Mitral Valvotomy in a Provincial Hospital Group

Abstract

Published accounts of mitral valvotomy have come from hospital departments specially experienced in thoracic surgery and with resources much above the ordinary. Their eminent authors have contributed to the pioneer work and development of this brilliant advance in surgery and medicine. Conscious of the comparison and of our few cases, we explain that the purpose of this paper is simply to indicate that the selection of cases and the operation itself are now a well-established procedure within the competence of a general physician and surgeon interested in the subject. At the time we decided to do this work candidates for the operation were sent away far from home, there was a long waiting-list, and it had been reported (British Medical Journal, 1950) that patients had died in acute pulmonary oedema while waiting.The better interpretation of clinical findings resulting from the work to which we have already referred enabled us to make more accurate pre-operative diagnoses and to manage without cardiac catheterization. Latterly the operation was done in the ordinary theatre list, electrocardiograms were no longer taken during the operation, and we dispensed with the post-operative oxygen tent; oxygen, if required, was given by means of Tudor Edwards's spectacles frame. The approach to the heart was made through the fifth left intercostal space; it was seldom necessary to resect a rib. To reduce the risk of emboli the auricular appendage was opened without clamping but after the insertion of two thread purse-string sutures. Any thrombus in the appendage was usually palpable and could be dissected out with finger or scissors before any attempt was made to split the mitral opening. The split was made with the finger alone in 16 patients; in five Brock's knife, as modified by one of us (Lentin, 1955), was needed; and in four patients the valve was not altered. While the mitral opening was being manipulated the anaesthetist maintained carotid compression.In assessing the severity of the disease we adopted the criteria used by Baker et al. (1952) and later summarized (Baker et al., 1955) in the following grades: 1, slight disability; 2, moderate disability; 3, gross disability; and 4, total incapacity. Two of the three patients in grade 1 were brought to hospital on account of near-fatal attacks of pulmonary oedema. ResultsAll patients who had their chest opened for intended valvotomy have been included (see Table). There One of the deaths occurred in a patient who had an auricular appendage which was too small and the heart was not entered; she remained in congestive heart failure and died 23 months after her operation. Another death occurred 11 months after an incomplete and unsatisfactory mitral dilatation, which was, however, followed by temporary improvement; the patient developed auricular fibrillation a few weeks before she died. In the third fatality the patient was known to have a degree of aortic stenosis: a tight fibrous mitral orifice was found, which failed to yield to manipulation, and she died in pulm...