Posteromedial annuloplasty for acquired mitral insufficiency: Methods and results

P o s t e r o m e d i a l A n n u l o p l a s t y for Acquired Mitral I n s u f f i c i e n c y : Methods and Results By

G~:Ol~eE P

JR, ArcrHu~ M. AN,~msoN. L~so~,~u) A Co~3~. ROBE~.T A Bx~ucE ar,'D K. ALVXN MEREND~,rO STEINI%IETZ,

H I S R E P O R T on naltral annuloplasty i n c l u d e s all of o u r 39 pataents xwth p r e d o m i n a n t m l t r a l ~egmg~tatxon w h o h a v e b e e n o p e r a t e d u p o n since S e p t e m b e l 19, 3[956, w h e n our first p a t i e n t was s u b j e c t e d to this p r o c e d u r e . Several factors w h i c h h a v e g r e a t l y affected this experxence d e s e r v e speczal c o m m e n t lest t h e y b e f o r g o t t e n in o u r p r e s e n t - d a y a c c e p t a n c e of n e w e r stand a r d s T h e m o r t a l i t y r a t e e n c o u n t e r e d m thzs ] e a r n i n g expemence is i n t i m a t e l y i n t e r w o v e n w i t h t h r e e majo~ factors. ( 1 ) p u m p - o x y g e n a t o a e q u i p m e n t a n d k n o w l e d g e regai d m g the c a r d t o p u l m o n a r y b y p a s s state, ( 2 ) the operation, a n d ( 3 ) t h e choice of p a t i e n t s c o n s i d e r e d suitable for surgery. At the ]mtiat]on of ou] o p e n heal t p l o g r a m m 1956, a b u b b l e o x y g e n a t o r of o u r oxvn design was utilized m a p l ) r o x n n a t e l y the first 200 cases S u b s e q u e n t ly, w e h a v e u s e d g~avity venous d r a i n a g e a n d t h e Kay-C~oss o x y g e n a t o r ~ Therefore, s o m e w h e r e b e y o n d h a l f - w a y t h r o u g h this seines, ]naportant changes in e q m p m e n t w e r e m a d e E a r l ) in th~s experience in p a t i e n t s w i t h m i t r a l insufficiency, pelfusaon rates w e r e u s e d w h i c h p r e s e n t l y w o u l d b e c o n s i d e r e d i n a d e q u a t e . I t }s n o w a]?pm e]~t that the c o m b i n a t i o n of low p e r f u s l o n l ates tog e t h e r w i t h e v e n m i n i m a l aortic m s u t ~ c ] e n c y can b e lethal D u r i n g t h e dev e l o p m e n t of th~s series our concepts of a c c e p t a b l e flow ~ates altered considera b l y All these c h a n g e s h a v e exerted effects in o n e dtrection, v i z . the over-all i m p x o v e m e n t in o u r abd~tv to offer the p a t t e n t a safer total c a r d ~ o p u l m o n a r y byp,,ss per~od. T h e open correction of m~tral msufflciency b y p o s t e t o m e d m l a n n u l o p l a s t y was the logical o u t g r o w t h from o b s e r v a t m n s m a d e d u r i n g closed o p e r a t t o n s fo~ mixed m]tral lesions Ilistorically, m e t h o d s of closed correction of tmtral insufficiency using a u t o g e n o u s t~ssue b e n e a t h the v a l v e e ~ o~ p r o s t h e t i c devices ~n t h e o~fice ~-~ w e r e followed b y the t e e h m c of purse-st~ing n a ] ~ o w m g of the a n n u l u s TM~'~ a n d va, ious m e t h o d s of phcat~on a~.~ All m e t with r a t h e , ]m~ited success. '-'~,~-~ "~Vith t h e a d v e n t of open h e a r t surgery, di, ect vision a n n u ] o p l a s t y b e c a m e possible a n d ha,, d e v e l o p e d t e c h n i c a l l y rote an a c c e p t a b l e procedme'-.~ ~n Because past observations md~eated t h a t p r a c t i c a l l y all ] e g u r g t t a tion s e c o n d , u y to , h e u m a t ~ c fcve~ o c c u r r e d ptm~arily at the p o s t e r o m e d i a l comm,ssure, w e h a v e used h e a v v i n t e r r u p t e d sutures a p p r o x i m a t i n g the an-

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lrrmn the D(,t,~artprt¢,n¢s of Sul[gertl and Mcchcmc, U'~;kersltli o~ ~,Vashtngt(m, Seattle° '~V . ~hh~t on. Snt~porlcd II~ part bit [! S l'ttblt(' lleallh S¢,rt u e l{¢'search (Iratdv # 1 t - 3 J 7 9 . 11-1110 (rod I f - 9 0 8 A f)ortion o[ thls u'opl~ was eondntter[ thrmt~th the Cfinlc'al H~;seareh C',mtet l:¢lcqltlt! o[ tht" I[ntper.sftf/ . [ lVashtnte, ton, sulJportg'd btt the National lnvltlnlc,s of lh'alth, (;rant No G(]-I,3. SulJportr'd hi/ U,S P.ll.b, l:elh~t sl:tlJ No 11F-14,658, 280 Pm)(.jo,,s~ IN (',^m,t()v^s( ut ^l~ ll)J~l ^~J~% V o i - . 5 ,

No. 3 (NovI,Mma~),

]f)(J2

F OSTREh~IEDIAL ANNULO]?LASTY

~81

n u l u s at t he 13osteromedial a r e a only, i n m o s t lnstance~ F a m x h a r i t y w i t h t h e b r o a d s p e c t r u m of v a r i a n t s in v a l v u l a r p a t h o l o g y , g r e a t e r c o n f i d e n c e i n th e c o r r e c t n e s s of t h e a n a t o m i c a p p r o a c h , as w e l l as t h e a d d i t m n of r e f i n e m e n t s m technxcs, e g , C O z l a y e r i n g , e t c , h a v e a l l o w e d t h e o p e r a t o r to p e r f o r m a m o r e a d e q u a t e c o r r e c t i o n of the h e m o d y n a m l r , d e f e c t w i t h less r i s k to e a c h s u c c e e d i n g pataent. At t h e b e g i n n i n g of this e x p e r i e n c e , all Class IV* p a t i e n t s w i t h p r e d o m i n a n t m l t r a l m s u f f i c l e n c y w e r e o f f e r e d o p e n h e a r t s u r g e r y for its c or r e c tion, a l m o s t r e g a r d l e s s of a n y o t h e r factors. :In g e n e r a l , C l a s s I I I pa ta e nts w e r e o f f e r e d s u r g e r y o n l y ff t h e r e w a s r e c e n t e v i d e n c e of p r o g r e s s i o n of t h e i r d i s a b i l i t y t o w a r d C l a s s IV status. E ar]y, t h e r e w e r e a f e w i n s t a n c e s w h e r e t h e m i t r a l l e si o n w a s g i v e n g r e a t e r c r e d i t for e x p l a i n i n g t h e total d i s a b i l i t y of the p a t i e n t t h a n p r o v e d to b e t h e case at s u r g e r y W h e n this w a s e n c o u n t e r e d in a s e r i o u s l y d i s a b l e d p a h e n t , a f a t a l issue r e s u l t e d I n a d d i t i o n , a ]?ew d r a m a t i c e a r l y successes w i t h this n e w o p e r a t a v e p r o c e d u r e r e s u l t e d in a n e x p a n s i v e e n t h u s i a s m fo r e x t e n d i n g t h e " b e n e f i t s " to s o m e pa ta e nts w h o w o u l d n o t b e c o n s i d e r e d surgical candidates today. Obviously, such testing must be done with any n e w o p e r a t i v e p r o c e d u r e m o r d e r to d e t e r r m n e its l i m i t s a n d its p r o p e r p l a c e i n t h e r a p y . U n f o r t u n a t e l y , in this s e t t i n g t h e p e n a l t y of i m p e r f e c t i o n is n o t o n l y i n a d e q u a t e r e p a i r b u t also a h i g h p r o b a b i l i t y of d e a t h . M o r e c o m p l e t e p r e o p e r a t a v e d o c u m e n t a t a o n of t h e p a t i e n t ' s h e r n o d y n a m i c status, c o m b i n e d w i t h p r e s e n t c l i n i c a l j u d g m e n t , h a v e m a d e s u c h errors n o w q u i t e u n c o m m o n XVh~le p r e s e n t l y o n l y C l a s s ][11 a n d I V p a t i e n t s a r e c o n s i d e r e d c a n d i d a t e s for s u r g e r y , e x p e r i e n c e h a s s h o w n t h a t c e r t a i n c o m b i n a t i o n s of findangs a r e associated with an excessive operative mortality. Patients with mixed mitral i n s u f f i c i e n c y a n d stenosis w i t h e v i d e n c e of c a l c i f i c a t i o n of t h e m i t r a l v a l v e b y x-ray, a n d p a t i e n t s w i t h m i t r a l insuffle~ency, w~th or w i t h o u t stenosis b u t w~th a s s o c i a t e d s i g m f i e a n t a o r t i c insufflc~eney, a r e n o t p r e s e n t l y c o n s i d e r e d c a n d i d a t e s f o r p o s t e r o m e d i a l a n n u l o p l a s t y for r e a s o n s w h i c h w i l l b e c o m e a p p a r e n t in t h e text. MATEBIAL In this group of 39 pahents v,nth aeqmred mltral insuflqe~eney, 21 patwnts were m Class lII and 18 were m Clas~ IV. To date, no Class II pahents have been offered surgery'. Major ~yrnptoms preoperatively~7-4o were fatigue, exert~onal dyspnea, orthopnea and palp, tahon Progression of disability, despite optmaum mecheal management, wa¢ regularly pre~ent All patients had a pansy~tolic apical murmur ,~xilia rad~atlon to the axdl,1 or ba~k. l~ecently, m three patwnts with pure mitral msumeiency due to torn ehordae tendmeae, the pansystohc murmur was noted by one of the author~ (K. A M.) to rachate not only to the back but to the top of the pahent's head, and could readdv be laeard with a ~tethoseope placed over the vertex. To datej such radmhon has not been noted except m these three pahents with mttral insufficiency due to ruptured chordae tendineae of the antermr or aortae ett~p Of the mitral valve. All patients underwent right heart catheterization anti in many mstanee~ left ventricular puncture, left atrial puncture, or retrograde femoral artery eatheterlzatlon w~th left ventrieulography.~°, nl An aortogram as now performed for coronary artery visualization and *Ncw York llcart Associatmn Functional Classification.4n

13 5

~

6 3

M

III

IV

7 18 4

33 45

F

--+ MS 12 39 8 4 5 Total 39 (37) 26 13 21 1 ye~ I0 34 5 5 6 MI = Mltral Insufficiency MS = M1tral Stenosls. AI = Aortic Insut~cleney PMA = Posteromedlal Annuloplasty. ALA = Antero|ateral AnnuIop}asty Comm = Comm~surotomy (number of patients), Valvuloplasty = leaflet repair. *New York Heart Assoclahon Functaonal Classification. }Annuloplasty lmposslble in one patient due to calcium $I2-month period ending March 1, i96'2 (all groups, see text). Parentheses ( ) indacate average for all patients,

i9 8

~

7 4

MI MI + MS MI, AI

Number of Age l~atlentz (average)

Pre OP funet ela~s*

12 4

1 2 3

Group

Sex

12 38 10

19 7t

PMA

0 2 1

2 0 1 7 5

t3 0 8 23 6

7 8

Valvul~l~lasty Comm

Operahon ALA

~l~tral Annulopl~ty--~9 Patients

5 14 1

2 7

40 (36) 53

35 32

Olden eard~otomy Calcified (mmul:es) valve Mean

Table 1.--Clinical and Operative Data Including Operative Mortality in 39 Patients

8 13 0

2 3

#

60 6 (33.3) 0

10.5 37 5

%

Operative mortaht~,

O

(3 O t~

z

O

1-,I

to

I'OS/71E~-'vlEDIAL ANN ULOFLASTY

-

-

283

.

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.

.

.

,

-

.

F i g . l . - - - 2 V I i t r a l i n s u f f i c i e n c y : a. c a l c i f i e d f i x e d v a l v e ; b . i n s u f f i c i e n c y a t p o s t e r o m e d i a l c o m m i s s u r e w i t h s h o r t c h o r d a e t e n d i n e a e a n d d i l a t e d a n n u l u s ; c. t o r n l?ost e r l o r l e a f l e t ; d. r u p t u r e d c h o r d a e t e n d i n e a e w i t h flail a n t e r i o r l e a f l e t . q u a n l a t a t i o n o f a o r t i c m s u i ~ c w n c y . I n d m a t o r cbluhor~ eurve.n w e r e o b t a i n e d b y r e j e c t i n g E v a n s b l u e d y e i n t o t h e p u l m o t m D a r t e r y a n d r e c o r d e d wath ,~ l i n e a r ear o x i m e t e r s y s t e m 52-~4 H E ~ I O D Y N A ~ I I C AND A ~ ' A T O ~ I I C V A R I A N T S

T h e eases w e r e d i v i d e d into three categories: ( 1 ) p u r e m l t r a l insuflqcmncy; ( 2 ) c o m b i n e d m i t r a l insui~clency a n d stenosis, a n d ( 3 ) mxtral insufficiency, with or w i t h o u t m i t r a l stenosis, plus aortic insufficiency. W h e n a valve is ind i c a t e d to h a v e a s t e n o h c c o m p o n e n t , this signifies the p r e s e n c e of an a n a t o m ically small valve orifice, w i t h c a l c i u m n e a r l y a h v a y s p r e s e n t ( t a b l e 1 ), a n d does not i n c l u d e valves w i t h m u r m u r s of functional stenosls d u e to hagh transvalvu]ar flow d u r i n g diastole. Several descriptions of mitral valve p a t h o l ogy are f o u n d in the literature, s4.ar,n~-'~s T h e a n a t o m i c lesions found in this g r o u p o£ patients ,are s u m m a r i z e d in figure 1. Varlations of types ( a ) and ( b ) , figure 1, w e r e f o u n d in 34 of the 39 valves. T y p e ( b ) , w i t h or w i t h o u t some fusion at tl~e antero]ateral commissure, has b e e n m o s t a m e n a b l e to annuloplasty. OPERATION

A s t a n d a r d right p o s t e r o l a t e r a l t h o r a c o t o m y has b e e n used in all except one l~ltient, w h e r e correction of the aortic insuft~cmncy p r e c e d e d mitra] annulo-

0..9-,84

S T b l N ~ I E T Z . A A D E R S O N , COBB~ B R U C E ; ~ I F ~ E N D I N O

p l a s t y T h i s w a s p e l f o n a a e d via m e d i a n ste, n o t o m y c o m b i n e d xv,th r i g h t thora c o t o m y . A l t h o u g h t h e r i g h t t h o r a e o t o m ) , h a s b e e n q m t e s a t i s f a c t o r y f or m a n y s u r g e o n s . -'z,~','~4 K a y *7 uses a m e c h a n s t c r n o t o m y , a n d N i c h o l s *~,~ a n d CIo~.ves 44 use a l e f t t h o l a c o t o m y B~gelow ~" me~ses t h e Iett att i u m p o s t e l t o r to t h e l u n g root a f t e r lxght t h o r a c o t o m y Scott '~" h a s u s e d a b i l a t e r a l t h o r a e o t o m y t l . m s e c t mg the sternum T h e o p e r a t i v e t e c h m c e t n p l o y e d for th~s g i o u p c f p a t t e n t s h a s b e e n d e s c r i b e d in d e t a i l p z e v m u s l v 2.' _.v.,~ ~,. a n d s u b s e q u e n t l y m o d a f i e d o n l y ~ h g h t l y A f t e r r i g h t t h o r a c o t o m y , c~tval c a n n u l a t m n s v m t h e 11ght a t r m m , a n d c a n n u l a t m n of t h e r i g h t f e m o l aI artery, c a l c h o p u l m e n a r 3 b y p a s s Js m s t a t u t e d u s i n g a K a y - G l o s s d i s c o x y g e n a t o l ~ at~d O l s o n H e a i t - L ~ m g M a c h i n e * w l t h m i l d h y p o t h e r m m m t h e r a n g e of 30-3.3 C C a r b o n d m x K l e ~s l a ) e l e d rote t h e o p e l a t l v e f i e l d a t t 0 to 12 L / r a m ._.~,.39 ~,4 S i n c e th~s t e c h m c w a s i n s t i t u t e d o v e r tw o y e m s ago. t h e r e h a v e b e e n no serious c o m p h c a t m n s a t t r i b u t a b l e to m r e m b o h V e n t i n g t h e l e f t v e n t r i c l e ~'~ for t h i s p u r p o s e ha s not b e e n t h o u g h t to b e n e c e s s a r y a n d h a s n o t b e e n u s e d In c a s e s w~th c o n c o m i t a n t aortic m s u f f l c i e n c y , t h e l e f t a t r m m l a p l d l y d~stends u p o n m s t ~ t u t m n of b y p a s s , a n d Is q u i c k l y e n t e r e d or t h e a o r t a c r o s s - c l a m p e d to p r e v e n t o v e r d ~ s t e n t m n of t h e left s i d e of tile h e a r t a n d p u l m o n a r y v e i n s .ca M l t r a l l e g u r g ~ t a t m n t h e n is a s s e s s e d a n d e o mm ~ s s u r o t o m y d o n e ff stenos~s as ]pa e s e n t I f a v a I v u l o p l a s t y I is m c h e a t e d b e c a u s e of r u p t u r e d c h o r d a o t e n d m e a e , t h e r e g m g i t a t ~ o n ~s c o r r e c t e d b y p h e a t i n g the leaflet t i s s u e b e t w e e n i n t a c t e h o r d a e t e n d m e a e as d e s c r i b e d b y }vlcGoon "" H o w e v e l . ff a tor n l e a f l e t or a c a l e t f i e d v a l v e e d g e is p ~ e s e n t w i t h r u p t u r e d e h o r d a e , exc~smn a n d d n e e t s u t u r e appos~t m n of f r e s h e d g e s of t h e leafle t a r e p e r f o r m e d AltJ~ough b u t t r e s s i n g m a t e riaI ires b e e n u s e d i n e o n j t m e t i o n w i t h t h e valx u l o p l a s t y m t h i n lemqets, it has n o t b e e n u s e d r e c e n t l y I n t h e laat vear. t h e s e t e c h n w l u e s h a v e b e e n u s e d w~th s u c c e ss m t h r e e p a t i e n t s w~th r u p t u r e d c h o r d a e t e n d m e a e w i t h o u t e v i d e n c e of r e c u l r e n e e of i n s u f f i c i e n c y to d a t e . B e c a u s e of p e r s i s t e n t m i n i m a l r e g m g i t a tion, a p o s t e r o m e d ~ a l a n n u l o p l a s t y w a s p e ~ f o r m e d afte~ t h e v a l v u l o p l a s t y in e a c h e a s e Th~s s u p p l e m e n t a l a n n u l o p l a s r y m a y also h a v e a f f o r d e d s o m e p r o t e c t m n to t h e v a l v u l o p l a s t y s u t u r e h u e T h e first of f o u r p a t i e n t s in th~s s e r ie s wath r u p t u r e d c h o r d a e t e n d i n e a e h a d c a / c r a m in t h e le a f le t at t h e a r e a o f c h o r d a l r u p t u r e , m a k i n g p l i c a t m n of t h e leaflet m~poss~ble P o s t e r o m e d m l ann u l o p l a s t y a l o n e a b o h s h e d t h e I e g u r g ~ t a n t jet m this o n e i n s t a n c e In t h e u s u a l case. t h e p o s t e r o m e d m l a n n u l o p l a s t y ~s p e r f o r m e d u s i n g i n t e r r u p t e d N o 2 silk s u t u i e s I f o b l i t e r a t i o n of t h e jet o e e u i s as t h e s u t u r e s a r e t~ghtened, t h e y a r e tied a n d c o v e r e d b~r a p p t o x u n a t m g t h e a d j a c e n t a t r i a l w a l l s a b o v e t h e l a r g e k n o t s w i t h a r o w of 3 - 0 silk suttu es In o n l y t w o i n s t a n c e s m th~s .series d~d c o n c o m i t a n t a n t e r o l a t e r a l a n n u l o p l a s t y a p p e a r to help a b o l i s h r e g u r g i t a t i o n . In s o m e eases, ~t w a s t r i e d a f t e r poste~omed~al a n n u l o p l a s t y w as o n l y p m t~alty s u c c e s s f u l , a n d m e a c h e a s e t h e s u t u r e s w e r e r e m o v e d , final e o ~ r e e t m n of r e g u r g t t a t m n r e s u l t i n g o n l y a f t e r f u r t h e r a t t e n t i o n w a s d~reeted to t h e p o s t e r o m e ¢ h a ! a n n u l o p l a s t y . A p o s t e r o *Rlanufactured by Edxxard A. Olson Company. Inc.. Ashland. Massachusetts |In tins rvport, the term "valvtdoplasty" ~s usvd t,~ s~t~nify any type of valve leaflet repair.

I~OST"RE%!EDIAL

AN~rULOPLA

$1-2t"

~O85

m e d m l a n n u l o p l a s t y was u t i l i z e d in all b u t one case w h e r e calcification defied all a t t e m p t s A r e s i d u a l orifice of 1Vz to 2 finger b r e a d t h s in d i a m e t e r ordmarxly has b e e n sul~iclent to p r e v e n t significant stenosls D u r i n g atrial closure t h e m i t r a l valve is h e l d m an i n c o m p e t e n t position by p l a c i n g t h e suction tip in t h e left v e n t r l c l e until the b l o o d level r e a c h e s m i d a t r i u m , w h e r e it is m a i n t a i n e d If significant aortic insufficiency is present, the left v e n t r i c l e m a y o v e r d i s t e n d if c a r d i o p u t r n o n a r y b y p a s s is m a i n t a i n e d with a c o m p e t e n t m i t r a l valve, a n d e e n s e q u e n t l y it m a y b e n e c e s s a r y to k e e p the mitral valve i n c o m p e t e n t until the a t r i u m is n e a r l y closed. T h e a t r i u m is a l l o w e d to fill as the last stitches of t h e atrial closure are taken, the suction tip Js r e m o v e d f r o m the ventricle, the a t r i u m is closed a n d b y p a s s d i s c o n t i n u e d Prior to d e c a n n u l a t l o n , left atrial pressures are r e c h e c k e d for c o m p a r i s o n w i t h those taken m t h e o p e r a t i n g r o o m prior to c a r d l o p u l r n o n a r y b ) ~ a s s . A s a h s f a c t o l y r e p m r has u m f o r m l y b e e n f o l l o w e d b y d e c r e a s e in m e a n a n d p e a k ( V w a v e ) p l e s s u r e . It has occasionally b e e n n e c e s s a r y to r e t u r n to c a r d ~ o p u l m o n a r y b y p a s s a n d r e o p e n the left a t r i u m to alter t h e original anntdoplasty OPEaAaaVE MORTALITY

O p e r a t i v e mortaht),, i n c l u d i n g t h e d a y of s u r g e r y a n d the first p o s t o p e r a t i v e m o n t h , has b e e n r e p o r t e d p r e v i o u s l y for the m a j o r l ~ of t h e s e cases, a6 a n d is s u m m a r i z e d in T a b l e 1 for t h e eno.re g r o u p T h e relative]y low m o r t a h t y of 10 5 p e r c e n t in g r o u p t w i t h "'pure" m i t r a l insuiJieiency is d u e in l a r g e p a r t to t h e fact t h a t a satisfactory a n n u l o p l a s t y was possible. O n l y t w o valves m this g r o u p c o n t a i n e d s~gnificant calcium In seven of these g r o u p 1 p a t i e n t s , c o m m i s s u r o t o m y was t ) e r f o r m e d for m i n o r d e g r e e s of cusp fusion. A l t h o u g h the a v e r a g e time of e p e n e a r d a o t o m y was 35 minutes, it v a r i e d c o n s i d e r a b l y dep e n d i n g u p o n the n e c e s s i t y for valvuloplasty. T h e t h r e e d e a t h s in g r o u p 2 w i t h c o m b i n e d m i t r a l i n s t , ~ c i e n c y a n d stenosis ( t a b l e 1 ) a c c o u n t e d for a 37.5 p e r c e n t m o r t a h t y C a u s e s of d e a t h w e r e in large p a r t a t t r x b u t a b l e to the eatclSed valves w h i c h p r e v e n t e d a d e q u a t e correction of t h e h e m o d y n a m l c p r o b l e m . This e x p e r i e n c e has led to our p r e s e n t p o l i c y of r e j e c t i n g for o p e n o p e r a t i o n those p a t i e n t s shown b y x-ray to h a v e a calcified m l t r a l valve 3G In the g r o u p 3 p a t i e n t s ( m i t r a I insuttleiency, w i t h or w~thout m l t r a l stenosis, plus a o r t i c msufflcJency), t h e r e w e r e 8 d e a t h s in 12 p a t i e n t s , a 66 6 p e r c e n t m o r t a l i t y . N e a r l y h a l f of this g r o u p h a d significant e a l c m m in t h e mitraI v a l v e as n o t e d in t a b l e 1, a n d over h a l f of t h e p a t i e n t s w e r e in f u n e h o n a l classification I V p r e o p e r a h v e l y , h a v i n g b e e n offered s u r g e r y only as a last resort. I n retrospect, s o m e of these p a t i e n t s w e r e p o o r c a n d i d a t e s for this or a n y operat i r e p r o c e d m e . T h e s o m e w h a t l o n g e r p e r i o d of open ca~rdiotomy ( a v e r a g i n g 40 m i n u t e s ) m this g r o u p reflects the difficulty of s u r g e r y in t h e p r e s e n c e of calcified valves a n d i m p a i r e d v i s i b l h t y from t h e aortic r e g u r g i t a t i o n . In view of these experiences, two c o n t r a i n d l e a t i o n s to o p e n h e a r t m i t r a l a n n u l o p l a s t y h a v e b e e n r e c o g n i z e d d u r i n g t h e last year, n a m e l y , mitral v a l v e calcification as seen on t h e p r e o p e r a t i v e x-rays and significant aortic r e g u r g i t a t/on. C o n s e q u c t l t l y , in the Iast year, l 0 c o n s e c u t i v e p a t i e n t s h a v e b e e n o p e r a t e d

~O86

STEINMETZ~ ANDERSON, COBB~ BRUCE, ~fERENDINO

on for mitral insufficiency without any operative mortality. A t operation there was minimal to no calcium £ound in the valves. O n e patient with m i n i m a l valve calcificatlon fell into group 2 wath coxnbmed mltral insufficiency and significant stenosis Seven w e r e in group 1. T w o patients were in group 5, having concomltant aortic regurgatatlon which, surprisingly, a m o u n t e d to 1600 to 2000 ce. per minute while on c a r d l o p u l m o n a r y bypass. T h e longer time of open cardlotorny (53 minutes) is explained by the need for some t y p e of valvuloplasty in addition to the posteromedial annuloplasty in one-half of the patients m this group. LATE RESULTS The clinical and h e m o d y n a m i c findings in 11 of the first 13 survivors of mitral annu]oplasty have b e e n reported by Anderson and colleagues. 6r In the entire group of 26 survivors, there were three /ate deaths. P o u r patients are now less than three months post operation, and although all are doing well, they are arbitrarily excluded from this follow-up group; one patient remains lost to follow-up after initial clinical i m p r o v e m e n t two months after surgery T h e remaining 18 patients h a v e been reevaluated clinically, and 9 have undergone recatheterization d u r i n g the last 18 months These 18 patients were reevaluated 3 to 41 months after surgery. Of the three late deaths, t-wo patients were in the combined mitraI insufficiency and stenosis group with heavily calcified valves One, a 45-year-old male, Class IV, h a d a satisfactory correction of his mitral insufl3eieney, b u t died two months later oxc a myocardial infarction. In the second, a 48-year-o|d male, Class III, a satisfactory repair was never accomplished d u e to the calcification, and the patient died of congestive h e a r t failure ten months ba{er. T h e third was a 38-year-old female, Class 1V, with mltral insufficiency and glomerulonephritis, in w h o m satisfactory correction was obtained b u t who discontinued taking her medications and expired six months post operation. An autoosv was obtained only in t h e first patient T h e annuloplasty was intact, and the recent myocardial infarct evident. Severe atheroselerosis was present in both coronary arteries without evidence of an embolus.

Clinical Changes Long-term results of annuloplasty have been reported b y several groups.43-4~,~r 7o In this series, there has been uniform and sometimes d r a m a t i c i m p r o v e m e n t in the p u r e mitral insufficiency group as noted in table 2 and figure 2. All 14 patients in this group are n o w Class I or II and have resumed full-tlme jolts or arc again able to do their housework. The four patients in group 2 and 3 showed lesser degrees of improvement. T w o of these patients experienced no actual change in functional classification, and although both reported initial subjective improvcmer~t, one who had a calcified valve is now back to her preoperative status, 41 months after surgery ( H . E . ) . This patient, in fact, never had a satisfactory correction of her mitral insufficiency d u e to the dlsnr]vantageo~s site of calcium in the mitral va|ve,

The decrease in intensity of the pat~syslolic apical m u r m u r s did not always

FOSTREA~IEDIAL ANNIYLOPLASTY

2~7

Table 2 . ~ E i ~ h t e e n Survivors of Mitral Annuloplastu Cbmcal and X-ray Change Fu~ctm~al Capacity

rZ':r.~nsvers e Cv.rdia,c I ) m.rrLeber

Follow ~p

~NTumber

Groul~

Ir~x-

"Un-

Deteased

proved changed

~M~e~Bn

14 2

9-42, 12-~1

17 27"

14 0

0 9,

13 1

2

1.~

15 mean (18)

2

0

~

Inere.reed

change

(era.]

i* it

--2 3 +1 0

0

--1.5

Total 18 3-41 16 :2 15 2 *Patient A. F.--see text. JPataent H E.---see text ,X-rays of one pataent not avadable Moderate decrease m heart size reported.

--2 0

1 2 3

MI MI + MS MI -¢- MS + A1

t~a~.g'e

p a r a l l e l t h e d e g r e e of f u n c t i o n a l i m p r o v e m e n t This m u r m u r r e m a i n e d unc h a n g e d in t w o p a t i e n t s a n d d e c r e a s e d in sixteen (figure 3 ) . T h e p r e o p e r a t i v e r a d i a t i o n of t h e m u r m u r to t h e back, w h e n p r e s e n t , u n i f o r m l y d i s a p p e a r e d after s u r g e r y , similarly, t h e left v e n t r i c u l a r h e a v e d e c r e a s e d in all p a t i e n t s except o n e ( H . E . ) . In t w o p a t i e n t s t h e r e Is no r e s i d u a l systolic m u r m u r . O n e is an I S - y e a r - o l d b o y w h o h a d p u r e m i t r a l insufficiency a n d a g r a d e I V m u r m u r , a n d t h e o t h e r is a 37-year-old m a l e w h o h a d r u p t u r e d c h o r d a e t e n d i n e a e In the other patients with ruptured chordae tendineae, the murmtws decreased m o d e r a t e l y a f t e r s u r g e r y , h o w e v e r , t h e r a d i a t i o n of t h e systolic m u r m u r to t h e top of t h e h e a d d i s a p p e a r e d m all tharee p a t i e n t s in w h o m it was h e a r d preoperatively. F o u r t e e n p a t i e n t s h a d atrial fibrillation a n d f o u r p a t i e n t s h a d sinus r h y t h m p r e o p e r a t i v e l y . T h e r e w e r e no c h a n g e s in r h y t h m following surgery, and, in fact, no serious a t t e m p t s h a v e b e e n m a d e to c o n v e r t these p a t i e n t s to n o r m a l sinus r h y t h m . T h e e n l a r g e d atria m a k e it unlikely t h a t p e r s i s t e n t conversion w o u l d b e possible in m a n y patients. T a b l e 2 a n d figure 4 s h o w t h e c h a n g e s in t r a n s v e r s e c a r d i a c d i a m e t e r t h a t o c c u r r e d following surgery. T h e m e a s u r e m e n t s w e r e taken from t h e i m m e d i a t e p r e o p e r a t i v e film a n d from t h e film t a k e n a t the last follow-up visit. T h e transverse d i a m e t e r d e c r e a s e d in all b u t t w o patients, one b e i n g t h e p a t i e n t in Group I (MI)

Funct. Ctoss.

Group 2 ( M i + MS)

IV

Group 3 MI, AI +- MS =

:t

II! 1

I1

14

I

, i ........i..

~4

5

i

bI ......

. . . . . . . . . . .

Fig. 2 . - - C h a n g e s in functional classification (New York H e a r t Association) following posteromedlal annuloplasty. N u m b e r s indicaLe n u m b e r of 10atients; O preoperative, 0 -- postoDerative.

~88

STEIN1VIETZ~ ANDERSON, COBB~ BltUCE~ 1VLERENDINO Murmur ( g r a d e )

6 5 4 5 2

I

0

987'6,5-

]Fig. 3 . - - I n t e n s i t y o f apical systolic m u r m u r f o r e a n d after mitral annuloplasty.

4,

•

Preoperattvely

[~

Postoperahvely

be-

]

g r o u p 2 w h o was n o t p e r m a n e n t l y u n p r o v e d b y s u r g e r y ( H , E ), a n d t h e s e c o n d beang a pataent who, a l t h o u g h £unctaonally i m p r o v e d , p r o b a b l y has sigmficant m i t r a l r e g u r g i t a t i o n (A. F . ) Of the five p a t i e n t s w i t h t h e g r e a t e s t decreose in t r a n s v e r s e cardiac d i a m e t e r , ~vo h a d mitraI insut][iciency d u e to r u p t u r e d e h o r d a e t e n d m e a e , a n d t h r e e h a d p u r e mltral insu~ieiencv a n d w e r e ages 18, 21 a n d 45 at t h e t i m e of ,-mnuloplasty. F i g u r e 5 shows the m a r k e d red u c t i o n in t r a n s v e r s e c a r d m c d i a m e t e r t h a t o c c u r r e d folIowang r e p a i r o~ m i t r a l insufficiency d u e to r u p t u r e d c h o r d a e t e n d m e a e an a pataent w h o is n o w eight m o n t h s post operation. T h e physical fitness index, as calculated by t h e m e t h o d of Bruce, rl in 13 patients w h o w e r e t e s t e d b o t h pre- a n d postoperatively, i n c r e a s e d m 10 patients, r e m a i n e d the s a m e in t w o patients a n d d e c r e a s e d in one p a t i e n t ( H . E ) ~r 25-

!

20-

q.}

E F

c3

o., 15q~

I0

Pre- Op

Post- Op

m e o n chonge= - 2 0 c m

Fig. 4 . ~ d [ a x i m u m transverse cardiac d i a m e t e r before and after mltra| annulopla~ty (in 17 patients). It. E. and A. F.: s e e text.

POSTI~E~clEDIAL A N N U L O P L A S T Y

~-~9

Fig. 5 , ~ P r e o p e r a t i v e (A and C) and recent postoperative (B and D ) posteroanterior and lateral films of a 30-year-old female patient who, eight months ago, underwent correction of mitral insufficiency due to ruptured ehordae tendineae.

H elyugd yna m ic Changes

Hemod)waamio changes £ol]owLng mitral annuloplasty have been reported by Bigclow, 4"~ Clowes 4~ and Kay. 4r' Nine patients in this group have undergone both preoperative and postoperative cardiac catheterization and have been reported in detail by Anderson and others. "r The results are summarized in figure 6. The resting cardiac index increased in seven of nine pataents, and the resting forward stroke .index increased significantly in six of nine patients. Arteriovenous o~),gen difference decreased in eight patients and was unchanged in one patient, with a mean change of - 1 2 m l . / L . Pulmonary artery and pulmonary "'capillary' mean pressures decreased in all hut one patient who is thought to h a ~ some mitral stenosis at this time, although she is functionally impaoved over her preoperative status. Mean change in the pulmonary artery

~090

STEINS, lET-Z, ANDERSON-, COBB, BRUCE, i%IERENDINO

...~ .. P Value of c h a n a e

zz9

CI.

P <: 2 0

L/m~n/m 2

302"

F. S I

A-v

63 6 ml/L

o,,,

~

P A. ( m e a n )

24.5

~

mmHg

kx:~\\\\\\\\\\\\\\~

C I -- Cardiac index F S I = For wa r d stroke index A - V Oz Dtff = Ar~ P < : 05 terlovenous oxygen difference P A m e a n ~- Mea n pulP ~:.005 monary artery pressure P.C. m e a n -- Me a n pulmona r y capillary pressure P<: 05 D-1/A T ~- D~e dalut~on ratao

18

O C (mean)

mm

P<08 Hg

P <: 0 5

f~ f ! -70-60-50-40-30-20

~

i

t .... -I0 0

I

o

!

D-1 "Tzme2 -- T n n e 1 Log~Conea -- Log~Conc~ A T. -- Appearance time

|

+1o +9.0+3,0

Percent Change Fig. 6 . - - ~ l e a n h e m o d y n a m i c changes after mitr a l annuloplasty in nine patients. p r e s s u r e s w a s --7 m m H g a n d m e a n c h a n g e m p u l m o n a r y " c a p i l l a r y " p r e s sures was --6 m m Hg. I n c h c a t o r d i l u t i o n c u r v e s o b t a i n e d a f t e r p u l m o n a r y a r t e r y r e j e c t i o n s of E v a n s b l u e d y e s h o w e d a p r o l o n g e d d o w n s l o p e in e i g h t of t h e n i n e p a t i e n t s p r e o p e r a t z v e l y . P o s t o p e r a t i v e d y e c u r v e s s h o w e d s u b s t a n t z a l r e d u e t a o n of a b n o r m a l m i x i n g c o n s i s t e n t w i t h r e d u c t i o n of m i t r a l r e g u r g i t a t i o n i n a ll p a t i e n t s S a t i s f a c t o r y a n g l o c a r d i o g r a m s w e r e o b t a i n e d i n sLx p a t a e n t s a n d t h e l e f t v e n t r l c u l a r v o l u m e w a s c a l c u l a t e d in systole a n d d i a s t o l e b y t h e m e t h o d of D o d g e a n d o t h e r s r2 T o t a l left v e n t n c u l a r stroke v o l u m e w a s t h e n c o m p a r e d to f o r w a r d stroke v o l u m e as c a l c u l a t e d b y t h e d i r e c t F t c k p r i n c i p l e . R e g u r g l t a n t v o l u m e s a m o u n t e d to 0, 0, 21, 24, 35 a n d 46 p e r c e n t of t h e total left v e n t r i e u l a r stroke v o l u m e m t h e six p a t i e n t s s t u d t e d p o s t o p e r a t i v e l y . I n s u m m a r y , of this g r o u p of 18 p a t i e n t s , 16 a r e i m p r o v e d f u n c t i o n a l l y o v e r t h e i r p r e o p e r a t x v e status. A n i m p e r f e c t a n n u l o p l a s t y in o n e p a t i e n t w i t h a h e a v i l y c a l c i f i e d v a l v e d i d not r e s u l t m p e r m a n e n t b e n e f i t ( H . E . ) . A s e c o n d p a t i e n t w i t h a c a l c i f i e d v a l v e wa s s o m e w h a t i m p r o v e d s u b j e c t i v e l y , b u t w a s n o t i m p r o v e d e n o u g h to w a r r a n t c h a n g i n g h e r f u n c t i o n a l classification. H e m o d y n a m i c s t u d i e s i n d i c a t e s i g n i f i c a n t r m t r a l stenosis in t w o p a t i e n t s w h o a r e n o n e t h e l e s s i m p r o v e d o v e r t h e i r p r e o p e r a t i v e status. ~r R e s i d u a l m i t r a I r e g u r g i t a t i o n is l i k e l y p r e s e n t in s e v e r a l p a t i e n t s in s m a l l d e g r e e . T h e p a t i e n t w i t h a r e g u r g i t a n t v o l u m e of 46 p e r c e n t of his total l e f t

POSTREMEDIAL

291

ANNULOPLASTY

v e n t r i c u l a r stroke v o l u m e continues fulltime heavy m a n u a l labor a n d is a s y m p t o m a t a c 32 m o n t h s afte~ annuloplasty, m spite of s~g~ificant r e c u r r e n t m i t r a l l e g u r g l t a t m n . O n e o t h e r p a t i e n t (A F ) w h o was not recatheterized, now has a 0 8 cm increase in h e r transverse c a r d i a c d i a m e t e r as c o m p a r e d to the p r e o p e r a t i v e films, a n d p r o b a b l y has d e v e l o p e d sigmficant m~tral insuffielency 41 m o n t h s after p o s t e r o m e d l a l a n n u l o p l a s t y for "pure" mitral insufficiency She, too, r e m a i n s subjectively i m p r o v e d over her p r e o p e r a t i v e status. No other pataents h a v e s h o w n r e c o g n i z a b l e r e c u r r e n t mltraI msuft~clency. T h r e e a d d i t m n a l p a t i e n t s h a v e b e e n followed at least 28 m o n t h s since surgery T w o h a v e m a i n t a i n e d their i m p r o v e d status a n d one ( H E ) has b e e n dzscussed above. Disc ussioN

A r e v i e w of t h e status of pataents s u b j e c t e d to p o s t e r o m e d i a I annuloplasty for the correction of a e q m r e d matral r e g u r g i t a t i o n firfnly e s t a b h s h e s t_has proced u r e as 6ne of m e r i t whefa utilized m the p r o p e r e~rcumstances It is n o t a p e r f e c t o p e r a t i o n for the correctaon of mltral regurgitation, for it is n o t applacable ~to all patients. E v e n - I n ,patients with the ideal mdacations, it is an amperfect operataon, as m a n y of~the p a t i e n t s in this series h a v e persistent apical systolic m u r m u r s a n d h e m o d y n a m m e v i d e n c e - o f mitral regurgitation. O n the ot]aer hand, t h e initial m a p r o v e m e n t has m~the mare b e e n m a i n t a i n e d up to 3 ½ years a n d it w o u l d seem unlikely t h a t a n y t h i n g short of active disease could alter the result. F u r t h e r m o r e , 26 of t h e 18 survivors are n n p r o v e a functionally over thezr p r e o p e r a t i v e status, d e s p i t e an i m p e r f e c t operation a n d on occasion m u l t i v a l v u l a r disease. Therefore, p o s t e r o m e d i a l annuloplasty m u s t be c o n s i d e r e d an effective palliative o p e r a t i o n for the p a t i e n t with m i t r a l reg u r g l t a t i o n W h i l e it does n o t cure, it allows_ t h e rehabilitation of the p a t i e n t in a fashion similar to comm~ssurotom~ for m i t r a l stenosis. A n a c c e p t a b l e palliative o p e r a t i o n s h o u l d h a v e a r e a s o n a b l y low m o r t a h t y F r o m this experience the g r e a t e s t m o r t a l i t y o c c u r r e d in patients w h o h a d associated significant aortic insufficiency. P r e s e n t technics in the p r e s e n c e of aortlc ilasufl]ciency i n c l u d e periodic aortm occlusion a n d m i n i m a l to m o d e r a t e h y p o t h e r m i a . Also, t h e v o l u m e of aortic r e g u r g i t a t i o n is n o t e d a n d t h e systemic perfusion is i n c r e a s e d b y a h k e a m o u n t , t h u s m a i n t a i n i n g a d e q u a t e systemic perfusion. D e s p i t e these i m p r o v e m e n t s in techme, we presently avoid open operations on t h e m~traI valve an the p r e s e n c e of significant aortic regurgitation. T h e p e r s i s t e n t large v e n t ~ c u l a r c a w t y u n d o u b t e d l y places a continuing stress on t h e annuloplasty, a n d t h e surviving patient, t h o u g h Improved, will still be d i s a b l e d in p r o p o r t i o n to t h e a m o u n t of aortic insuKiciency present. T h e s e patients p r o b a b l y s h o u l d h a v e b o t h valves corrected at one p r o c e d u r e . H o w e v e r , our initial sklrmlshes w i t h b l v a l v u l a r correetaons h a v e b e e n disappointing, to say the ]east. Patients w h o also d e m o n s t r a t e d a high mortality r a t e w e r e those w h o h a d p r e d o m i n a n t m i t r a l insufficiency associated with stenos~s a n d calcification of the mitral valve. T h e operative p r o c e d u r e a p p h e d to thi~ g r o u p of patients was p o s t e r o m e d i a l a n n u l o p l a s t y c o m b i n e d with commissurotomy. It b e c a m e

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a p p a r e n t that pataents with calcnqcatton of the m l ~ a l valve d e m o n s t r a b l e by x-ray w e r e poor canchdates for posterornechaI annuloplasty, i n the first place, there was always m o r e ealclficataon o£ the valve at surgery than one suspected from t h e x-rays. Often the calc~cataon occurred in tlle posteromedial area of the valve, and p r e v e n t e d satasIactory approximation of the annulus. F u r t h e r more, w h e n calcification revolved the annulus, the latter b e c a m e friable and lacked su:fl~icient strength to hold sutures Most patients with calcification of the rmtral valve h a d b o t h insufficiency a n d stenosis, u n d o u b t e d l y with some dlsabihty attributable to each of the h e m o d y n a m i c lesions Therefore, in the seriously dlsabled pataent wlth mixed msufl~cleney a n d stenosis, an Imperfect correction of the lrntral stenosls c o m b i n e d with an imperfect or impossible eorrectaon o£ mitraI mstfl~ciency resulted m a tugh m o r t a h t y rate Furflaermore, the survivors w e r e seldom slgnuficantly improved. For these reasons, patients ,,wth mitral insui~e~ency a n d stenosis with x-ray e w d e n c e o£ calcification of the mitral v a l v e are not considered candidates for posteromedial annuloplasty. This group o1 patients should not be confused with patients having p r e d o m i n a n t rnitral stenosis wath msufl~clency who often can be xrnproved s~gnfl~cantly b y transatraal or transventricular cornmassurotomy As has been demonstrated an th~s series, ff one excludes these two groups from operatave cons~derataon, the rnortahty rate should be small xaadeed. Obwously, ~t ~s not zero, as has been our experience with a few cases using these criteria, b u t it is a p p a r e n t that it should be low Utihzing these contraindmations, an occaslonal p a t i e n t with rnitral valve c a l c m m seen by x-ray m a y b e turned down for open surgery w h e n the valve is actually correctable b y annuloplasty. Also, these eontramchcataons b e c o m e restrictive, particulaaly w h e n one reahzes t h a t most patients -,wth rnitral valve disease have mixed lesions which are f r e q u e n t l y ealclfic W h a t of this large group? Present p o h c y is one of delay w h e r e possible This group m a y best be treated by total valve replacement. 7z'~z W h e n presently available prostheses are proven to be of value after further follow-up, or w h e n our own prosthes~s reaches such a stage of d e v e l o p m e n t t h a t elimeal traal seems w a r r a n t e d , these patients will be offered open operation on an experimental bas~s. H o w e v e r , prosthetic m~tral valves of current p r o t o t y p e (ball valves) m a y not always b e suitable because of the large cross-sectional area at the mitral annulus in some situations. Consequently, posteromedial annulop]asty m a y well be a p a r t of such reconstructions w~th a total valvular prosthesis. In the ideal situation, w h e r e a posteromedial annuloplasty is capable of correcting regurgitation, it w o u l d seem ,,vise to avoid the use of such prosthetic materials ff possible. SUI~I~fAI4Y

i. A developmental experience with posteromedial annulophisty in 39 patients is presented. This group comprises all patients operated upon for acquired mitral insu~/icieney since the institution of open operation for this lesion in 1956. Preoperatively, fll patients were in functional elasszfieatlon III and 18 were in fimctional classification IV, with p, ogresslo,1 of disability

FOSTREMEDIAL ANNULOPLASTY

g93

despite good m e d i c a l m a n a g e m e n t Presently only patients in Class [ I I and IV status are offered surgery. 2 T h e operative mortality w a s 10 5 p e r eerit in 19 p a t i e n t s w i t h p u r e matral mstfftlclency, 38 p e r cent m elght patients w i t h c o m b i n e d mitral insut~cieney a n d stenosis, and 67 p e r cent an 12 patients w~th mitral insufficiency, w i t h or w i t h o u t stenoms, c o m b i n e d wxth aortic insuflle|ency Because of t h e h t g h risk and lack of significant i m p r o v e m e n t m most surwvors in t h e two latter groups, patients with predominant mitraI r e g u r g t t a t l o n a n d associated aortic insufficiency a n d / o r mltra] valve calcifieataon by x-ray are not considered satisfactory c a n d i d a t e s for p o s t e r o m e d m l annuloplasty. 3 Improvements m p u m p - o x y g e n a t o r e q u i p m e n t , i n c r e a s e d k n o w l e d g e reg a r d i n g total e a r d i o p u l m o n a r y bypass, i n c r e a s i n g familiarity w i t h a n d imp r o v e m e n t s of operative a n d ancillary t e c h n i q u e s , plus an i m p r o v e d selection of patients, h a w n g o c c u r r e d d u r i n g the b u i l d i n g of this series. Consequently, w h e r e a s t h e over-all mortality was 33 per cent, the last 10 consecutive cases, constituting one year's experience, h a v e b e e n p e r f o r m e d wathout a death. 4, A m o n g 18 survivors w h o w e r e r e e v a l u a t e d 3 to 41 m o n t h s postoperativeIy, 16 h a d functional i m p r o v e m e n t s u b s t a n t i a t e d by c h m c a l observations I-/emod y n a m i c studies £urther d o c u m e n t the i m p r o v e m e n t in 9 p a h e n t s S~gmficant r e g u r g i t a t i o n has b e e n recognized m only two patuents after an a p p a r e n t l y satisfactory a n n u l o p l a s t y 5. Posteromedial mitra] annuloplasty is a v a l u a b l e palliative p r o c e d u r e for selected patients. F u r t h e r m o r e . its benefits h a v e persisted as long as this group of pataents has b e e n followed 1

2.

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PdEF]ERENCES Cross, F. S , Berne, 1~ M . Htrose, Y , 28:551, 1954. 6 t~/arkcn, D. E , Black, I-I, Elt~, L B., Jones, R D., a n d Kay, E B.' Deser, pand Dexter, L : Surgacal correelaon tmn a n d evaluation of a rotating dase of mltral lnstl~eieney J. Thoracic type rcservoir-oxygenator Surg. Surg. 28:604, 1954. Forum 7:~74, 1956 7 Johns, T N. P., a n d Blalock, A . Mltral Murray, C., W d k i n s o n , F R., a n d Macmsufflc~ency, experimental use of Kenzxe, B.: Reconstruetiort of t h e mobile polyvinyI sponge prosthesis. valves of t h e h e a r t Canad. /~I A. J. Ann. Surg. 140:335, 1954. 38.317, 1938. 8 Beniehoux, R., a n d Chalnot, P.: A m e t h Tcmpleton, J. Y., LU, a n d Gibbon, J. H , od for the surgueal correction o~ m~tral Jr. Experimental reconstruction of insufficiency. J. Thoracic Surg 30: cardiac valves b y venous a n d p e n 148, 1955. cardial grafts. Ann. Surg i 2 9 : 1 6 1 , 9 De~Vall, R. A , W a r d e n , H. E., LIllehel, 1949. C \V., a n d Varco, R. L . A prosthesis Barley, C P., O'Neill, T. J El., Clover, for the palliation of mitral insu£R. P., Jamison, V¢ L., a n d Redondoficleney. Dis C h e s t 30 I33, 1956. Ramirez, N, P.: Surgical repair of 10. Bernhelrn, B. M.: Experimental surgery mitral insufficiency. ( p r e l i m i n a r y reof the mitral valve. Bull Johns Hopport). Dis. Chest 19.125, 1951. kins Hasp. 20:107, 1909 Badey, C. P., Jamison, ~V. L., Bakst, A. 11. Ellison, R. G., MaJor, R. C., Picketing, E , Bolton, H. E., Nichols, H. T., and R. ~V., a n d Hamilton, ~,V F.: TechGcmeinhardt, W . : Surgaeal correction n i q u e of producing rmtral stenosis of of mitral insutllctency b y the u~c of controllee[ degree J. Thoracic Surg pcrtcardtal grafts. J. Thoracic Surg.

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24 154, 1952 12 Davfla, J C , hlattson, ~V ~V, J r , O'Neill, T J E , a n d Glo~,er, R P . A Met!~od for the surgical correction of m~tral insufficiency, p r e h m m a r y considerations Surg. Gynee. Obstet. 98.407, 1954 i 3 D a w l a , J. C , Glover, R. P , Trout, R G , /~lansure, F , W o o d , N., Janton, O H , and Iam, B D Circumferential suture of the mitral ring, m e t h o d for surgical correction of m~tral msufficiency J T h o r a e m Surg 30_531. 1955 14 Borne, J : M~tral ms-ufficmncy, ex]pemmental c~rcular suture a r o u n d t h e atrmventneulax n n g J. Thoracic Surg. 30"687, 1955. 15. G]over, R P , a n d Davi/a, J C.. T h e t r e a t m e n t of m~traI insttlqqcaeney" b y t he purse-string t e c h m q u e , initaa] e h m e a l apphcataon J. Thoraeae Surg 33:75, 1957 16 Albanese, A R D~seuss~o~ o[ h I e t h o d s of surgical t r e a t m e n t for valvular insul~c~ency of t he heart in Cardaovascular Surgery, H e n r y F o r d Hospital Internataonal Sympos~tun, PhiladeIpbaa, "~V B Saunders Co., 1955, p. 262 17. Kay, E B., a n d Cross, 1~' S.. Surgical t r e a t m e n t of matraI ansufl~cieney, exp e r i m e n t a l observataons J. Thoracic Surg 29 618, 1955. 18 Kay, E B., a n d Cross, F. S " Surgical t r e a t m e n t of mxtral msui~ciency. Surgery 37.697, 1955 19. Badey, C. P , Bolton, H. E., Jamtson, ~,V L , Nmhols, t t T., a nd L~koff, ~ V . h l e t h o d s of surgical t r e a t m en t for valvular msnflqeiency of t he h eart zn Cardaova~eutar Surgery, H e n r y F o r d Hospital Internatmnal Symposmm, Phfladelphm, %V. B. S a u n d e r s C o , 1955, p. 292 20 Naehol% H. T M~tral insufficiency, t r e a t m e n t by polar cross-fi~sion of the mffral annulu~ fibrosus. J. T h o r a c i c Surg 33 102, 1957. 21. Johnson, A. S.. A stmple surgical m e t h o d for the correctmn of mitral regurgttation w a n g the finger ring va l ve elevator. J. Thor a c m Surg. 32.557, 1950, 22. Henderson, A. R,, and L a w , C. L.: T h e surgmal t r e a t m e n t of mttral lnsuf-

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ficlency, experhraental use of transplanted p e r i c a r d m m m dogs. Surgery 33 858, 1953. Moore, T. C., a n d S h u m a e k e r , H. t3. J r . Un s mtab d tty of t r a n s v e n t n e u l a r autogenous shags for d imim~hm g vMvular insufficiency. Surger2," 33.173, 1953 Curt, V L , De~VNI, It A , Gonzalez, J L , Hodges, P. C.. V,trcx% R. L , and La|lehei. C. \V.- T h e direct vi.~ton surgacal correction of pure nutral msufficiency by use Of annu]opLasty or a va|vu]-ir prosth~s~s. Untv. ~ltrm Med. Bull ~9.69, 1957. Lllldlel. C. %'., Gott, V. L , De'~Vall, R A . =rod Varco, R. L : S urgtc,'d correctaon of pl,re m~tral insufficiency by nnmdoplas~" u n d e r durect vasion. J. Lancet 77.446. 1957 3 l e r e n d m o , K A , a n d Br~,ce. R A.: An ob}eehve e~altmtion of 117 surgIcally treated cas~s of valvular r h e u m a t i c h~art disease, wath a p r e l i m i n a r y report of tv, o eases of mitrrtl reffu~glh~tmn treated trader d,reet vtsion ~ a t h th e aid of a pump-oxygenator. J. A. M. A. 16-t-749, 1957. M e r e n d m o , K. A., Jes~,,eph, J. E., t i e r ton, P 3,V., Thomas, G. L, a n d Vetto~ R. R.: Posteromedtal annulopLasty, correction of a c q u i r e d mitral in~afffieicney u n d e r direct w s m n u h h z i n g a pt~rnp-oxygenator. Pre~ented at 30th Scientific Sesszons of A m e r i c a n H e a r t Assoe, October 25-28, 1957. Ldlehei, C. $V., Gott, V. L., DeVVall, R. A., a n d Varco, R. L.: T h e surgical t r e a t m e n t of stenotic or regurgatant lesmns of the m~tanal and aortm valves by" direct vtston uttl~7"ing a p u m p oxygenator. J. Thoracae Surg. ~5-154, 1958. Effler, D. B , Groves, L K , Martmez, XV. V., a n d Kolff, gV. J Open h e a r t surgery for mflral insufficiency. J. Thoractc Surg 36.06,5. 1958 Scott, II ~V, Jr., Daniel, R A , J r , Adam% J E , an d Shull, L G Surgical correction of mitral msufllciency u n d e r dJrect vismn, report of clinical ca~c~. A n n Surg. 147:62,5, 1958 Gu,dry, L D , Callahan, J, A,, Mar~hal], l-l. "W, an d EItt% F. H., Jr.: Tho surgical t r e a t m e n t of rnitral mstff-

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295 lion C~rculataon PA:I005, 1961. 41. Kcrth, %V J , a n d Gerbode, F.- Correction of nntral msuft%ienc'y using extracorooreal eireulahon a n d mild hypothermla Circulation 99.4.971. 1961 42 Eifler, O B,, a n d Groves, L. K : Open heart surgery for acquired valvular heart d/sense A. Nf. A. ArCh Surj~. 84:155, 1982 43. Bigelo~', %V. G., Kuypers, P J., Heimbeoker, R. O., a n d Gunton, R. W.: Chnica] assessment of the efficiency and durab~Ifty o f direct vision annu]oplasty Ann Surg 154.3"20, 1961 44 C|owes, G H., Jr., Nevdle, %V- E , S,-u~eetta, S. ,%1, Wra-ks, E., Lira, K., Barwmsky, J.. and D e Guercio, L R M- Results o f o p e n surgical correetmn of mitral valvular insufficiency and d t ~ c n p t i o n of t e c h n i q u e for approach from left side. SurgeD" 51 138, 1962. 45 Kay, E. B., ~[endeLsohn, D., a n d Ztmm e r m a n , H A " Evahmtion of the surgical ¢orr~.~tion of in~tral regurgttation. Circtdation 23:813, 1961 46. N e w York YIeart A.~oe., Inc.: F u n c h o n al classification in N o m e n c l a t u r e a n d C n t e r m for Diagnosts o/r Diseases of the He.art and Blood Vessels, by Criterfa Committee, H a r o l d E. B. IK~rdee, Chmrman, 5th E d , tion. N Y,: .Am. }teart A., 1953, p. 81. ,IT Bentavogho, L., Uricehio, J., a n d Goldberg, H.: Clinical a n d h e m o d y n a m i c feature.~ of advance*] rheumatic mltral rega,rgttatmn. Am. J. tkled 30:372, 1961. 48. Frtedberg, (3. K.: Disease~ of the Heart, 2nd Edttion, Philadelphia: XV B Saundcrs Co., 1956, 10 643. 49 McDonald, L Dealy, J B , J r , Rabmowxtz, M , a n d Dexter, L.- Clinical, phys~ologae.'tt a n d pathologtcal findmg~ in rnitra| stenosL~ ancl regurgatat~on. Medicine 36:9.37, 1957. 50. ,Marshall, H. XV., a n d %Vood, E H." Hemody~mmic conslderattons m mttral regurgitation Proc Nlayo Chn. 33: 517, 1958. 51 Rushmer, R F : Cardiovascular D y n a m ics, 2nd Edition, Philadelphia. %V. B Saunders C o , 1.C~l, p 359. 52 l h , b b a r d , T, F.: The d y e d d u h o n curve

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STEINMET'Z, ANDERSON~ COBB~ BBUCE. ~£F,I~.F-~I)INO

in t h e e v a l u a t i o n o f m~tra/ insufficiency. J L a b & C l m M e d 51 835. 1958 Wiederhle]m, C Amphfier Ior hnear r e c o r d i n g of o x y g e n saturatxon a n d d y e d~]ut~or~ c u r v e s CJrculat iqes 4 . 4 5 0 , 1956 Parker, R H " E v a l u a t i o n of m l t r a l regurgatataon b y d y e chlutlon curves. M e d . Thesxs, U o~ ~vVash School of M e d , 1958 B r o c k , R. D . T h e s u r g m a l a n d p a t h o logical a n a t o m y of t h e m~tral valve. Brlt H e a r t J 14.489, 1952 Edwards, J E, and BurcheU, H. B. P a t h o l o g i c a n a t o m y of m l t r a l insufficiency ~ r o c M a y o Clan 33 497, 1958. D a w l a , J C , a n d P a l m e r , T. E . . T h e m~tral valve, a n a t o m y a n d p a t h o l o g y for t h e s u r g e o n A M. A. A r c h . Surg. 84 174, 1962 O s m u n d s o n , P J., C a l l a h a n , J. A., a n d E d w a r d s , J E - R u p t u r e d n u t r a I chord a e t e n d a n e a e . C~rcutatton 23 42, 1961 Miller, 9 J , G i b b o n , J. H . , J r , Greco, V F , C o h n , C. /-I, a n d A l l b n t t o n , F. F., J r : T h e use of a v e n t f o r t h e left v e n t r i c l e as a m e a n s of a v o i d i n g mr e m b o h s m t o s y s t e m i c e i r e u l a h o n during open eardiotomy with mainten a n c e of t h e c a r d i o r e s p a r a t o r y f u n c h o n of anm~als b y a p u m p oxygenator. S u r g . F o r u m 4:P-A), t 9 5 3 . M y e r l y , V/. H , T h r o c k a n o r t o n , T. D , a n d Gustafson, J E : T h e closure of c a r t h a c s e p t a l defects. A M. A. Axe~. Surg. 7 4 . 9 1 8 , 1957. Cross, F. S , a n d Thorns, O. J.: E v a l u a tion of a p p r o a c h e s to t h e m~tral valve. A M A. A r c h Surg. 7 7 : 8 7 5 , 1958 Nichols, H T, Morse, D . P., a n d Fhrose, T" C o r o n a r y a n d o t h e r a/r embohzatxon occurring during open eardme surgery, prevention by the use of c a r b o n dioxide. S u r g e r y 43: 23B, 1958 Gott, V. L., a n d L i l l e h e i , C. W . : ArJ i n s t r u m e n t f o r t h e p r e v e n t i o n of mr e m b o l i s m d u n n g darect visaon closure of atrial septal d e f e c t s a n d mitral valvuloplasties. Surg. G y n e c . Obstet. 108:747, 1959. K u n k l e r , A , a n d King, H : C o m p a r i s o n of air, o x y g e n a n d c a r b o n dioxide era-

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boIizat~on. A n n . Surg. 149.95, t 9 5 9 . Start, A The mechanism and prevention of air e m b o h s m d u r i n g correctxon of c o n g e m t a l cleft mxtral valve. J T h o r . Carlov. S u r g 39 808, 1960. M c G o o n , D C 1RepaLr of matral insufficiency d u e to r u p t u r e d c h o r d a e t e n d m e a e . J. T h o r C a r d l o v . Surg. 39. 357, 1960 A n d e r s o n , A M , C o b b , L A , B r u c e , R. A , a n d M e r e n d , n o . K A.: E v a l u a t a o n of m l t r a l a n n u l o p l a s t y for n n t r a l regurgatataon, e h n i c a I a n d h e m o d y ~ a m i c status 4 - 4 1 m o n t h s after s u r g e r y Circ u l a t i o n 2 6 : 2 6 , 1962. Kay, E. B , M e n d e l s o h n , D , J r , a n d Z m a m e r m a n , H . A . T h e r o l e of surg e r y ira t_he t r e a t m e n t o~ mztrat regurgatataon P r o g r C a r d , o r Dxs. 4 259, 1961 G r i s w o l d , H . E , Start, A., Bristow, J D, Menashe, V D, and Adrouny, Z A . L a t e results f o l / o w m g m l t r a l replacement with the Start-Edwards prosthesm. C i r c u l a t i o n 2 4 . 9 4 6 , 1961. Kay, J. H . M a g t d s o n , O , a n d Meflaaus, J. E.. T h e surgical t r e a t m e n t of m l t r a l msu~cmncy and combined mitral stenos~s a n d m s u f l l c i e n c y u s i n g t h e h e a r t - l u n g m a c h i n e . A m . J. Cardxol 9 300, 1962 B r u c e , R A. E v a l u a l a o n o1 funetaonaI c a p a c i t y a n d exercise t o l e r a n c e of c a r d m c p a t i e n t s M o d Cone. Cardaov. Dis. 25"321, 1956 D o d g e , H. T , S a n d i e r , I-I, B a l l e w , D . V¢., a n d L o r d , J. D . : T h e u s e of b i p l a n e a n g a o e a r c h o g r a p h y for t h e m e a s u r e m e n t of left v e n t n c u l a r volu m e m m a n A m H e a r t J. 6 0 : 7 6 2 , I960 Start, A , a n d E d w a r d s , M. L Total m~tral r e p l a c e m e n t , c l m l c a l expexm n e e w i t h a ball valve prosthesis. A n n Surg. i 5 4 . 7 2 6 , 1961 B r a u n w a l d , N. S., C o o p e r , T , a n d Morrow, A O. Complete replacem e n t of t h e m i t r a l valve, successful c h m c a I a p p l i c a t l o n of a flexible p o l y u r e t h a n e prostlaesis. J. T h o r . C a r d i o v . S u r g 4 0 . 1 , 1960 R e p l a c e m e n t of t h e m i t r a I v a l v e I n P r o s t h e t i c V a l v e s for C a r d i a c S u r gery, K. Alvan M e r e n d m o , Editor-anChief. Springfield, C h a r l e s C T h o m a s , 1961, p p . 244-49.,5.

PosT:a~MEDr.~ A ~ L O X ' L a S T Y

George P ~teinmetz, Jr., M.D., Assiseant in SurgertI and Research Fellow, Unwersity of Washington School of Medicine, Seattle. Wash. Arthur M. Anderson, M.D, ]ormerly A~s%~tant in Medicine and Research Fellow, UmversiCy of Washington School of Medicine, Seattle, Wash Leonard A. Cobb. M.D., Assistant Professor of Med~ne, University of Washington SohooI of Medicine, Seattle, Wash. Robert A Bruce, M.S, M.D, Head, D~t~on of Cardwlogy, Professor of Medicine, University of Washington School of Medicine, Seattle, Wash K. Alan Merendino, M D., Ph.D.. Administrative O~cer, Department of Surgery, Professor of Surgery, Univer~h~j of Washington Schoo( ~f Medicine, Seattle, Wash.

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