October 1953 SOMERVILLE: Mitral Stenosis: Selection of Cases for Mitral Valvotomy 497

for prompt treatment of sore throats or recurrencesof limb or joint pains and on the importance ofpenicillin cover for dental extractions if heartlesions persist. If sulphonamide prophylaxis hasbeen started in hospital it should be continued forat least another two years. Patients should attendafter-care clinics at regular intervals. Our own areseen at the third, sixth and twelfth month after dis-charge and then once each year. These examina-tions are of value for the following reasons. First,to establish as far as possible whether there hasbeen any fresh rheumatic activity; the occurrenceof sore throats or limb and joint pains is noted; thehaemoglobin, blood sedimentation rate and weightare recorded and a search is made for nodules. Ifthere is any question of present activity the patientsare re-admitted for assessment and treatment.

Secondly, to ensure an adequate check on anychange in the cardiac status they may haveoccurred; at follow-up clinical and radiologicalsigns in the heart may be either more or lessmarked than they were in hospital and furtheradvice on physical activity must be given. Thirdly,to re-emphasize to the patients or their parents thecontinued need for sulphonamide prophylaxis andprompt treatment of sore throats or limb or jointpains should they occur.

BIBLIOGRAPHYABRAHAMS, D. G. (I949), Brit. Heart 7., II, 342.'American Heart Association Statement' (1953), Lancet, i, 285.BESTERMAN, E. M. M., and THOMAS, G. T. (I953), Brit.

Heart J., I5, 113.TARAN, L., and SZILAGYI, N. (I947), Amer. Heart 3'., 33, 14.THOMAS, G. T., BESTERMAN, E. M. M., and HOLLMAN

A. (1953), Brit. Heart3'., 31, 29.

MITRAL STENOSIS:SELECTION OF CASES FORMITRAL VALVOTOMY

By WALTER SOMERVILLE, M.D., M.R.C.P.Cardiologist, Thoracic Surgical Unit, Harefield Hospital. Assistant, Department of Cardiology,

The Middlesex Hospital. Chief Assistant, National Heart Hospital.

When it became apparent that the stenosedmitral valve could be treated by surgery, cliniciansimmediately were faced with the problem of de-ciding which patients would benefit by operation.The more obvious indications were predicted fromthe abnormal anatomy and physiology. Otherswere arrived at in time by the expedient of trialand error. A number of important points are stillsub judice.

It was soon evident that not every person withmitral stenosis was suitable for operation. Someof the earlier cases were failures partly because ofthe newness of the technique of operating insidethe heart and partly because of clinical featureswhich today would have contraindicated operation.In each of the first four cases, all fatal, reported byBailey and his colleagues (I950), one or more ofthe following features were present: A very largeheart, mitral incompetence, advanced cardiacfailure, gross left atrial enlargement and bronchiec-tasis. The unsuitability of each of these findingswill be referred to later.The broad principles for selection laid down by

the earlier workers in this field (Bailey, et al.,

I950; Harken, et al., 1950; Baker, et al., 1950)were applied to our first patients (Bedford, et al.,1953). With experience, criteria were modifiedslightly, mainly towards including patients withfeatures which heretofore would have been re-garded as unfavourable or frank contraindications.The current basis for selection, influenced to someextent by discussion with others interested in thesubject, but mainly by our observation and ex-perience, is in close accord with the views expressedrecently by Baker and his associates (1952). Theterm ' mitral valvotomy' refers to splitting of themitral valve commissures by finger or knife; it issynonymous with 'valvulotomy' and 'com-missurotomy ' used by other writers.

SymptomsThe main indication for mitral valvotomy is

breathlessness attributable to mitral stenosis. Thisfact needs emphasis, for patients with mitralstenosis may be breathless from other causes suchas severe associated aortic valve disease or chroniclung disease.

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498 POSTGRADUATE MEDICAL JOURNAL October I953

3 3

;Ig 1snap

first second firstsound sound sound1' 4, ~thirdsod

sound

I

IFIG. I.-Diagram of auscultatory findings in mitral stenosis (after Wood). A complete cardiac cycle is

depicted, commencing with the first heart sound and ending with the first heart sound of the succeedingcycle. The second sound is followed by the mitral opening snap, represented arbitrarily by a single line.If the two elements of the second sound are heard, they are shown as two columns in apposition, theheights and grading depending on which element is the louder. A diastolic murmur follows the openingsnap, ending with a crescendo pre-systolic murmur which is also shown commencing the cycle. Thenumerals are grades of loudness, from i to 4 (loudest)-N is normal. The diastolic and pre-systolicmurmurs are graded separately. The figure below the line represents the duration of the murmur, heregrade 4 (from opening snap to first sound). The grading is assessed by auscultating at the apex for thefirst and third sounds, and pre-systolic and diastolic murmurs, if necessary with the patient lying onthe left side; at the third left interspace for the second sound, and at the fourth left interspace close tothe sternum for the opening snap. Aortic murmurs are entered verbally below the diagram.

Fig. Ia represents the auscultatory findings in a patient suitable for mitral valvotomy. In Fig. ib thesigns of mitral incompetence are depicted. The third sound, later than the opening snap and withoutits abrupt, sharp quality, is followed by a short diastolic murmur. Patients with this auscultatorypattern are unsuitable for valvotomy.

It is not always an easy matter to assess to whatextent a person is embarrassed by breathlessness.Many individuals are unable to explain theirsymptoms in their own words or they omitsignificant details because they are so familiar withthem. However, the majority know how far, orfor how long, they can walk at a brisk pace, whetherthey can keep up with their friends, travel towork or do their shopping or house work. Patientsshould be encouraged to recount such everydayexperiences for they provide a good assessment ofthe degree of incapacity and of the improvementfollowing operation; for these purposes they aremore intormative than standard exercise tolerancetests. Orthopnoea, haemoptyses and attacks of pul-monary oedema awakening the patient from sleepor precipitated by effort are common manifesta-

tions of severe mitral stenosis and are signs ofpulmonary congestion resulting from obstructionof blood flow from left atrium to left ventricle.

Physical Signs of Mitral Stenosis and Pul-monary HTypertensionThe importance of distinguishing the types of

mitral stenosis likely to benefit by valvotomy hasfocussed attention on the other palpatory andauscultatory signs which accompany the classicalmitral diastolic or presystolic murmur. In theideal case the first heart sound is abrupt, loud andsnapping in quality, features which with the pre-systolic thrill are responsible for the characteristicapex beat. Direct auscultation of the exposed heartand palpation within the left atrium during opera-tion point to the fact that the first heart sound with

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October I953 SOMERVILLE: Mitral Stenosis: Selection of Cases for Mitral Valvotomy

these qualities is produced by the anterior leafletof the stenosed mitral valve when its texture ispliant and supple. Similarly the sharp additionalsound which follows the second sound, the so-called mitral opening snap originates from thisleaflet early in left ventricular diastole. Theevidence is convincing that these two signs, theloud sharp first sound and the opening snap, areaccompaniments of a mitral stenosis amenable tovalvotomy. When the mitral valve is predominantlyincompetent from retraction and deformity of theleaflets and hence unsuitable for valvotomy, thefirst sound invariably lacks the features mentionedabove (Brigden and Leatham, I953).The auscultatory signs of mitral stenosis can be

depicted conveniently by a diagram, a techniquewhich is time-saving and at a glance gives to thosefamiliar with the system a comprehensive idea ofthe most important auscultatory findings. Thesymbols and grading used by Paul Wood (Fig. i)are preferred to the more detailed scheme ofLevine (I94).The signs of mitral stenosis outlined above are

not of themselves indications for mitral valvotomybecause they can be present without symptoms andmay be discovered unexpectedly in the course of aroutine medical examination. However, when pul-monary hypertension is present symptoms areseldom absent and then the indication for surgicaltreatment is more secure.When the mitral valve is narrowed to a suf-

ficiently severe degree, the blood pressure in theleft atrium rises. The elevated pressure is re-flected backwards through the pulmonary veins tothe peripheral capillary vessels where the pul-monary venous radicles commence and thearterioles end. To maintain blood flow in face ofthis raised pressure, pulmonary arterial and rightventricular pressure must also increase. This hasbeen called passive pulmonary hypertension(Wood, 1952). By a series of imperfectly under-stood reflexes, certain patients with severe mitralstenosis develop, in addition, an active constrictionof the pulmonary arterioles; the resulting in-creased resistance to blood flow causes a furtherelevation of pulmonary blood pressure which maythen reach extreme levels.

In the normal person physical exercise raises thepulmonary arterial and venous pressure but theincrease is always within fairly well-defined limits.The pulmonary hypertension of mitral stenosisexceeds these limits with exercise and is the mostimportant factor governing the amount of exercisethat can be taken without breathlessness. Ex-cessive elevation of the blood pressure in the pul-monary capillaries leads to haemoptysis or pul-monary oedema and severe, often paroxysmal,dyspnoea. The latter distressing symptom is more

common with sinus rhythm than auricular fibrilla-tion; it occurs whenever the left atrial pressureexceeds about 35 mm. Hg. Hence, it followsunusually strenuous exercise and may be theinitial symptom responsible for drawing attentionto the heart disease. Attacks of pulmonary oedemaat rest are precipitated by tachycardia, for examplewith terrifying dreams, or excitement, sexual inter-course, fever, thyrotoxicosis, pregnancy andparturition, and by certain drugs with an atropine-like action.Pulmonary hypertension in mitral stenosis may

be inferred from the physical sign of right ven-tricular enlargement, a visible and palpable pulsa-tion over the third and fourth left interspaces closeto the sternum. Rarely the enlarged pulmonaryartery can be felt in the second left interspace, andjust below it, the pulmonary valves produce apalpable shock when closing, heard through thestethoscope as a loud second sound. The GrahamSteell murmur of pulmonary incompetence may bepresent when the pulmonary arterial pressure isvery high. The electrocardiogram (Fig. 2) showsright ventricular hypertrophy and, with sinusrhythm, the characteristic widened, notched P-mitrale. The radiological features are referred tobelow. Pulmonary hypertension is confirmed andmeasured by cardiac catheterization.

Cardiac catheterization has played an invaluablerole in the investigation and explanation of thehaemodynamics of mitral stenosis. It has allowedpulmonary arterial and capillary hypertension to beinterpreted in terms of symptoms and physicalsigns. However, it is not an essential part of theinvestigation of mitral stenosis, and when theindications for operation are clear-cut, we nolonger catheterize the patient. We restrict it todoubtful cases or where a discrepancy exists be-tween symptoms and physical signs. Sometimesthe physical signs ordinarily found with pulmonaryhypertension are masked or attenuated by obesity,chest deformity or other causes not alwaysidentifiable. In two instances cardiac catheteriza-tion demonstrated high pulmonary pressure in theabsence of physical signs or electrocardiographicchanges.

AgeThe danger of activating the acute rheumatic

state by mitral valvotomy in young persons hasfixed the lower age limit as 20, although occasion-ally younger patients have severe mitral stenosisfor which operation cannot be delayed. Suitablecases are uncommon over the age of 50.

Associated Valve DiseaseSevere aortic valve disease or gross mitral in-

competence disqualifies a patient for mitral

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500 POSTGRADUATE MEDICAL JOURNAL October I953

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FIG. 2.-Electrocardiogram of patient with mitral stenosis on whom mitral valvotomy was performedsuccessfully.. P-mitral is well shown in leads I and II. Pulmonary hypertension was also present andthe tall R in Vi indicates right ventricular enlargement. -

valvotomy. These lesions may be regarded ascontraindications when they are responsible forclinical, radiological or electrocardiographic evi-dence of moderate to severe left ventricular en-largement. Mitral incompetence excludes thepatient when it causes a mitral systolic thrill andmurmur, left ventricular enlargement and greatenlargement of the left atrium with or withoutexpansion during ventricular systole.Mild aortic valve disease with little or no left

ventricular enlargement, or a mitral systolic mur-mur without the other associations of mitralincompetence, are not contraindications.

Tricuspid incompetence may be an additionalsign of high pressure in the right ventricle andpulmonary artery. Then it is functional and re-versible and a reflection of the severity of thedisease, not a contraindication. This type oftricuspid incompetence may improve or disappearwith the pre-operative medical treatment.. Or-ganic tricuspid disease, stenosis and incompetence,may be disclosed by longstanding, intractable signsof incompetence (prominent systolic pulsation inthe neck veins and liver) and can be confirmed bypressure tracings in the right atrium and rightventricle. A limited personal experience suggeststhat patients with this complication do poorly aftermitral valvotomy.Pulmonary incompetence (the Graham Steell

murmur) is the result of high pulmonary arterypressure and is appraised accordingly.

Heart RhythmWhen the patient is suitable otherwise, the

heart rhythm whether regular or irregular fromauricular fibrillation appears to have no bearing onthe suitability for operation. Auricular fibrillationin a, patient in the early 20'S or younger bespeakssevere rheumatic damage to the heart, a fact whichmust be borne in mind when considering surgicaltreatment. Older persons with auricular fibrilla-tion have shown satisfactory improvement aftervalvbtomy. The arrhythmia persists; we are notaware of an instance of established auricularfibrillation reverting to sinus rhythm afteroperation.

EmbolismPrevious emboli, systemic or pulmonary, have

been encountered in many patients who have laterundergone a successful valvotomy. The evidenceis strong, in fact, that operation diminishes orabolishes the tendency towards embolus formation.

Cardiac FailureParoxysmal dyspnoea is one of the cardinal

features of severe mitral stenosis and one of theurgent indications for operation. The ease withwhich pulmonary congestion can be induced bytachycardia has been referred to above. A patientin frank congestive (right ventricular) failureshould not be submitted for operation; he mayrespond well to medical treatment, however, andthe case should be reassessed in his improvedstate. It has been widely taught that intractableheart failure is evidence of advanced heart diseasewith widespread myocardial damage. Recentobservations have shown that this is not always so

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October 1953 SOMERVILLE: Mitral Stenosis: Selection of Cases for Mitral Valvotomy 50S

M7

FIG. 3.-Radiographs taken before (A) and one year after (B) successful valvotomy for mitral stenosis. Inthe post-operative picture, the pulmonary artery is much less prominent.

and that active pulmonary hypertension which canbe relieved by valvotomy is often the causativefactor (Wood, 1953).Mitral Calcification

Calcification of the mitral valve is best detectedby radioscopy with the patient turned slightlytowards the right oblique position. Extensivecalcification is seen without much searching, for itstands out under the fluoroscope as a dense mobilemass at the site of the mitral valve. Formerly itwas our opinion that calcification of this degreewould be an insuperable obstacle to valvotomy,apart from the hazard of detaching a fragment intothe circulation. However, Mr. T. HolmesSellors has operated on a patient with grosscalcification of this type who was otherwise suit-able. The valve was split easily and the functionalresult was gratifying. No emboli were detached.Nevertheless, extensive mitral calcification isusually a feature of severe, longstanding diseasewith incompetence, cardiac enlargement and otherunfavourable factors which contraindicate opera-tion. The decision against operation seldomdepends on calcification alone.

Less degrees of calcification in the form of dis-crete, opaque flecks which can be discovered oftenafter more or less diligent fluoroscopic search areinconsequential and have no bearing on selectionfor operation.

RadiographyFrom what has been said about the clinical

indications and physical signs of the suitable casefor mitral valvotomy it should be possible topicture the radiographic features of the ideal case.The cardiac shadow should be no more thanmoderately enlarged; the cardio-thoracic ratio,despite its obvious shortcomings as an accuratemeasure of heart size, allows this permissibledegree of enlargement to be expressed as notgreater than 6o per cent. The left atrial appendixis visible on the left cardiac border above theventricular curve, by virtue of the left atrial en-largement and of the adjacent infundibular (rightventricular) enlargement. The pulmonary arterycurve is more or less prominent; when the pul-monary arterial pressure is greatly elevated thiscurve is, as a rule, conspicuous. The aorticknuckle is small or absent. Pulmonary venouscongestion causes a characteristic fan-shapedshadow radiating outwards from the hilar regions.The primary subdivisions of the right and leftpulmonary arteries may be dilated and super-imposed on the pulmonary venous shadows.Pulmonary haemosiderosis does not appear to

influence the operative result over a period of atleast I8 months. Unless longer follow-up studiesalter this impression, haemosiderosis should not beregarded as a drawback to surgical treatment.

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POSTGRADUATE MEDICAL JOURNAL

Fig. 3a illustrates the typical radiographicappearances of a patient considered to be ideal forvalvotomy. A good functional result was achieved.Fig. 3b was taken one year after operation.

Associated DiseasesPatients with mitral stenosis are often affected by

attacks of bronchitis from which permanentresidual changes in the lungs such as bronchiectasisand emphysema may entail a reduced efforttolerance. Therefore breathlessness in thesepatients calls for careful appraisal, for when lungdisease is the dominant factor it will not be im-proved by valvotomy. On the other hand, if thelungs have escaped detectable damage surgicalrelief of mitral stenosis scems to leave the patientless susceptible to recurrences of lung infections.Pulmonary tuberculosis is seldom found with

severe mitral stenosis, but if the indications forvalvotomy are otherwise clear-cut, there is noreason why it should not be performed. RecentlyMr. Holmes Sellors has operated successfully on agirl with the tetralogy of Fallot and left upperlobe tuberculous cavitation, a left upper lobec-tomy being followed immediately by a Blalockanastomosis. It would appear that equally en-couraging results may be expected from surgicaltreatment for co-existing mitral stenosis andpulmonary tuberculosis (Hill, 1952).Angina pectoris occasionally complicates mitral

stenosis, but there is little information on theeffect of valvotomy on this symptom. In twoinstances where it was present no attacks haveoccurred since operation, two to six months ago.A third patient, a woman aged 49, had angina ofeffort for a year and a cardiac infarction fivemonths before operation. Since valvotomy twomonths ago she has had one attack of chest pain atrest.The aggravating effect of uncontrolled thyro-

toxicosis on mitral stenosis has been referred toearlier. The severity of the cardiac symptomscannot be assessed until the thyrotoxicosis istreated. A course of thiouracil may alter the com-plexion of the heart disease in dramatic fashion;thyroidectomy, if preferred can then be carriedout with safety. If mitral stenosis can still beblamed for symptoms and the indications outlinedabove are present, valvotomy should be performed.

It will be recalled in this respect that 20 yearsago total thyroidectomy was in vogue for thetreatment of heart failure (Blumgart, et al.,1933). The results were unpredictable and themethod has fallen into disuse. Yet occasionally,the distressing paroxysmal dyspnoea of mitralstenosis can be improved or even abolished bythyroidectomy.

Mrs. A. T. (B 69026), aged 45, admitted to

The Middlesex Hospital under Dr. D. EvanBedford; mitral stenosis with sinus rhythm: fornine months frequent attacks of pulmonaryoedema at night and with effort; exercise toler-ance reduced to less than 50 yds. walking.Total thyroidectomy (Mr. R. Vaughan Hudson)was followed by complete freedom from symp-toms. Pattern of right ventricular enlargementin chest leads VI-6 disappeared. Myxoedemawas controlled with small doses of thyroidextract. After three years, heart symptomsreturned and mitral valvotomy was performedwith satisfactory results.Pregnancy in patients with mitral stenosis does

not call for a different set of criteria for selectionfor operation. In the majority of instances theyproceed to term uneventfully. Yet a sufficientlylarge number, usually in sinus rhythm, developacute pulmonary oedema. The physical signs ofpulmonary hypertension in a pregnant woman withrapid diminution in effort tolerance are a warningand indicate bed rest. If in spite of routine treat-ment with digitalis, sodium restriction and mer-curial diuretics no improvement is apparent, or aradiograph shows the vascular markings of pul-monary venous congestion, then the danger ofpulmonary oedema is great. This hazard mayappear as early as the third calendar month or inthe eighth month when the burden on the circula-tion is said to reach its peak. Pulmonary oedemais a specially terrifying experience for the pregnantwoman and recurrences are common. Mitralvalvotomy may be life-saving under these circum-stances, allowing the pregnancy to continue andlater making the patient a fitter person to undertakethe responsibilities of motherhood.

Until more is known about the long-term re-sults of mitral valvotomy, women who have beenoperated on successfully should not be encouragedto embark on repeated pregnancies.

SummaryThe criteria for selection of patients with mitral

stenosis for mitral valvotomy are:i. Breathlessness, pulmonary oedema and

haemoptyses resulting from mitral stenosis notfrom associated valve lesions or complications.

2. Signs of the type of mitral stenosis amenableto surgery, namely a loud, abrupt first heartsound and opening snap together with the murmurof mitral stenosis.

3. Signs of pulmonary hypertension, namelypalpable pulsation of the right ventricle, a loudpalpable second sound and sometimes the GrahamSteell murmur of pulmonary incompetence.Tricuspid incompetence may be an added sign ofpulmonary hypertension; it has this significancewhen gross cardiac enlargement is absent. Cardiac

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October 1953 SOMERVILLE: Mitral Stenosis: Selection of Cases for Mitral Valvotomy 503

catheterization confirms pulmonary hypertension.It no longer forms part of the routine investigationand need only be performed when a discrepancyexists between symptoms and signs.

4. The most suitable age range is 20 to 50.5. Severe aortic valve disease, tricuspid stenosis

and mitral incompetence should be absent,although mild degrees of these lesions are per-missible.

6. The rhythm may be either regular sinus orauricular fibrillation.

7. Previous emboli, systemic or pulmonary, arenot contraindications. Operation may preventfuture emboli or lessen their frequency.

8. Right ventricular failure should be absent,although a patient in failure may respond to treat-ment and eventually become a candidate foroperation.

9. Gross cardiac enlargement from cardiacfailure, severe associated valvular lesions orirreversible rheumatic muscular damage, contra-indicates surgery.

io. Thyrotoxicosis should be controlled withthiouracil before mitral stenosis is assessed forsurgery.

i i. Repeated chest infections with residual per-manent. lung damage such as bronchiectasis oremphysema sufficient to produce symptoms, makevalvotomy of dubious value.

12. During pregnancy, if symptoms increaseand pulmonary oedema develop3 in a patientotherwise suitable for mitral valvotomy, the opera-tion may be life-saving and allow successful de-livery later. The majority of pregnant women withmitral stenosis do not require surgical treatment.

The patients referred to in this paper were underthe care of Dr. D. Evan Bedford in conjunctionwith whom the observations were made. Many ofthe views expressed were influenced by the teach-ing of Dr. Paul Wood, whose chief assistant thewriter is at the National Heart Hospital. Mitralvalvotomy in all cases was performed by Mr. T.Holmes Sellors assisted by Mr. J. R. Belcher.

BIBLIOGRAPHYBAILEY, C. P., GLOVER, R. P., and O'NEILL, T. J. E. (I950),

J. Thorac. Surg., ig, i6.BAKER, C., BROCK, R. C., and CAMPBELL, M. (I950), Brit.

med. Y., i, 1283.BAKER, C., BROCK, R. C., CAMPBELL, M., and WOOD, P.

(1952), Ibid., i, 1043.BEDFORD, D. E., SELLORS, T. H., and SOMERVILLE, W.

(I953), To be published.BLUMGART, H. L., LEVINE, S. A., and BERLIN, D. D. (I933),

Arch. intern. Med., Si, 866.BRIGDEN, W., and LEATHAM, A. (1953), Brit. Heart J., i5, 55.HARKEN, D. E., ELLIS, L. B., and NORMAN, L. R. (1950),

Y. Thorac. Surg., I9, I.HILL, I. (1952), Proc. R. Soc. Med., 45, 538.LEVINE, S. A., and HARVEY, W. P. (I949), 'Clinical Ausculta-

tion of the Heart,' ist ed. pp. 145-I48. London: Saunders.WOOD, P. (1952), Brit. med. Bull., 8, 348.WOOD, P. (I953), Personal communication.

RADIOACTIVE ISOTOPESAN INTRODUCTION TO THEIR PREPARATION, MEASUREMENT

AND USEby W. J. WHITEHOUSE and J. L. PUTMAN

Both with the Ministry of Supply, Atomic Energy Research Establishment, HarwellWith a Foreword by SIR JOHN COCKCROFT

440 pages 160 illustrations 50s. net

DISEASES OFTHE HEART AND CIRCULATION

by ALBERT A. FITZGERALD PEEL, D.M., F.R.F.P.S.(G)Physician for Diseases of the Heart, Victoria Infirmary, Glasgow; Medical Consultant, Department ofHealth

Jbr Scotland and Ministry of Labour and National Service Recruiting Boards

SECOND EDITION 496 pages 176 illustrations 35s. net

OXFORD UNIVERSITY PRESS

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