MITRAL VALVOTOMY

ORIGINAL

ARTICLES

SEPT. 15, 1956

of auricular fibrillation (Fraser and Turner 1955b and the value of electrocardiography (Fraser and Turn

MITRAL VALVOTOMY

1955a).

A PROGRESS REPORT

Method

RICHARD W. D. TURNER O.B.E., M.A., M.D. Camb., F.R.C.P., F.R.C.P.E. SENIOR LECTURER IN MEDICINE IN THE UNIVERSITY OF

EDINBURGH; PHYSICIAN, WESTERN GENERAL HOSPITAL, EDINBURGH

HUGH R. L. FRASER M.B. Edin., M.R.C.P.E. ASSISTANT CARDIOLOGIST, STOBHILL HOSPITAL, GLASGOW ; LATE SENIOR REGISTRAR, WESTERN GENERAL HOSPITAL, EDINBURGH

Each patient was assessed in the usual way by histor physical examination, radioscopy, radiography, an electrocardiography. These methods are almost alwa sufficient for deciding about an operation. Where

cardiac catheterisation was done as a routine in t first 100 patients, it is now rarely considered necessa unless there is some special indication (see below Sometimes intra-arterial tracings helped in assessing t severity of aortic stenosis. --

experience gained from100 cases of mitral valvotomy has already been reported, together with THE

manifestations of rheumatic heart-disease and on the value of special methods of investigation BLogan and Turner 1953). The first 250 patients from the cardiac department of the Western General Hospital, Edinburgh, have now been analysed, and by discussing results in relation to as many factors as possible, we indicate here how the largest number of patients with mitral stenosis can be benefited by operation with the smallest proportion of disappointments. For this reason we emphasise errors of judgment and causes of disappointing results. views

on

’

Material

All the patients in this series have been followed up for more than twelve months, 202 for more than two years, 116 for more than three years, 37 for more than four years, and 12 for more than five years. The cases have been analysed in detail in relation to the various factors which may influence the result of the operation. The series is uniform in that all 250 patients were admitted to the same medical unit and almost all were operated on by the same surgeon (Mr. Andrew Logan). )K’e all the patients were assessed and followed up by the same team they have been known very well individually. The patients were aged 16-60, 29 being aged 50 or more ; TABLE I-PREOPERATIVE

CARDIAC RHYTHM IN

250

PATIENTS

SUBMITTED TO MITRAL VALVOTOMY

!

.B::’(’

’)r.)

--.:IIale:I IrhythmI teiraje

sinus

I fibrillationI Auricular

Before operation cardiac failure was treated on co ventional lines. Unless signs of failure were presen salt was not restricted. Patients with auricular fibril tion were digitalised, but not those in sinus rhyth In the first 150 cases quinidine was given before operati to all those in sinus rhythm, but this practice w abandoned when it appeared that there was no convin ing evidence of its efficacy in preventing postoperati auricular fibrillation. To a few patients with rece embolism anticoagulants were administered preoperative for three or four weeks, but anticoagulants were n given postoperatively except to the few who develop thrombophlebitis. Valvotomy was done with the fing with or without the aid of a knife or a mechanical dilato but we do not discuss surgical techniques here. Penicill was given to all the patients for ten days. Digital was not given after operation to those previously sinus rhythm unless auricular fibrillation develope If the fibrillation persisted for fourteen days quinidi was given (see below). All being well, the patients we allowed to get up when they felt like it, usually af the first week. Thereafter a gradual increase in physic activity was encouraged. Ten days after operati they were transferred back to the medical ward. Follo ing discharge from hospital the patients were asked return for review after a month, three months, six month and thereafter every twelve months. Some were se more frequently and a few, living at a distance, l

frequently. r’ntit Total

dllrieular fibrillation was present in 43% (table i), and 1.11(-iti(-ation of the mitral valve in 27% (table v) ; intracardiac clot was found at operation in 19% (table iv) ; "’ut a third had aortic incompetence ; 12 patients had d"nil’ stenosis, and 6 of these also underwent aortic

:,1!YOrolllY;5 were pregnant at the time of operation ; 24- had considerable cardiac enlargement (cardiothoracic ’d’io -60°o), and many had had congestive failure ; ’<7 , had tight (finger-tip) or fairly tight (terminal 1’:.aLiUX) stenosis. A parallel series of 250 patients were seen over approxi:.stely the same period but not advised to undergo ’ur/ical treatment.

BB’é deal mainly here with our personal experience, and ’-nam aspects have been discussed in more detail - ft-where—e.g., clinical features of mitral stenosis Lagan and Turner 1953), valvotomy in pregnancy 1.(,:an and Turner 1952a), the diagnosis of mitral incompetence (Logan and Turner 1952b), the diagnosis -1 stenosis (Logan and Turner 1954), the importance 6942

Management

Symptoms exertion, paroxysmal dyspnoea, a

Dyspnoea haemoptysis are the usual symptoms which bring t patient with- mitral stenosis to the doctor. Fatigue occasionally the primary complaint, but this sympt should always lead to a search for evidence of predomina mitral incompetence, myocardial damage, anaemia, a neurosis. Recurrent haemoptysis and pulmonary oede do not necessarily signify tight mitral stenosis, partic larly in pregnancy, and may be associated with p dominant mitral incompetence. Chest pain and synco on

dramatic but much less comm embolism or the distress pr duced by the onset of auricular fibrillation sometim first bring mitral stenosis to notice. The symptoms are mainly related to the mechanic effects of mitral stenosis on the lungs. The great var tion in pulmonary vascular resistance from medi hypertrophy, intimal proliferation, and (possibly) incre in arteriolar tone, in patients with apparently simi degrees of valvular defect is unexplained. This resista may tend to protect the lungs from pulmonary oedema b increases the strain on the right ventricle and contribu to eventual cardiac failure. Factors which aggrav and can be influenced symptoms partly by manageme include exercise—e.g., arduous domestic duties in a wom and unsuitable occupation in a man-auricular fibri on

exertion

are more

manifestations.

Systemic

infarction, pr thyrotoxicosis, and anaem

tion, pulmonary infection, pulmonary nancy,

active

carditis,

526 TABLE II—GOOD RESULTS IN RELATION TO HEART SIZE AND CARDIAC RHYTHM

i ratio

( %)

Preoperative cardiac rhythm (%)

No. of

Cardiothoracic

I

I

cases

Sinus !

I

Auricular fibrillation

rhythm

Breathlessness accompanying normal activities is the indication for treatment. Most patients learn to limit their activities short of much discomfort, but on occasion, particularly in young people, discretion is forgotten and we have seen pulmonary oedema precipitated by dancing, by cycling against the wind, and by hurrying in the dark from fear. Emotion may also precipitate pulmonary cedema. The duration of symptoms in patients with tight mitral stenosis is often surprisingly short, even in the Thus the duration, from the onset older age-groups. of the first symptoms to operation, was two years or less in 25% of the 250 patients and four years or less in 34% of those aged more than 50.

principal

The differentiation of these two extreme other grounds, rarely presents difficulty. Murmurs.—In our experience the duration and other qualities of the mid-diastolic murmur are principal determined by the rigidity or otherwise of the valve and not by the degree of stenosis or pulmorar vascular resistance. Predominant mitral incompetence.—The auscultater findings which indicate predominant mitral incompeterare referred to below. Failure to detect signs of mitral stenosis.—S times, in patients with severe symptoms from tion stenosis and a rigid valve, no abnormal auscultater signs can be detected when the patient is first seen.’!.’:’ in such cases the characteristic cardiac contour witi apparent on radioscopy. In our experience abnor signs were always heard subsequently when the pat was re-examined under conditions of different card rate and output. " Diaphragmatic valve."-It has been claimed thu clear signs of mitral stenosis-i.e., a loud slappin, tir--. heart sound, an opening snap, and a rumbling diast murmur-signify_ a pliant diaphragmatic valve suitable for valvotomy. In our experience it often happen;, that operability cannot be predicted on these grounds, and the finding of such a valve at operation is uncommon When the physical signs are not clear, it often happen-

petence. on

Signs

III-INFLUENCE

TABLE

PALPATION

OF

RESULT

The value of palpation is confirmed in that it may evidence of ventricular hypertrophy which cannot be obtained in any other way, because the radiological assessment of possible ventricular enlargement is often difficult, and the electrocardiogram may be unchanged until hypertrophy is considerable. Right ventricular hypertrophy is an indication for considering operation, and left ventricular hypertrophy is a warning that some important complication is present. A systolic thrill at the apex usually signifies an important degree of mitral incompetence.

No. of

provide

AUSCULTATION

Reference will only be made to certain points considered of emphasis. Sounds.—In mitral stenosis the first heart sound, representing the closure of the valve, is typically sudden, loud, and slapping. More often than not a characteristic additional sound, coinciding with the opening of the mitral valve, can also be heard distinctly. This so-called " opening snap " comes shortly after the second sound and is best heard down the left sternal edge. The presence and qualities of these two sounds are important, but changes in one do not always accompany changes in the other. To an observer familiar with these qualities it is, paradoxically, their absence which is most important in differential diagnosis. In a patient under consideration for mitral valvotomy the absence of either a clear first sound or an opening snap should give rise to concern. Sometimes it will be due to tight stenosis with a rigid or caicmed valve but more often to predominant incom-

worthy

OF

I

AURICULAR

FIBRILLATION 0B

OPERATION

B

No. of

l

patients patients with sinus ’ with auricular rhythm fibrillation

Result of

operation

Total

before

before operation

operation

calcified or rigid valve will be found whicha only be widened to a moderate degree, an even then the functional result may be poor. In som patients with the clearest of signs a most disappointingly rigid valve may be found and little can be achieve despite strenuous efforts with the finger aided by a km or mechanical dilator, and with such efforts there always the risk of traumatic mitral incompetence Very occasionally such clear signs, together with j apical systolic murmur, may even accompany predon. nant mitral incompetence. On the other hand some cases with similar signs surprisingly good sphtt of the commissures may be achieved.

that best

a

can

Special

Methods of

Investigation

ELECTROCARDIOGRAPHY

Just as absolute reliance can rarely be placed u: single physical sign, so there are few absolute ::: about special methods of investigation. Neverth

TABLE IV—INTRACARDIAC CLOT

Cardiothoracic ratio

Age Age

(r.)

No of

patients

Xo.with clot

*

3

Ratio

No of

(°o)

patients

cases

’,

No. with clot

Left atrial enlargement

!

had associated mitral incompetence.

Left atrium

No of

patients

No w ..

527 TABLE V—CALCIFICATION

OF MITRAL VALVE

Calcification Total in

Age

no.

,yr.’

agegroup

+++++

Degree +f-

Calcification occurred in 56 males.

I

Sex

MI

F

I

Total

I

no. of cases

% of the males and in 20 % of the

Evidence of preoperative progression or postoperativ regression of R.V.H. may be recorded. Finally, there is no absolute electrocardiographi sign of R.V.H., because occasional exceptions have bee found or published for every criterion. Signs of left ventricular hypertrophy (L.v.s.) invari ably mean that some important complication is present and when it is due to mitral incompetence it must b taken as an absolute contra-indication to operation Likewise signs of biventricular hypertrophy alway mean that some important complication is present When L.V.H. is due to associated aortic valvular disease severe mitral stenosis may be present in addition, an the relative importance of each defect must be assesse on other grounds. RADIOLOGY

consider that the cardiogram may give useful information in the assessment of patients with rheumatic valvular disease, especially in relation to operation. We have analysed our experience in detail (Fraser and Turner 1955a), and for convenience the findings are summarised here. An entirely normal cardiogram suggests that symptoms may be out of proportion to the real physical disIf doubt about the necessity for operation exists on other grounds, cardiac catheterisation may we

‘

ability.

giveuseful guidance. Left axis-deviation suggests that some significant complication may be present, and other evidence for this should be sought. Tight mitral stenosis may be associated with a normal electrical axis, but the greater the degree of right axis-deviation the more likely is right ventricular hypertrophy (R.V.H.) to be present. In our experience an algebraical sum of R and s in standard lead I amounting to -3 mm. (or less) provides strong presumptive evidence in a VR, a depth of s in V5 for R.V.H. S>R in V5, R>Q of 5 mm. or more or a height of R in a VR of 3 mm. or more are other indirect signs providing strong presumptive evidence for R.v.H. R.V.H. is a strong indication for considering surgical treatment because it usually signifies considerable pulmonary hypertension and a poor prognosis. Tight mitral stenosis is the usual cause, but severe pulmonary hypertension is occasionally asociated with predominant mitral incompetence, and this possibility should be remembered and the other evidence reviewed with care.

Although changes indicating R.v.H. are commonly nought in lead Vl, sole or stronger evidence may be found m V2 or in the right-side V leads (V4R, V3R, VE). An absolute height of R>7 mm. in V½ or an R/s>1 in all,V lead recorded over the right ventricle, irrespective of the absolute height of R, almost certainly signifies R.V.N. Complete or incomplete right bundle-branch block has a similar significance in mitral stenosis ; has a negative T in VI if accompanied by a negative r iu V2 or in CRi. A ventricular activation time >0.03 sec. m V1 is a sign of R.V.H. but, in our experience, never occurs as a sole sign and is therefore of no practical value. Particular emphasis is laid on the value of the right-side V leads because they give evidence of R.v.H. more uften than any other leads and in fact provide the sole evidence in 15-20% of cases. For practical purposes sufficient to record V4R in addition to the conventional chest leads. Depression of the s-T segment he found when other signs of R.v.H. are well marked. tent depression may be due to ischuemia. It is important to realise that electrocardiographic signs do develop until the anatomical degree of R.V.H. is considerable. They were present in 158 (61%) of the 250 patients in the surgical series. It is impossible to ......- the severity by the electrocardiogram, because - .’. rL’-umatic heart-disease various factors in addition to the degree of mitral stenosis and of pulmonary hypertention influence the development of the R.V.H. pattern.

References will only be made to a few special point because the general value of radiology has been discusse previously (Logan and Turner 1953).

Cardiac Enlargement The heart’s size varies according to general body build and from person to person, even in people of abou the same build. An increase in the transverse diameter of the hear In the postero-anterior view is’usually due to right The occasional instance in whic sided enlargement. aneurysmal dilatation of the left atrium forms part of th right border can be readily distinguished. If the lef ventricle is enlarged, some cause will usually be eviden - e.g., mitral incompetence, aortic valvular disease Referenc and, occasionally, systemic hypertension. is made below to the occasional exception of rheumati myocarditis. For practical purposes it rarely matter that enlargement of the right atrium cannot always b differentiated from that of the right ventricle. The cardiothoracic ratio is generally accepted as th best approximate guide to the presence or absence o enlargement and changes in size following treatment but there are many difficulties as regards the accuracy and validity of serial observations unless changes o considerable degree have taken place. Technical factor are by no means constant in any one radiological depart ment and vary between different departments. Centrin varies when judged by eye and not actually measured from the floor to a certain vertebral level. In spite o careful instruction to the patient the breath is not always held in the same phase of respiration. This affects the widest diameter of the chest as customarily recorded and the height of the diaphragm, which in turn modifies the transverse diameter of the heart. The transverse diameter of the heart also depends on whether the exposure is taken in systole or diastole, and seria films may easily be taken in a different phase of the cardiac cycle unless the exposure is timed by an electro cardiograph. For all these reasons caution is required in drawing conclusions from apparent changes in heart size Since an analysis of our material shows that the degree of general cardiac and individual chamber enlargement cannot be correlated with the degree or duration of valvular stenosis or incompetence or to the presence or absence of cardiac failure presumably it is principally related to the degree of myocardial damage.

P,ulmonary Artery The apparent size of the pulmonary artery assessed by the convexity of the arc below

cannot be the aorta in theanterior view, because this varies in arteries of the same size (measured at operation) and is influenced by the contours immediately above and below. The widtlx of the vessel-i.e., from the mid-sternal line to the outer border-must also be taken into account. A large pulmonarv artery is usually associated with - considerable pulhypertension, but the converse does not hold. One important factor in .the great variations in size which

monary

528 are seen

must be the

varying distensibility

of the vessel

wall. Branches of Pulmonary Artery We have paid close attention to the narrowing and irregularity in calibre of the peripheral branches of the pulmonary artery which are often seen in patients with

Peripheral

mitral stenosis, but cannot confirm the practical value of these changes as a measure of pulmonary hypertension. Many variable factors influence the readiness with which these changes are seen ; often there is no close correlation between the apparent degree of vascular change and that of pulmonary hypertension, and usually little if any change follows operation. Of more value is the detection of transverse striations. Transverse Striations In recent years attention has been paid to the transverse lines best seen in the right costophrenic angle and first described by Kerley (1951). Although by no means pathognomonic of mitral stenosis, ,in this context they are usually a good guide to the presence of pulmonary oedema in much the same way as a large pulmonary artery and electrocardiographic evidence of right ventricular hypertrophy are good evidence of pulmonary hypertension. In all probability these lines are due to distended lymphatic vessels, and they often disappear after successful valvotomy. They were observed in 37% of the present series. If other factors are favourable, the presence of transverse striations is a strong indication severe

for advising operation. Left Atrium

If exposure and contrast are good, the postero-anterior film provides a better guide to left atrial enlargement than the customary right oblique position with barium in the oesophagus. In the latter view apparent size depends on the precise degree of rotation and on whether the oesophagus has been displaced to the right or the left by the enlarged left atrium. We again emphasise that so-called systolic expansion of the left atrium is of no practical value as evidence of mitral incompetence.

Calcification Valvular calcification is better detected by radioscopy than by either plain radiography or tomography. Its significance as regards the mitral valve is fully discussed below. Right Atrium

Disproportionate enlargement

of

the

right

atrium

may be due to disease of the tricuspid valve, in which case the pulmonary artery may be relatively little enlarged, or to myocardial damage. In either case it is a sign of severity of the underlying rheumatic heart-

disease. CARDIAC CATHETERISATION

the value of cardiac catheterisation are in most cases catheterisation is unnecessary because the. results rarely influence the decision about Our views

on

unchanged ;

’

operating. Catheterisation is sometimes of value when the of

severity

and signs is in doubt. On the other hand, accompanying the patient up several flights of stairs is a simpler and often an adequate test. There is no convincing evidence that either the shape or the time relationships of the pressure curves, recorded with the tip of the catheter wedged in a peripheral branch of a pulmonary artery, are of reliable practical value in the diagnosis of predominant mitral incompetence. Catheterisation may be of value in the assessment of the respective parts played by aortic stenosis and by mitral stenosis when both defects are present. Severe pulmonary hypertension which increases on exercise can be attributed to the mitral stenosis because- there is little pulmonary hypertension from diseases of the aortic valve unless

symptoms

left ventricular failure is present. On the other hand. if one is reasonably certain that the degree of ao stenosis is important-e.g., from electrocardiographie evidence of left ventricular hypertrophy--other special investigations are unnecessary because mitral and aon. valvotomy can be done at the same thoracotorm Catheterisation is also of value when the relative pdnplayed by chronic bronchitis and emphysema and mitral stenosis are in doubt. It has been claimed (Harvey et al. 1955) that, patient believed to have severe mitral stenosis, faihrof the pulmonary arterial pressure to rise on exencan be accepted as presumptive evidence that m;r.. carditis is the limiting factor, and this fits in with our own observations. Risk

Operative

Of these 250 consecutive patients 16 died during the operation, or shortly afterwards, giving an immediatt mortality of 64%, but 4 other patients died withing two months, while still in hospital, from condition that must be attributed to the operation, making the over-all operative mortality, from the commencement lif the series, 8%. However, the operative risk for au individual patient cannot reasonably be assessed frn;h the analysis of a large series such as this, which consists of patients of differing age with various degrees of severityjudged by cardiac enlargement, cardiac failure, and cardiac rhythm, and various degrees (if associated mitral incompetence, aortic valvular disease. pulmonary disease, and systemic hypertension. In a patient aged less than 40 with the signs of uncom. plicated mitral stenosis, sinus rhythm, no more than moderate cardiac enlargement, and no history of cardiac failure or of systemic embolism the risk is small and no more than that of the occasional mishap which accompanies almost any surgical operation or anæsthesia. No such patient died in this series. On the other hand, in a patient aged more than 50 with considerable enlargement, auricular fibrillation, and a history of systemic embolism or of gross cardiac failure the risk may be as high as 20%, mainly from embolism or from cardiac arrest at the operation. In our experience, if there has been a history of systemic embolism, the chances of clot being present in the auricle or the atrium are high ;and, if clot is present, there is a 21P, risk of systemic embolism at the operation. The over-all mortality in patients with a cardiothorac ratio under 60% was 5%. In patients aged less thaI: 50, even with moderate cardiac enlargement and auricular fibrillation but without any history of systemic embolism. the operative mortality was 3%. In the last 100 cases there were 3 deaths. From the analysis of our material we appreciate that, with a stricter selection of cases, some deaths might have been avoided, and in this respect there must be although very few deaths will regrets. Nevertheless, take place if only " good risks " are accepted, such 3 restricted selection would deny a new lease of life t many patients with a considerable or severe disability (see below). The deaths due to the operation were : follows : No. of deaths

Cause

Early (16)

:

Cerebral embolism , ... Cardiac arreat

6 3 ... 2 Haemorrhage 2 failure Hepatic 1 Hypotension... 1 Intracardiac thrombosis 1 Transfusion reaction.. ....

....

Late

(4):: Mitral incompetence Cerebral embolism

..

....

Total

Early Operative The principal operation were

..

3 1

20

Deaths

of death during or shortlv after cerebral embolism from the

causes

displace

529 ment of intra-auricular or intra-atrial clot or of fragments of calcified mitral valve ; and cardiac arrest or

In addition 2 patients died ventricular fibrillation. from hæmorrhage secondary to technical difficulties, 2 from hepatic failure secondary to cardiac cirrhosis of the liver, 1 from a mismatched blood-transfusion, 1 from cardiac failure three days after operation, apparently as a result of the postoperative formation of clot occluding the mitral valve, and 1 from persistent hypotension. Of the 3 patients with cardiac arrest or ventricular

tibnllation, the first was

large heart,

a

heavily

woman, aged 51, with a very calcified valve, and an intra-

a

atrial clot; the second was a woman, aged 58, with considerable cardiac enlargement ; and the third was a woman, aged 38, with a very large heart and aneurysmal dilatation of the left atrium. In each instance it was considered that the operative risk was above average owing to the degree of cardiac enlargement, which presumably indicated muscle damage, and such patients should probably not be subjected to operation. From experience of this series and of other patients withsevere cardiac cirrhosis of the liver subjected to operation under general anaesthesia we have decided that the risk of hepatic failure in such cases is prohibitive. Operative Deaths patients died, four

Later 2

and eight weeks after operation, with cardiac failure which was probably secondary to traumatic mitral incompetence. A regurgitant jet and an apical systolic murmur followed valvotomy, but the the degree of mitral incompetence produced was difficult to assess post mortem. In a 3rd patient, who died weeks after operation, traumatic mitral incomeight petence was definitely the cause. The 4th death was in a woman, aged 59, who developed paroxysmal auricular fibrillation during the night, at home, eight weeks after operation. Three days later she had a fatal cerebral embolism, presumably as a result of thrombosis during the period of rapid ventricular action.

Subsequent Deaths 7 patients died from one to thirty-nine months after leaving hospital; 1 death was probably attributable to quinidine ; 1 was due to an unrelated pulmonary condition ; 1, who discharged herself against advice, may hare died from bacterial endocarditis ; in 1 young girl the operation appeared to be only an incident in her progressive deterioration due to active carditis ; 1 woman died suddenly three months after successful valvotomy and no cause was apparent at necropsy ; and 2 patients with gross cardiac enlargement, of a degree which

consider precludes operation, had a poor and died from the natural consequences of mitral stenosis two years and three and a quarter years after operation. we now

symptomatic result

Results in Survivors

Grading (Subjective)

I’)%- a cardiac

good result we mean freedom from congestive failure, attacks of pulmonary oedema, and hæmoptysis, and a striking improvement in effort

hyspnœa. By

a

fair result

we mean

that both

was obtained. the condition did not ·.‘’-: the operation.

By a poor result we improve or became

mean worse

subjective Assessment jective evidence of improvement is difficult to -"-. It is simple enough to decide whether the patient plers- the operation to have been worth while (almost do so at least for a time) ; but whether a result is se classified as fair, good, or very good depends on erous variable factors, including the length of w.up. -

Objective Assessment Objective evidence of improvement is not easy to obtain ; the least equivocal is provided by the electro cardiogram. In our experience the auscultatory signs of mitral stenosis are rarely materially altered by operation, and this is not surprising, because only the degree of stenosis and not the quality of the valve cusps is changed by the operation. In no case did the auscultatory evidence for mitral stenosis completely disappear. The nutrition often improves. On radiography the heart size, judged by the cardio-

thoracic ratio, may be reduced, but there are considerable difficulties in assessing it (see above). The transverse striations mentioned above often disappear. Electrocardiography may show regression of the pattern of right ventricular hypertrophy. 14 (9%) of 158 patients with signs of R.v.H. died, and in 10 (6%) who live at a distance, although clinical reports have been received, adequate follow-up electrocardiograms are not available. The electrocardiographic signs of R.v.H. disappeared in 26 (16-5%), regressed variably in 38 (24%), and are essentially unchanged in 70 (44%). Many patients in whom there has been no electrocardiographic change have had an excellent symptomatic result, but in this group well-developed patterns of R.v.H. had not been present, the signs being inconspicuous in the majority. Few of our patients were subjected to re-catheterisation. Initially some volunteers were re-examined in this way because we wished to study the natural history of the condition after operation. However, it became clear that serial observations would have to be made because improvement often progressed over many months and because some conditions during the catheterisation-e.g., the degree of relaxation of the patient and the amount of exercise given-could not be precisely reproduced, and therefore errors of deduction might be considerable. Some patients, however, were re-catheterised to assess the degree of pulmonary hypertension before deciding on reoperation.

patient

and doctor are convinced that the operation was well whith, while in that a material degree of symptomatic

anprovement

In the first place the degree of previous disabilit varies widely. Young people expect to be able to d some tolerate their symptom more than older ones ; If symptoms were progressive better than others. some patients were operated on when the conditio was mild to prevent further deterioration and destruc tion of the valve ; whereas others, who found life almos intolerable, were anxious to be treated if no more tha a fair chance of improvement could be offered. Mos were principally disabled by dvspnoea on exertion but in some the chief indication for operation wa recurrent haemoptysis, systemic embolism, attacks o pulmonary oedema, or, occasionally, angina. A few patients who improved considerably at first and con tinued to do so for two or even three years have recentl shown evidence of regression. 5 have been subjected to a second operation owing to an inadequate firs valvotomy when experience was limited.

Analysis Embolism 2 survivors sustained calcified material and

of Poor Results

Systemic

hemiplegia made

a

from displacement of moderate functional

recovery. Poor Selection of Cases Cardiac enlargement depends mainly not on the degree or duration of valvular defects but presumably on the degree of rheumatic myocardial damage. A good result was obtained in only 51% of patients with a cardiothoracic ratio>60% but in 82% of those with a ratio The combination of a large heart, auricular <55%. fibrillation, and the absence of electrocardiographic

530

signs of right ventricular hypertrophy is particularly unfavourable. Associated mitral incompetence in 8 patients was less severe than had been predicted; consequently it was only to be expected that there would be no dramatic improvement in symptoms as a result of the modest degree of splitting of the commissures that was achieved. In occasional cases of special difficulty exploratory thoracotomy is justifiable ; but, if due attention is paid to all the relevant signs, errors of judgment on this account should now be rare. Active carditis.-On the whole there has been a poor correlation between the histological findings in the biopsy specimen taken from the left auricle at operation (250 cases), the erythrocyte-sedimentation rate, and clinical and electrocardiographic evidence of active carditis. However, in a few patients active carditis is believed to have been the reason for an unsatisfactory result despite adequate valvotomy. Pulmonary disease.-In 4 patients chronic bronchitis is still troublesome, but each considers the operation to have been worth while. ’

Inadequate Valvotomy In 4 patients without calcification a poor result was attributed to inadequate splitting of the commissures because of rigidity of the valve. No other adverse factor appeared to be responsible. In 4 patients gross calcification of the mitral valve may have been responsible for a poor functional result despite good splitting of the commissures, but 2 of these patients also had very large hearts.

Traumatic Mitral Incompetence In 6 patients it is believed that a material degree of mitral incompetence produced as a result of mitral valvotomy contributed to a disappointing result ; 3 of these patients are included in the deaths. There is no doubt that, in patients with a rigid valve, when vigorous attempts are required to achieve adequate splitting of the commissures either with the finger, a knife, or a mechanical dilator, a higher incidence of traumatic mitral incompetence will result. However, there is also no doubt that in other patients such efforts have produced better results than were obtained earlier in our experience.

Postoperative Complications Cardiac Failure retention of fluid, shown by a rise of pressure and slight peripheral oedema, is very common in the first postoperative week but, unless persistent, does not require treatment with mercurial diuretics or with digitalis. Frank congestive failure is very uncommon. Auricular Fibrillation Postoperative auricular fibrillation in those previously in sinus rhythm developed in 24% of the patients. In most instances fibrillation develops in the first few postoperative days, but occasionally the onset is delayed for a week or two and then is possibly related to increasing physical activity. Occasionally the onset was apparently precipitated by some minor surgical procedure-e.g., bronchoscopy and paracentesis thoracis-but usually there was no obvious reason. It is presumed that iibrillation in these patients is related to traumatic pericarditis and epicarditis in the setting of rheumatic heart-disease. We found it was impossible materially to decrease the incidence of postoperative fibrillation by the administration of quinidine prophylactic ally even in fairly high dosage, such as gr. 24-36 daily. We also found, as have others, that it was unprofitable to attempt to restore sinus rhythm by treatment with quinidine in the first ten postoperative days, because success was uncommon. However, when quinidine was given after the first fortnight, sinus rhythm was restored in all but 2 cases.

Postoperative

venous

We have been unable to demonstrate that digitalis given before operation has any effect in diminishing the occurrence of postoperative auricular fibrillation.

Postoperative Pyrexial Syndrome Since pyrexia and some pain in the chest are verr common in the first week or ten days after operation a:: usually subside by the-time the patient should be up and about, we take no particular note of them. Occasionall. however, they persist longer or develop some weeks after operation and are accompanied by pains in the joints, and very occasionally they recur during suh sequent weeks. Sometimes the chest pain is sevre Signs of cardiac failure (increased venous pressure and peripheral oedema) are common in the early po operative period and may be somewhat accentuated in patients who develop this pyrexial syndrome but they subsequently subsided in all the cases. Although this complication superficially resembles rheumatic fever we

are

in

our

not convinced that this is the cause, becaus

experience there has been no joint swelling little subjective improvement with salicylates, and after subsidence of the attack, no evidence of deter The course ioration in the cardiac condition. uninfluenced by antibiotics. The syndrome is probabl due to traumatic pericarditis and pleuritis resulting fro the operation, with accompanying systemic disturbance. Some workers report an incidence of this syndrome i 25-40% cases. In our series it was less than 5%. I is important that this syndrome should be widel recognised because, when it occurs later-i.e., afte the patient has returned home-it may lead to admissio to a local hospital and give rise to unnecessary alarm. Personality Change

-

We have observed personality change and occasionall frank psychoses, as have other workers. All the patient recovered.

Subsequent Progress

Deterioration after Initial Improvement If postoperative grading is accepted as establishe six months after valvotomy, 22 patients are to b considered as regards subsequent deterioration. 5 patients subjected to a second valvotomy becaus of an inadequate first attempt and 4 who develope non-cardiac complications (such as cancer) are excluded 13 remain who did not maintain their initial improv ment. The initial results had been fair in 6 and poor in 1 so only 6 of our 250 patients operated on more than. year ago, in whom adequate valvotomy was achieve and the initial result was good, deteriorated. Valvotom is in no sense a cure, and it is only to be expected that th number of patients who maintain a good initial reuu will decrease progressivelybut, so far as the nrst te years are concerned, it seems that the result is usuall determined by the surgeon at the operation. In most cases the subsequent course has been essential the unfolding of the natural history of mitral ste in advanced cases, and in 4 of these the developmen of auricular fibrillation was apparently responsible for t onset of deterioration. In 1 patient retinal embol was the reason for dropping a grade. Re-fusion of Commissures

possibility of re-fusion must be entertained whe symptoms recur after valvotomy. Such an ocetirrt,,, must, of course, be distinguished from mere progressin of symptoms in the natural course of mitral ste when, for one reason or another, the operation however, sometim Symptoms, unsatisfactory. recur after a considerable period of unquestio improvement. In our experience re-fusion of the commissures be very uncommon. 5 of our patients were subjecti to a second valvotomy, and 3 more are under considerab The

ever

531 case the first operation was early in of these 8- patients were among the 7 experience. first 15 to be treated, and the 8th was no. 53. The reason for the recurrence of symptoms is difficult to demonstrate conclusively, but the second valvotomy was done by the same surgeon, and in his opinion inadequate splitting of the adherent commissures at the first operation rather than re-fusion was the condition found. If this is the case myocardial failure from inadequate valvotomy is presumably responsible for subsequent deterioration. In each of the 5 patients the second operation produced much improvement, which so far has been maintained twelve months to three years). That re-fusion is likely to recur often seems improbable on theoretical grounds because the surfaces of the valve leaflets usually consist of avascular fibrous tissue which would not be affected by a recurrence of active carditis. However, with adequate splitting and little resultant improvement in cusp movement there must be a possibility of thrombosis. in the narrow slit-like aperture between the partially divided commissures. That re-fusion can take place is well illustrated by a case of Blalock’s (McKusick 1955) and a case described hy llatthews (1954). However, from the published reports it seems that most of the cases described can be better explained on the basis of inadequate valvotomy. In the last 200 cases of the present series there was no reason to suspect re-fusion, and from the practical point of view this possibility is not at present important ,llld should not influence the decision about operating.

tion, but in each

our

Factors

Influencing Result of Operation

.lye oi-er 50 Uf the 250 patients 29 were aged 50 or more, 8 being 55 and the eldest 60. 7 died as a direct result of the operation ; 2 from cardiac arrest, 4 from cerebral embolism, and 1 from traumatic mitral incompetence. 2 of those with cerebral embolism died in the early before the importance of allowing gushes of blood to escape from the auricle before valvotomy was appreclated. Of these 29 patients 80% had auricular fibrillation and about 50% each had clot, calcified valves, of a cardiothoracic ratio of 60% or more ; 1 of them has since died. In 20 survivors treated more than twelve months ago 13 results are good, 4 are fair, and 3 are poor i.e.. worth-while improvement was obtained in 65%. As in analysing the importance of auricular fibrillation as opposed to sinus rhythm, it is impossible to assess the effectof age because of the other variable factors involved, as cardiac size, calcification, and clot ; but it is clear that the operative risk is greater than in the ger age-group and good results are less likely to obtained. However, a good result was obtained in ’ of 8 patients with a cardiothoracic ratio less than go who had no past history of embolism. The 8th patient, aged 59, died at home as a result of an attack paroxysmal fibrillation, which is an over

-

of uncontrolled

uncommon event.

Enlargement the whole the

larger the heart the poorer is the mentioned above, cardiac enlargeflectsnot so much the degree or duration of valvular defects as the degree of myocardial

look because,

as

Hypertrophy judged electrocardiographically, cardiac enlargement judged radiologically, least partly reversible, but the effects of rheumatic are not. In our experience a reduction in

much

’

all f ardiac size has been

uncommon

after successful

utny.

series enlargement judged by the cardiothoracic was divided into four grades : <50%, 50-54%, and60% or more. The results in the fourth as might be expected, are definitely less good ’..’. the grades with less cardiac enlargement (table II).

Nevertheless considerable enlargement is not an absolut contra-indication to operation. Gross enlargement of the left atrium is not necessaril a sign of predominant mitral incompetence and may occur with tight stenosis ; and gross enlargement of th right atrium is not necessarily a sign of tricuspid diseas or of severe pulmonary hypertension. Good operativ results are unlikely to last in either of these groups Enlargement of the left ventricle, where not attributabl to aortic valvular disease, is almost always due to mitra incompetence but occasionally may be found with tigh mitral stenosis, presumably as a result of rheumati

myocarditis. Finally, severe

mitral stenosis may occur rarely i the absence of any enlargement of the right atrium o ventricle, with but slight enlargement of the left atrium and with normal lung fields.

Auricular Fibrillation In the ’surgical series 111 of 250 (44%) patients had auricular fibrillation before operation, and 34 of 140 (24%) of those previously in sinus rhythm developed fibrillation in the early postoperative period. Only 5 patients developed fibrillation later than that. In the medical series 115 patients were considered unsuitable for operation because the mitral stenosis was too mild, and 135 because it was too severe or because of some other factor complicating mitral stenosise.g., mitral incompetence or aortic valvular disease. Of the mild group 5 (4%) had auricular fibrillation, and of the severe group 110 (81%). Precipitating factors which we have observed include exertion, emotion, infection, active carditis, and thoracotomy, but usually there is no obvious cause. Clinical aspects of auricular fibrillation in rheumatic heart-disease have been discussed elsewhere (Fraser and Turner 1955b) ; here fibrillation will be considered only in relation to operation and its results. From this point of view disadvantages are from the greatly increased probability that clot is present in the auricle or in the atrium, with the consequent risk of embolism at operation, and from the presumed presence of myocardial damage, which probably explains why postoperative improvement, though often striking, is more often less so than in patients with sinus rhythm. This is only to be expected because, before the introduction of valvotomy, the onset of auricular fibrillation in a patient with mitral stenosis reduced the probability of survival to no more than a few years. Oleson (1955) found that 50% of patients lived for less than six years. Prognosis cannot be directly related to the effects of fibrillation per se, because other related factors, such as the presence of clot, and unrelated factors, such as calcification of the mitral valve, influence the operative result. The results obtained in those with auricular fibrillation who had comparable degrees of cardiac enlargement judged by the cardiothoracic ratio are shown in table 11. Sometimes the importance of auricular fibrillation has been underestimated (table III). All but 2 of the operative deaths took place in patients with auricular fibrillation ; and, except for 1 patient with an unrelated pulmonary condition, all the subsequent deaths took place in patients with fibrillation. Also twice as many of the results classified as poor or fair were in those with fibrillation as in those with sinus rhythm, and 81% of those considered unsuitable for surgical treatment on grounds of severity had auricular fibrillation.

Conclusion Auricular fibrillation is not

a contra-indication to but is a relative disadvantage in that the incidence of clot and therefore the risk of systemic embolism are much greater than in patients with sinus rhythm and there is less chance of a good result.

operation

(To

be concluded)