkov. In 1905, he moved to Switzerland and continued his study at the University of Geneva. Upon graduating with honors in 1909, Djanelidze returned to Russia, where he passed the required exams and was qualified as a physician in 1910. He successfully defended his doctoral dissertation the next year, and in 1912 he was appointed assistant surgeon at the Petropavlovskaia Infirmary in St. Petersburg, where Professor Kadian was the chief surgeon. Djanelidze and Kadian also taught surgery to students at the Women's Medical Institute in St. Petersburg (Fig. 1).

Fig. 1 Dr. Djanelidze (5th from the left, 1st row) and Professor Kadian (7th from the left, 1st row) among the students of the Women's Medical Institute in St. Petersburg, in 1912.

Courtesy of Dr. M. Kavtaradze, Tbilisi, Georgia.

During World War I, Djanelidze was a senior surgeon in a military field hospital. After the war, he returned to St. Petersburg and headed the Department of Surgery at the Petropavlovskaia Infirmary. In 1926, Djanelidze traveled in Europe, visiting the surgical clinics of Gosset, Leriche, Delanjinier, Bier, and Kay. From 1928 until his death in 1950, Djanelidze headed the Department of Surgery at the Women's Medical Institute. In 1932, he was also appointed head of the newly opened Emergency Institute in St. Petersburg, which in December of 1950 was renamed the Djanelidze Emergency Institute in his honor.

During World War II, Djanelidze was Surgeon-in-Chief of the Soviet Navy (Fig. 2). In 1947, he was elected chairman of the Russian Surgical Society. That same year, he visited hospitals in the United States. Djanelidze died on 14 January 1950.

Fig. 2 Dr. Djanelidze in 1946.

Courtesy of Mrs. L. Arifulova, Deputy Director, Medical Museum of the Russian Academy of Medical Sciences, Moscow.

Repair of Penetrating Heart Injuries

Djanelidze 1st repaired a penetrating heart injury on 1 September 1911, when he was 28 years old. ⁶ At the Congress of Russian Physicians in 1913, he reported a survival rate of 27% in 15 cases of penetrating heart injuries treated surgically at the Petropavlovskaia Infirmary. ⁷

Subsequently, Djanelidze evaluated the long-term results of surgical repair of penetrating heart injuries ⁸ and, in particular, injuries of the coronary arteries. ⁹ In the later article, he reviewed 43 cases of coronary vessel injury out of the 535 total cases of heart injuries recorded in the world medical literature that were available to him. ¹⁰ In 1927, Djanelidze published a monograph of his detailed review of these 535 cases (Fig. 3).

Fig. 3 Title page of Dr. Djanelidze's monograph Cardiac Injuries and Their Surgical Treatment, published in 1927.

In the preface to this monograph titled Cardiac Injuries and Their Surgical Treatment, Djanelidze wrote the following description of the conditions under which he conducted his review:

It should also be mentioned that the time chosen for reviewing the material was immensely difficult. With the beginning of the war, our ties with the West deteriorated. From 1918 to 1920, we were completely isolated from Western science. After 1921, the normal delivery of the world's medical journals was restored, but the communications with our colleagues abroad remained difficult. It either took a long time to receive a journal, an article or a book, or it was impossible. Personal inquiries to many surgeons abroad were also troublesome. Despite the numerous letters sent by me, only Professor Sauerbruch informed me kindly about a case of heart injury operated by him. However, the most unpleasant circumstance was the fact that our medical journals ceased to exist and we did not know what was done in our own country.

Because of the difficulties mentioned above, I would not dare to state that I gave an account of all cases of surgical treatment that occurred from 1896 to 1921. ¹⁰

In spite of any real or perceived shortcomings, Djanelidze's was, to our knowledge, the world's 1st book on cardiac injuries. In 1941, Djanelidze wrote a review of 1,000 cases of surgical treatment of heart injuries. He reported a survival rate of 57%. ¹¹ In 1948, he published his observations regarding treatment of gunshot injuries of the heart during World War II. ¹² In the same year, Djanelidze also attempted the 1st ligation of a patent ductus arteriosus in Russia; unfortunately, this operation was not successful.

Surgical Repair of the Aorta

Djanelidze performed his historic repair of the ascending aorta on 27 October 1913. ¹³ This was the 1st successful repair described in the world medical literature (Fig. 4). ^3–5 The patient, a 20-year-old man, had been brought into the emergency room with multiple stab wounds in his head, chest, and right arm. There were no signs of pneumothorax or cardiac tamponade. The patient was initially stable, and the wounds were closed in standard fashion. However, 2 hours later, the patient developed arrhythmia, tachypnea, cardiac tamponade, and progressive rapid hemodynamic deterioration, and the decision was made to operate. There was a 3-cm stab wound at the 1st intercostal space left of the sternum, which Djanelidze extended down 12 cm, parallel to the sternum. He removed the second rib, transected the cartilage of the 3rd rib, and ligated the left internal thoracic artery. The pericardium was opened, and a large amount of fresh blood was evacuated. A wound, 8 mm in length, was found on the ascending aorta about 1 cm from its origin at the heart. Djanelidze repaired this wound with 3 interrupted sutures. The patient's postoperative course was uneventful, and he was discharged 30 days after surgery. Djanelidze presented the patient at the meeting of the Russian Surgical Society in November 1913.

Fig. 4 Title page of Dr. Djanelidze's article “A Case of the Repair of an Injury of the Ascending Aorta,” published in 1916.

In 1916, Djanelidze reviewed 17 cases of ascending aorta repair and gave a detailed, 15-page description of the diagnostic methods, operative techniques, anesthesia, and postoperative management involved in this operation. ¹³

Conclusion

In the earliest decades of the 20th century, cardiac surgery was limited to the repair of injuries to the heart and great vessels. Dr. Yustin Y. Djanelidze successfully repaired a heart injury when he was only 28, and he performed the 1st repair of the ascending aorta at the age of 30. The young surgeon demonstrated great knowledge and outstanding surgical skill, as well as great courage, to undertake these operations at such an early point in his own career and in the history of cardiac surgery.

We hope that our article will bring appropriate recognition to the pioneering work of one of the great surgeons of the past, upon whose shoulders we stand as we move into the new millennium.