Determination of Success After Mitral Valvotomy

Abstract

The object of this paper is to describe the progress during two to six years of patients following mitral valvotomy for mitral stenosis at the London Hospital, and to emphasize the relative importance of circulatory obstruction, the state of the myocardium, and other factors in determining clinical improvement after operative treatment. Description of the Material and the InvestigationOne hundred patients, operated upon by Mr. Vernon Thompson and Mr. Geoffrey Flavell and under the care of the cardiac department, were followed before, during, and after operation by one observer. There were 71 women and 29 men in the series and their ages varied between 17 and 55 years. Fifty-six patients were in sinus rhythm before operation and the remainder in atrial fibrillation. In 68 patients the width of the heart was less than half that of the chest, measured in a postero-anterior radiograph, while in the remaining 32 patients it equalled or exceeded this measurement. Significant pulmonary hypertension was present in 47 patients. Associated valve defects, complicating dominant mitral stenosis, included mitral incompetence which was slight in 30 and considerable in 10 patients, aortic stenosis in 3, and aortic incompetence which was judged to be slight in 17 and moderate in 5. In addition 7 patients had pulmonary incompetence from pulmonary hypertension. No patient with tricuspid stenosis or organic incompetence before operation was included in this series. Severe emphysema and chronic bronchitis were present in four patients.A detailed history was taken; this not only provided a subjective account of the patient's exercise tolerance but also afforded an opportunity of getting to know the patients, and their reaction to the disease, which was thought to be an important factor in the selection of patients for mitral valvotomy. In addition, in 47 patients pre-and post-operative exercise tests were carried out, the patient being tested on his ability to climb the hospital stairs.Clinical examination included an electrocardiogram, using the standard leads and CR leads 1, 4, and 7, with the addition of full circumferential V leads in patients with doubtful right ventricular hypertrophy. Teleradiograms were obtained in every patient and each patient was screened, special care being taken to recognize calcification of the mitral valve. Phonocardiograms were recorded before and after operation in 68 patients.Cardiac catheterization was carried out in 10 patients, and was reserved for those in whom some adverse complicating lesion was present or suspected.While in hospital awaiting mitral valvotomy, patients, including those in sinus rhythm, were given full doses of digitalis in order to prevent a rapid heart rate, should atrial fibrillation occur during or shortly after operation. A mercurial diuretic was given where indicated. A strict low-salt diet was in general avoided before operation, in the belief that it predisposed to serious electrolyte disturbances during the immediate post-operative period.At operation a careful apprais...

Course and Prognosis in Operable Rheumatic Heart Disease

“…since the paper by Baker, Brock and Campbell (1950), the value of surgery in the treatment of mitral stenosis has been established in this country. Numerous reports of the success of mitral valvotomy have been published, and recently Mounsey (1957) has analysed in some detail the progress of 100 patients operated upon from 2 to 6 years ago.…”