Valvotomy for Mitral Stenosis

1952 BMJ (Clinical Research Edition)  
VALVOTOMY FOR MITRAL STENOSIS Rapid progress has been made in the surgical treatment of mitral stenosis in the past two years since the first reports' 2 were published showing that direct operation on the mitral valve was a reasonably safe procedure and that the majority of patients submitted to it were greatly improved. In the opening pages of this issue Mr. R. C. Brock and Drs. Charles Baker, Maurice Campbell, and Paul Wood report the results obtained in 100 patients: the progress of the
more » ... rogress of the first 50 to be operated on has now been followed for at least six months. In the whole series of 100 cases there were 13 deaths, seven occurring in the first 20 cases, so that in the last 80 cases the mortality was under 8%. These results become even more impressive when it is seen that 49 out of the first 50 cases were classified as being seriously or completely incapacitated by dyspnoea, orthopnoea, or pulmonary oedema. The effect of treatment is often spectacular. In the 41 surviving patients cut of the first 50 operated cn (in one case valvotomy was found not to be possible) the result is described as good or excellent in 32. Seventeen of these were restored to normal health and activity after having been completely incapacitated before operation. In a series of 352 cases collected from seven surgical centres Bland' found that threequarters were improved, the mortality being 15%. Already, as the low mortality and good results of mitral valvotomy have become known to doctors and patients, there is great pressure on those surgical centres where this work is being carried on, and the waiting-lists are long. But not all patients with mitral stenosis are suitable for or in need of a valvotomy, and careful selection is essential. The disease is not necessarily progressive, and only a minority of those with little or no cardiac enlargement ever develop serious symptoms.4 5 In symptomless mitral stenosis operation is unnecessary: it should be reserved for those patients who do develop symptoms at a later stage. The selection of cases is largely influenced by the severity of the respiratory symptoms which are caused by pulmonary congestion. If, as seems certain, the operation of mitral valvotomy is to be more widely carried out the cause of the dyspnoea in each case must be critically 'assessed. Many patients with mini-mal valve damage are dyspnoeic either because of unwarranted limitation of their physical activities which has induced a cardiac neurosis or because of a complication such as obesity, pulmonary infection, or anaemia. Dyspnoea is a symptom which is notoriously difficult to assess, and in heart disease, as has already been shown in chronic pulmonary disease, any new and spectacular treatment is likely to cause temporary improvement. For this reason selection of patients for operation should be the responsibility of a physician working in close collaboration with the surgeon, so that only those patients whose disability can be shown to be largely due to the mechanical obstruction at the mitral valve will be operated on. Priority must be given to those with severe mitral stenosis but with little cardiac enlargement who have increasing dyspnoea and recurrent attacks of pulmonary oedema and haemoptysis. Many of these patients have died in an attack of pulmonary oedema while waiting for the operation which would have restored them to normal activity. Mitral valvotomy, by relieving pulmonary congestion and pulmonary hypertension, has in fact improved patients with congestive failure, greatly enlarged hearts, and presumably severe myocardial damage. Active rheumatism is at present considered to be an absolute contraindication to operation, and therefore valvotomy is rarely carried out until after the age of 20, when recrudescences of activity are less likely. Even when infection has been thought clinically to be inactive, biopsies of the auricular appendage at operation have shown Aschoff nodes in 4 of 11 specimens,6 although in one other published case subsequent careful examination of the rest of the heart at necropsy failed to show any other signs of activity. Brock and his colleagues have shown that, even in the presence of aortic valvular disease, valvular calcification, or auricular fibrillation, good results can be obtained, though with a higher mortality. The diagnosis of mitral incompetence in patients with mitral stenosis has proved to be unexpectedly difficult, and it now appears that the only sure way is to feel the regurgitant stream of blood with the finger in the left auricle. The loudness of the mitral systolic murmur often gives some indication of the extent of the incompetence, but many patients with loud murmurs are found at operation to have pure stenosis, while conversely the valve may be found to
doi:10.1136/bmj.1.4767.1073 fatcat:4kfe6fhf3zar5cog547wvn2t24