Problems in the Diagnosis and Surgical Treatment of Pulmonic Stenosis with Intact Ventricular Septum

Kirklin, John W.; Connolly, Daniel C.; Ellis, F. Henry; Burchell, Howard B.; Edwards, Jesse E.; Wood, Earl H.

doi:10.1161/01.cir.8.6.849

Cited by 55 publications

(20 citation statements)

References 22 publications

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“…systolic pressure of 100 mm. though Kirklin et al (1953), Blount et al (1954, and Brock (personal communication) thought that a pressure of 75 (or a gradient of 55 mm.) was enough to demand operation.…”

Section: Discussionmentioning

confidence: 99%

Valvotomy as a Curative Operation for Simple Pulmonary Stenosis

Campbell¹

1959

Heart

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Four years ago we reported the results of pulmonary valvotomy in 58 patients with simple pulmonary stenosis (Campbell and Brock, 1955). This, I think, is the best term for pulmonary valvular stenosis with a closed ventricular septum, whether the foramen ovale is unsealed in which case central cyanosis will develop if the stenosis is severe enough, or whether it is sealed in which case there cannot be central cyanosis, however high the right ventricular pressure. We gave our reasons for thinking it was a good operation. As with operation for Fallot's tetralogy, it relieved the symptoms and cyanosis, if these were present. In addition it enabled a large heart to become smaller and right ventricular strain to become less-changes that cannot be expected with Fallot's tetralogy where generally, with the increased activity that is made possible by a successful operation, the size of the heart and the right ventricular strain increase.We are now reporting the further progress of these patients and of another 18 operated on up to the end of 1956, making 76 in all. There were 13 more acyanotic and only 5 more cyanotic patients, making a total of 46 acyanotic and 30 cyanotic. But our main purpose is to assess the results more critically and to consider how far pulmonary valvotomy for simple stenosis can be considered a curative operation. More patients have been recatheterized, and the significance of the pressure readings taken at operation is now better understood.At first, results were judged mainly on clinical grounds, and improvement in the size of the heart and in the electrocardiogram were so welcome, and perhaps so unexpected, that they were added as something extra. Now we have tried to assess, mainly by the objective changes, how many patients have improved enough to be regarded as nearly normal. Previously, we had studied the diminution of T inversion across the chest leads, which, even when it had been present from VI to V4, often disappeared entirely or nearly so: now we are adding the diminution of right ventricular preponderance as shown by the decrease of the size of the R wave in VI and of the sum of SI and RIII, which are among the reliable measures (Woods, 1952).Earlier, we excluded one girl with sole infundibular stenosis and thought this was rarely found alone or in combination with valvular stenosis when the ventricular septum was closed, though it so often is with Fallot's tetralogy. Now, however, we have included her and two others operated on since. Apart from true infundibular stenosis, the greatly hypertrophied muscle of the right ventricle often produces infundibular obstruction, sometimes with a large gradient. Campbell and Brock (1955) emphasized that when a gradient remained at the time in spite of a successful valvotomy, recatheterization a year or so later might show that it had become much smaller. The great improvement in some such patients, clinically and in the reduction of right ventricular preponderance and strain, convinced us that such a residual gradient could regress. In retrosp...

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Section: Discussionmentioning

confidence: 99%

Valvotomy as a Curative Operation for Simple Pulmonary Stenosis

Campbell¹

1959

Heart

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“…In order to explain this, Kirklin, Connolly, Ellis, Burchell, Edwards, and Wood (1953) con-cluded that before the development of open heart surgery there were two main reasons: (1) failure to open the valve adequately (they advocated repeated attempts until a satisfactory diminution in the gradient could be demonstrated), and (2) stenosis of the infundibulum due to right ventricular hypertrophy, a hypothesis also suggested by Soulie, Joly, Carlotti, Sicot, and Voci (1952).Introducing the open transarterial operation under hypothermia, Swan and his associates (Swan, Cleveland, Mueller, and Blount, 1954) and Blount, McCord, Mueller, and Swan (1954) obtained a fall in right ventricular pressure to normal and an abolition of the gradient across the pulmonary valve in almost all their cases, assessing them after some months. In a recent review of their later cases (Blount, van Elk, Balchum, and Swan, 1957), they have found that in one-third, approximately, there is a residual gradient three months after operation; they explained this as an infundibular stenosis, which could be obscured by the distal, i.e., valvular, stenosis before operation.…”

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Pulmonary Valvular Stenosis: The Infundibular Factor in Relation to Valvotomy

Bassett¹

1958

Thorax

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It has been found that after pulmonary valvotomy for pulmonary valvular stenosis with an intact interventricular septum a satisfactory fall in right ventricular pressure is not always achieved immediately. In order to explain this, Kirklin, Connolly, Ellis, Burchell, Edwards, and Wood (1953) con-cluded that before the development of open heart surgery there were two main reasons: (1) failure to open the valve adequately (they advocated repeated attempts until a satisfactory diminution in the gradient could be demonstrated), and (2) stenosis of the infundibulum due to right ventricular hypertrophy, a hypothesis also suggested by Soulie, Joly, Carlotti, Sicot, and Voci (1952).Introducing the open transarterial operation under hypothermia, Swan and his associates (Swan, Cleveland, Mueller, and Blount, 1954) and Blount, McCord, Mueller, and Swan (1954) systolic nature of the stenosis by the early or asynchronous wave pattern of the infundibulum in 10 out of 13 cases. In their remaining three cases the contractions were synchronous, the stenosis being presumably of the pure fixed type.This study was initiated by the finding that such asynchronous ventricular contractions occurred also in a proportion of cases of congenital pulmonary valvular stenosis, and was undertaken to determine whether such contractions would allow the pre-operative recognition of infundibular hypertrophy, and furthermore whether such hypertrophy regressed after operation when the ventricular contractions should become synchronous. Between 1954 and June, 1957, 40 patients, investigated by cardiac catheterization at the Toronto General Hospital, had been found to have a pulmonary valvular stenosis, with an intact interventricular septum. MATERIAL AND METHODSOwing either to the absence of a synchronously recorded electrocardiograph, or to failure to make the catheter enter the pulmonary artery, 21 cases have been excluded, leaving 19 as the basis of this study. Ten of these were confirmed at operation; in nine an open transarterial operation was done at which the valve was seen and a fixed fibrous infundibular stenosis was considered to have been excluded by passing a finger back into the ventricle. There are also four operative recordings and five post-operative catheter pressure recordings included in this study.For comparison the intracardiac pressure tracings of " normal " cases and cases with pulmonary hypertension and with Eisenmenger's complex have been examined because they have no pulmonary stenosis. Seven cases with Fallot's tetralogy have also been included.The cardiac catheterizations were performed with the patients supine, using an electromanometer (Sanbom) and a two-channel direct writing recorder with a paper speed of 25 squares per second. The recordings made at operation were made direct through a right ventricular stab wound with a metal catheter passed up into the pulmonary artery.The " R-peak " intervals, or the time intervals between the R-waves of the electrocardiograph and the peaks of the following pressure waves, rega...

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“…It was soon found that this could not always be achieved at operation and for this three main reasons have been suggested. Kirklin et al (1953), reporting twelve cases of transventricular pulmonary valvotomy, discussed the possibility that right ventricular hypertrophy might result in secondary stenosis in the infundibular region. Brock (1955), in an account of control mechanisms in the outflow tract of the right ventricle following a careful study extending over seven years, described and illustrated with pressure records secondary infundibular stenosis after pulmonary valvotomy.…”

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Hypertrophic Infundibular Stenosis Complicating Simple Pulmonary Valve Stenosis

Johnson¹

1959

Heart

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Pulmonary valvotomy by the closed transventricular technique was introduced as an alternative to the Blalock-Taussig operation in Fallot's tetralogy (Brock, 1948) and for relief of pulmonary stenosis in the presence of a closed ventricular septum (Brock and Campbell, 1950). In Fallot's tetralogy, at least until closure of the ventricular septal defect became feasible, some residual pulmonary stenosis was considered desirable. With a normal aortic root, however, complete relief of the stenosis was sought. It was soon found that this could not always be achieved at operation and for this three main reasons have been suggested. Kirklin et al. (1953), reporting twelve cases of transventricular pulmonary valvotomy, discussed the possibility that right ventricular hypertrophy might result in secondary stenosis in the infundibular region. Brock (1955), in an account of control mechanisms in the outflow tract of the right ventricle following a careful study extending over seven years, described and illustrated with pressure records secondary infundibular stenosis after pulmonary valvotomy. He discussed two factors responsible for this, the first mechanical, particularly in the region of the greatly enlarged crista supraventricularis, the second an exaggeration of the infundibular muscle tonus that normally functions to support the pulmonary valve ring. He suggested that, when this condition prevented complete relief of right ventricular hypertension, even a partial relief might suffice to allow regression of right ventricular hypertrophy and thus of secondary infundibular obstruction.Comparing their results of transventricular pulmonary valvotomy and ofthe open procedure Swan et al. (1954) expressed the view that inadequate valvotomy was the usual cause of failure to reduce right ventricular pressure with the closed technique. They contrasted the complete relief obtained in every one of five open operations in which they performed pulmonary valvotomy through the pulmonary artery, using hypothermia, and concluded that hypertrophy of the right ventricle was not a cause of outflow obstruction. The same group, however, found later that open valvotomy did not always completely remove the systolic gradient between right ventricle and pulmonary artery (Blount et al., 1957) and agreed that this was sometimes due to infundibular obstruction which, they observed, was capable of regression. Campbell and Brock (1955) suggested a third explanation of residual stenosis, namely that the valve ring itself and the outflow tract were small. They noted that, in spite of a high residual gradient following valvotomy, the clinical improvement and the diminution of right ventricular strain were better than they had expected. In one such case the right ventricular pressure was found to have fallen further at recatheterization a year after operation. McGoon and Kirklin (1958)

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Problems in the Diagnosis and Surgical Treatment of Pulmonic Stenosis with Intact Ventricular Septum

Cited by 55 publications

References 22 publications

Valvotomy as a Curative Operation for Simple Pulmonary Stenosis

Valvotomy as a Curative Operation for Simple Pulmonary Stenosis

Pulmonary Valvular Stenosis: The Infundibular Factor in Relation to Valvotomy

Hypertrophic Infundibular Stenosis Complicating Simple Pulmonary Valve Stenosis

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