The Surgical Treatment of Mitral Stenosis (Mitral Commissurotomy)

1) Surgical technique and methods and anesthesia have now advanced to the point where intracardiac manipulations may be undertaken with reasonable safety. 2) The mitral valve is best approached through the left auricular appendage by an anterolateral approach. Approach through the apex of the left ventricle is less desirable, in our opinion. 3) Accurate surgical maneuvers depend upon control by vision or digital palpation. In closed surgery of the mitral valve digital palpation through an opening in the left auricular appendage is the logical method of control. 4) Commissurotomy enlarges a stenotic mitral valve orifice and permits valvular function without an appreciable increase in the pre-existing amount of mitral regurgitation. 5) Three cases of mitral valve surgery are presented with one survivor who shows a gratifying early postoperative result. One other case could undoubtedly have been salvaged with our present knowledge, and one case probably was too advanced to help. Two cases of mitral stenosis in which surgery was planned and started but not completed are described. 6) We believe that the operation of commissurotomy has great value in certain cases of mitral stenosis. The selection of cases should undoubtedly be limited to those with essentially single valve lesions in which all rheumatic activity is healed. It is doubtful in the present state of our knowledge whether cases in chronic or acute congestive failure should be operated. Certainly results will be poorer in this group. One of the most urgent indications for surgery is hemoptysis, especially if severe. 7) We believe that commissurotomy is preferable to a shunt operation (azygos-pulmonary vein anastomosis, or opening of the interauricular septum), because the latter merely relieves pulmonary symptoms by destroying one of the natural compensating mechanisms. What is the gain if the signs and symptoms of pulmonary congestion are relieved and yet the patient goes on to systemic circulatory failure? Or if the left ventricular output is so reduced by loss of its compensating mechanism that the patient's physical activities are still more limited? However, in a hypothetical case where the opening of the valve might not sufficiently reduce pulmonary congestion (due perhaps to too limited incision of the valve commissures) we would not hesitate to perform such a shunt if the pulmonary symptoms endangered life. It is our belief that a high pressure in the left auricle is helpful postoperatively in maintaining separation of the valve cusps after commissurotomy. If a shunt is performed before the valvular surgery, there is undoubtedly a much greater tendency for the raw edges of the commissure to seal together and re-establish the mitral stenosis. 8) We feel that preoperative digitalization, quinidinization, and the use of intravenous procaine during surgery are valuable in supporting cardiac function and in prevetning arrhythmia. Antibiotics are given to prevent infection of the wound and of the cut valve surfaces (subacute bacterial infection). Apparently anticoagulant therapy is dangerous and unnecessary. 9) We believe that ballistocardiography before and after exercise offers us the best single objective measure of ventricular output and reserve. February 1, 1949: Since this time, 5 additional patients have been subjected to this operation. Two are doing very well. One died 2½ months after surgery. One died of an error in technique at operation (cutting across a valve leaflet). One did very well for 6 days but died suddenly of a cerebral arterial embolus. Clotting had occurred in the sutured left auricular appendage. We now ligate the appendage at the base to prevent this.