A 41-year-old man underwent diagnostic coronary angiography for the evaluation of chest pain. In 1965 (at the age of 2 years), he had undergone tetralogy of Fallot repair that had been complicated by accidental damage to the left anterior descending coronary artery (LAD), which arose anomalously from the right sinus of Valsalva (RSV) and crossed the right ventricular outflow tract. At that time, he underwent direct implantation of the left internal mammary artery into the left ventricular myocardium (Vineberg procedure) as a remedy.
The coronary angiogram showed a patent right coronary artery, a patent anomalous left circumflex artery arising from the RSV, and an occluded anomalous LAD from the RSV, which was reconstituted by collateral vessels from the left circumflex artery (Fig. 1). The left internal mammary artery that had been implanted directly into the left ventricular myocardium was found to be atretic (Fig. 2). The left ventricular ejection fraction was estimated at 0.50, with mild septal hypokinesis. Medical treatment was advised for the patient.
Fig. 1 Left anterior oblique view shows an occluded left anterior descending coronary artery (arrows) reconstituted by collateral vessels from the left circumflex artery.
LAD = left anterior descending coronary artery; LCx = left circumflex coronary artery; RCA = right coronary artery
Fig. 2 The left internal mammary artery (LIMA) graft that was implanted directly into left ventricular myocardium (Vineberg procedure) was atretic (arrow).
Comment
Two important points are highlighted by this presentation:
Coronary artery anomalies occur in 2% to 9% of patients with tetralogy of Fallot and are usually not clinically relevant.1,2 However, the anomalous LAD crossing the right ventricular outflow tract is of particular note, because it may be susceptible to damage during surgical reconstruction. In such situations, the approach to the ventriculotomy may need to be modified to avoid vascular injury.
The Vineberg procedure was named after Arthur Vineberg, a Canadian surgeon who developed the technique of direct implantation of the internal mammary artery into a superficial tunnel in the myocardium, believing that it would establish retrograde coronary perfusion through communicating myocardial sinusoids to the native coronary arteries.3 This procedure, first performed successfully in 1950 and popularized in the 1960s, was abandoned in favor of coronary artery bypass grafting fewer than 10 years later. The Vineberg procedure is of historical significance because the experience gained from it contributed to the growth of coronary artery bypass grafting and established the use of the internal mammary artery as a preferred bypass conduit.
Footnotes
Address for reprints: Y. Birnbaum MD, FACC, Division of Cardiology, University of Texas Medical Branch (UTMB), 5.106 John Sealy Annex, 301 University Blvd., Galveston, TX 77555-0553
E-mail: yobirnba@utmb.edu
References
- 1.Fellows KE, Freed MD, Keane JF, Praagh R, Bernhard WF, Castaneda AC. Results of routine preoperative coronary angiography in tetralogy of Fallot. Circulation 1975;51:561–6. [DOI] [PubMed]
- 2.Dabizzi RP, Teodori G, Barletta GA, Caprioli G, Baldrighi G, Baldrighi V. Associated coronary and cardiac anomalies in the tetralogy of Fallot. An angiographic study. Eur Heart J 1990;11:692–704. [DOI] [PubMed]
- 3.Thomas JL. The Vineberg legacy: internal mammary artery implantation from inception to obsolescence. Tex Heart Inst J 1999;26:107–13. [PMC free article] [PubMed]