Some clinical notes on patients with mitral valvular disease who have had mitral valvuloplasty. Part II

Abstract Seventy-two patients subjected to mitral valvuloplasty were studied. They were all personally examined before and after operation. An analysis was made of the clinical features that might serve as a guide to the severity of the condition, the risk of the operation, and the degree of improvement to be expected. There were 61 females and 11 males (ranging in age from 27 to 62 years). The average age at the time of the operation was 44 years. There were 6 surgical deaths, 1 in the operating room and 5 during the immediated postoperative days. During more recent years the operative mortality in Group III cases has fallen to about 1 per cent. There were 5 fatalities during the follow-up period, with an average survival of 36 months. The average follow-up period of the living patients was 42 months. The patients were divided preoperatively into four groups: Group I (symptomless), no patients; Group II (slight limitation), 19 patients; Group III (significant symptoms on slight effort), 41 patients; Group IV (seriously ill with irreversible failure), 11 patients. The average disability of the entire group was 2.9. The figures were 3.2 for those who died during the operation and 3.3 for those who died during the follow-up period. The postoperative clinical results were designated as: worse, unchanged, improvement (1) slight, (2) moderate, (3) good, and (4) excellent. Among the 58 patients who survived, and for whom results were known, 3 were worse, 5 were unchanged, and 7 had grade 1 improvement, 12 grade 2, 24 grade 3, and 7 grade 4. The degree of postoperative improvement declined somewhat with increasing blood pressure. The degree of stenosis was less among the hypertensive patients. In fact, no hypertensive patient had a “very tight” stenosis. Although a murmur in diastole at the apex is the most useful diagnostic sign of mitral stenosis, its intensity is only a fair guide to the degree of stenosis. Very tight stenosis was found with faint diastolic murmurs, and very slight stenosis with loud ones. Although the louder apical systolic murmurs generally signified more mitral regurgitation and a less favorable result from surgery, there were 6 exceptions. In these 6 cases, although the apical systolic murmur was loud or louder than the diastolic, there was a high degree of mitral stenosis. In the selection of patients for surgery, basal murmurs can be dismissed, for the most part, if there is electrocardiographic evidence of right ventricular hypertrophy. An accentuated apical first sound was found to be fairly good evidence of mitral stenosis but was also present with predominant mitral regurgitation. When the mitral valve was found to be calcified, the average intensity of the first heart sound was less, and the immediate risk of operation slightly greater, and the ultimate result was not quite so good as when the valve was not calcified. Those patients who had attacks of acute pulmonary edema or hemoptysis, or both, comprised a fairly distinct group. They generally showed a normal sinus rhythm, did not have great cardiac enlargement, had little if any evidence of right heart failure, and did very well both during the operation and in the follow-up period. Among 71 patients, 46 had auricular fibrillation at the time of operation. Of the 25 with a normal sinus rhythm, 8 developed auricular fibrillation during or shortly after the operation. It did not appear worth while to try regularization with quinidine before the operation or to use it after the operation in those who had had persistent fibrillation. Quinidine was helpful in some who developed the arrhythmia during or after the operation. The occurrence of previous arterial emboli made the operative risk slightly greater and the ultimate result slightly less favorable. However, operation appeared to lessen the likelihood of future cerebral emboli. Of the 16 patients who had previous emboli, 15 had chronic auricular fibrillation, while 1 had only transient bouts of the arrhythmia. None developed cerebral emboli during the follow-up period. The presence or absence of right ventricular hypertrophy in the electrocardiograms did not aid in predicting how tight the mitral valve would be nor how well the patient would do postoperatively. However, the clinical results were good if the tracing showed right ventricular hypertrophy, even if left ventricular hypertrophy was also present. The presence of left ventricular hypertrophy alone would militate against an expected favorable operative result. The average increase in the transverse diameter of the heart on x-ray examination was 28.1 per cent. The degree of improvement was not much different in those with greater enlargement than in those with less enlargement, although the larger hearts were found in those who were more gravely ill. Patients with huge hearts such as are seen with mitral insufficiency were, for the most part, not selected for surgery. Those with “very tight” mitral stenosis had larger hearts (+ 28.4 per cent) than those with “moderately tight” valves (+ 20.2 per cent). The size of the pulmonary artery was greater in those with “very tight” than in those with “moderately tight” valves. An analysis of the age factor indicated that older patients did not do quite so well as the younger patients. Factors other than age, however, such as greater frequency of congestion, auricular fibrillation, or cardiac enlargement and the complete absence of “very tight” valves in the older group, must play a role. A comparison of the valve size as found at operation and the postoperative clinical result clearly indicates that those with the tightest valves do best. The surgeon's prediction as to how much improvement would take place by the type of valvuloplasty he accomplished was only partly accurate. When he thought the operation was “excellent,” the results were the best, and when he thought it was only “fair,” the results were poor. However, when he thought it was “good” or “very good,” the results varied and were about the same in the two groups. At the present stage of mitral valve surgery, the physician's goal is to select those cases that have the minimum degree of insufficiency and the greater degree of stenosis. The present experience affords convincing evidence that the mechanical factor of valvular defect is most important in causing the disability from rheumatic heart disease, a view that was belittled a few decades ago.