Laurence B. Ellis

Fifteen-to Twenty-Year Study of One Thousand Patients Undergoing Closed Mitral Valvuloplasty

A study is reported of an annual follow-up over a 15- to 20-year period of the survivors of the first 1,000 patients undergoing closed mitral valvuloplasty for mitral stenosis. In addition to a report of the status of the patients at each year of follow-up, a detailed analysis has been made of the factors influencing results of surgery 15 years after operation. The most important factor adversely influencing long-term results is significant mitral valve calcification. This is true regardless of age, sex, preoperative status, concomitant mitral insufficiency or minor degrees of aortic valve disease. A beneficial effect of younger age (below 40 years at surgery) or lack of associated mitral insufficiency is apparent only in Group III patients with noncalcific valves, and in these two subgroups the results were 41 and 37 percent improved, respectively. These figures do not include the large number of patients who have again been improved following a second or even third operation. Late systemic embolization occurs infrequently after such surgery. (1.1% per patient year of follow-up). In patients without significant valvular calcification and without substantial mitral incompetence or significant associated valvular disease, closed mitral valvuloplasty is the operation of choice. The indications for closed versus open operation for mitral stenosis are discussed in detail.

A clinical study of 1,000 consecutive cases of mitral stenosis two to nine years after mitral valvuloplasty.

A study is presented of 1,000 cases of predominant mitral stenosis operated by valvuloplasty between 1949 and 1956. It is shown that the survival of these patients is better than would have been expected under medical management. Sixty-nine per cent of the survivors of the operation in groups II and III improved, and 55 per cent in group IV. Factors influencing the late results are discussed. After substantial improvement lasting a year or more, 228 of this series deteriorated; the factors affecting this deterioration are discussed, of which mitral insufficiency, an inadequate valvuloplasty, and recurrent rheumatic fever are the most striking.

The Clinical Results in the First Five Hundred Patients with Mitral Stenosis Undergoing Valvuloplasty

A report is made of the clinical results in the first 500 patients operated on by mitral valvuloplasty in whom a preoperative diagnosis of predominant mitral stenosis had been made. The operation appears to offer some protection against late peripheral embolization. Four hundred forty of 442 surviving patients have been followed for periods of from six months to five years. Seventy seven per cent of the entire group are significantly improved. Thirty one per cent have had one or more attacks of a postoperative syndrome, but in only 7 per cent has there been clear-cut evidence of active rheumatic fever. Improvement in objective clinical findings, in particular in cardiac murmurs, heart size and the electrocardiogram, have been less striking than the subjective improvement.

The Responsibility of the Physician in the Selection of Patients with Mitral Stenosis for Surgical Treatment

The anatomy of the mitral leaflets, a classification of the variations in pathologic morphology of rheumatic stenosis, and the evolution of a practical technic for relief of that stenosis while restoring valve action are considered. The life cycle of patients suffering from mitral stenosis is reviewed and a clinical classification of these patients is presented. Some indications and contraindications for surgery are discussed in the light of strength and weakness of present surgical methods. Results of surgical treatment are reviewed.

Reoperation for Mitral Stenosis: A Discussion of Postoperative Deterioration and Methods of Improving Initial and Secondary Operation

A series of 80 reoperations for mitral stenosis in 79 patients is reported and analyzed. The most important causes of deterioration after valvuloplasty for mitral stenosis are inadequate initial operation, restenosis, and mitral insufficiency. Generally more than one of these factors pertain. An adequate mitral valvuloplasty requires the complete opening of both the anterior and posteromedial commissures and the mobilization of the chordae tendineae from each other and from the wall of the ventricle. The advantages and limitations of closed reoperation, open reoperation, the right-sided approach, and the use of the transventricular valvulotome are reviewed. More complete correction of stenosis with mobilization of posteromedial, anterior, and subvalvular chordae is emphasized. This is attained by operating from both the ventral and dorsal aspects of the patient through a left posterolateral thoracotomy incision. An Ivalon operating tunnel sutured to the left atrial wall at reoperation makes it possible to carry out the more extensive valvuloplasty at reoperations. A lower operative mortality, better longterm results, and fewer instances of deterioration are anticipated when this concept of improved valvuloplasty is effected initially.

Arterial embolization in relation to mitral valvuloplasty

Abstract The present study is based on our experience of peripheral arterial embolization in 1,500 consecutive patients with predominant mitral stenosis who underwent mitral valvuloplasty. The purpose of this study has been to define the conditions under which such embolization takes place. It has been shown that the presence of atrial fibrillation, increasing severity of heart disease, and the occurrence of preoperative embolization all increase the risk of operative embolization, which remains an inherent risk of the procedure and is a major factor in deaths from operation. Our findings suggest that an embolus within 8 weeks of operation carries a higher risk of operative embolization than does a preoperative embolus occurring earlier. Our present findings confirm our previous reports with respect to the protective value of mitral valve operation against future embolization. Late postoperative emboli have occurred in 38 patients of the entire group followed up for a mean period of 6 years, an incidence of 0.46 to 0.64 per cent per patient-year. Our figures show no beneficial results from preoperative anticoagulant therapy as given—for most it was given for a short period and stopped several days prior to operation—but shed no light on anticoagulant treatment given intensively for longer periods or through the period of operation. The low incidence of embolization after the immediate operative period would suggest that the routine administration of anticoagulant agents is unnecessary in the postoperative period, either early or late. The formation of peripheral emboli is an indication for mitral valvuloplasty in patients with mitral stenosis, even without symptoms. In certain patients the increased risk of operative embolization is about balanced by the increased hazard of recurrent spontaneous embolization.

The effect of myxedema on the cardiovascular system

Abstract Hemodynamic studies of the circulation are reported in five patients with myxedema and in two of these after treatment with thyroid. The varying circulatory responses to the myxedematous state are pointed out, and the complicating factors of associated arteriosclerosis are emphasized. The studies indicate that, although frequently changes in the circulation are parallel to reduction of oxygen consumption, the blood flow may be depressed out of proportion to the oxygen needs of the body. This finding, judged in conjunction with the development of cardiac enlargement and electrocardiographic abnormalities, is evidence of damage to the heart and of circulatory insufficiency.

Relation of the degree of coronary-artery disease and of myocardial infarctions to cardiac hypertrophy and chronic congestive heart failure.

HEART disease and heart failure in aging persons are usually assumed to be due to coronary arteriosclerosis (arteriosclerotic heart disease, ischemic heart disease) if other identifiable causes of ...

The effect of age and other factors on the early and late results following closed mitral valvuloplasty

Abstract A report is made of a consecutive series of 1,817 patients with predominant mitral stenosis operated by closed mitral valvuloplasty between 1949 and June 30, 1966, with a follow-up since operation. Particular attention was paid to the influence of various factors on the operative mortality rates and the results at 5 and 10 years after surgery. Severe disability (Group IV), atrial fibrillation, moderate to marked valvular calcification or insufficiency, all adversely affected operative mortality, but the effect of age per se was not in general statistically significant. The same factors which adversely affected operative mortality also militated against good results at 5 and 10 years with the exception of atrial fibrillation. In addition, advancing age adversely affected the results. A group of 56 patients 60 years and over at the time of surgery showed, in general, the same trends as patients 40 to 59 years old. The present study delineates those patients that can be expected to do well or poorly after closed mitral valvuloplasty and hence sets up guidelines for studies of patients operated by open techniques and valve replacement. Until it can be clearly demonstrated that such open operations can be done as safely and the late results are better, closed mitral valvuloplasty remains the operation of choice in properly selected patients with mitral stenosis.

The quantitative aspects and dynamics of the circulatory mechanism in arterial hypertension

Abstract The etiological causes of arterial hypertension are manifold. In that sense, arterial hypertension is not a disease entity. Its presence over a prolonged period of time, nevertheless, exerts such an important effect on the entire vascular system and on the functions of a number of organs in man, that it should not be considered so much a symptomatic manifestation as an important morbid state of the body. A number of studies are available in the literature on morphological changes in patients suffering from high arterial blood pressure of long duration. These studies fail to reveal either the etiology or the mechanism of the circulation in the presence of high arterial blood pressure. There is, moreover, a lack of quantitative evaluation of the cardiac work and of the peripheral circulation. The largest part of the available and conflicting information has been obtained from animals with experimentally induced high blood pressure, 1,2,3 or from observations of certain qualitative aspects of the circulation in man. 4