Recent Progress in Mitral Valve Disease

460 Pages·1984·18.711 MB·English

by  Carlos Duran, William W. Angell and Allen D. Johnson (Auth.)

Recent Progress in Mitral Valve Disease
Carlos Dur an, MD, PhD
Professor, Jefe, Centro Medico Nacional, 'Marques de Valdacilla',
Santander, Spain
William W. Angell, MD
Director, Cardiovascular Surgical Research,
Scripps Clinic and Research Foundation, La Jolla, California
Allen D. Johnson, MD
Head of Cardiovascular Disease,
Scripps Clinic and Research Foundation, La Jolla, California
James H. Oury, MD
Head, Division of Cardiac Surgery,
Scripps Clinic and Research Foundation, La Jolla, California
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First published, 1984
© Butterworth & Co. (Publishers) Ltd, 1984
British Library Cataloguing in Publication Data
Recent progress in mitral valve disease.
1. Mitral valve—Diseases
I. Duran, Carlos
616.1'25 RC685.V2
ISBN 0-407-00294-4
1"
Library of Congress Cataloging in Publication Data I
Main entry under title: ι
Recent progress in mitral valve disease.
Bibliography: p.
Includes index.
1. Mitral valve—Surgery. 2. Mitral valve—Diseases.
1. Duran, Carlos. [DNLM: 1. Heart valve diseases.
2. Mitral valve. WG 262 R295]
RD598.R37 1984 617'.412 84-1759
ISBN 0-407-00294-4
Photoset by Phoenix Photosetting, Chatham, Kent
Printed and bound by Robert Hartnoll Ltd, Bodmin, Cornwall
Preface
The International Symposium on the Mitral Valve and these Proceedings owe their
genesis to Dr Daniel Kalmanson who in 1976 organized the first International
Symposium on the Mitral Valve held in Paris, France. This meeting brought
together authorities from many varying disciplines relating to the mitral valve in a
unique 'pluridisciplinary' approach. The information at the Paris Symposium
served not only as a cornerstone for our present knowledge but also provided a
stimulus for continued research in this evolving area. Paris also provided me with
the opportunity to meet several individuals who became instrumental in the
organization of our Symposium. At the Paris meeting I had the opportunity of
meeting Dr Carlos Duran, a man who greatly influenced my interest in the mitral
valve and provided an opportunity for me to learn from him, in the operating suite,
the surgical techniques of reconstruction. A few years later while in Santander,
Spain, after a day in the operating room, an evening stroll in downtown Santander
and a wonderful Spanish tradition known as 'the vino', provided the setting in
which a 'pluridisciplinary' group of Spanish physicians and I formulated the plans
for a second International Symposium on the Mitral Valve.
Many friends and colleagues are responsible for the growth of this early idea. Dr
Alain Carpentier, the first surgeon to demonstrate to me the intracacies of the
mitral valve, graciously consented to attend and contribute to the Symposium. My
friend and partner, Dr William Angell, responded enthusiastically to the idea of a
second symposium and collaborated in its formulation. Dr Allen Johnson, Head of
the Division of Cardiovascular Diseases at Scripps Clinic and Research
Foundation, shared the responsibility of Program ^Chairman with Dr Duran and
myself and lent his expertise in the understanding of mitral valve function from a
cardiologist's perspective. Dr Charles Edwards, President of Scripps Clinic and
Research Foundation, eagerly supported our desire to provide a suitable setting to
address again in a multidisciplinary way the fascinating subject of the mitral valve.
To Catherine Williams, our Cardiovascular Nurse Clinician, goes my gratitude
for her tireless efforts in planning and coordinating the many different aspects of
the Symposium.
My hope is that the Proceedings of this second International Symposium will
once again provide a suitable stepping stone for future symposia of this nature and
will generate continued interest in pursuing an understanding of the Mitral Valve.
James H. Oury
Contributors
F. Alonso-Lej, MD
Chief of Thoracic and Cardiovascular Surgery, Ciudad Sanitaria; Chief of Cardiac and Thoracic Surgery,
Nueva Clinica Ouiron, Zaragoza, Spain
William W. Angell, MD
Director of Cardiovascular Surgical Research, Scripps Clinic and Research Foundation, La Jolla,
California, USA
Rene A. Arcilla, MD
Director, Pédiatrie Cardiology; Professor of Pediatrics, University of Chicago, Chicago, Illinois, USA
David B. Arkin, MD
Division of Anesthesiology, Donald N. Sharp Memorial Community Hospital, San Diego, California,
USA
Timothy Bateman, MD
Associate Cardiologist, Cedars-Sinai Medical Center, Los Angeles, California, USA
Saroja Bharati, MD
Chairperson, Department of Pathology, Congenital Heart and Conduction System Laboratory, Deborah
Heart and Lung Center, Brown Mills, New Jersey, USA
V. Bilca, MD
Cardiovascular Surgeon, Research Assistant, Clinic for Cardiovascular Surgery, Tirgu-Mure§, Romania
V. O. Björk, MD
Professor of Thoracic and Cardiovascular Surgery, Karolinska Sjukhuset Thoracic Surgical Clinic,
Stockholm, Sweden
Kim Book, MD
Thoracic Surgical Clinic, Karolinska Hospital, Stockholm, Sweden
G. Bougkioukas
Department of Cardiac Surgery, University of Munich, West Germany
S. Bradisteanu, MD
Cardiovascular Surgeon, Research Assistant, Clinic for Cardiovascular Surgery, Tirgu-Mure§, Romania
D. Bratu, MD
Cardiologist, Clinical Assistant, Clinic for Cardiovascular Surgery, Tirgu-Mure§, Romania
Blase A. Carabello, MD
Associate Professor of Medicine Physiology, Temple University, School of Medicine; Director, Cardiac
Diagnostic Laboratory, Temple University Hospital, Philadelphia, Pennsylvania, USA
Alain Carpentier, MD, PhD
Professor Agrège Chirurgie, Cardiaque, Universite Paris IV: Head, Laboratoire D'Etudes des Geffes et
Prothese Cardiaques, Hôpital Broussais, Clinique de Chirugio Cardio-Vasculaire, Paris, France
vii
viii Contributors
Kanu Chatterjee, MB, FRCP
Associate Chief, Cardiovascular Division, University of California, San Francisco, California, USA
Aurelio Chaux, MD
Senior Associate Surgeon, Cedars-Sinai Medical Center, Los Angeles, California, USA
Lawrence H. Cohn, MD
Professor of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts,
USA
Peirre L. Coulon, MD
House Officer, The General Infirmary, Leeds, UK
Lawrence Czer, MD
Associate Cardiologist, Cedars-Sinai Medical Center, Los Angeles, California, USA
Gordon K. Danielson, MD
Professor of Surgery, Mayo Medical School, Thoracic and Cardiovascular Surgery, Mayo Clinic,
Rochester, Minnesota, USA
Keith Dawkins, MD
Cardiac Department, Brompton Hospital, London, UK
R. Deac, MD
Chief, Clinic for Cardiovascular Surgery, Tirgu-Mure§, Romania
Carlos Du ran, MD, PhD
Professor, Jefe, Centro Medico Nacional, Marques de Valdacilla, Santander, Spain
E. Fargara§anu, MD
Cardiovascular Surgeon, Clinical Assistant, Clinic for Cardiovascular Surgery, Tirgu-Mure§, Romania
Robert W. Frater, MD
Professor and Chief, Division of Cardiothoracic Surgery, Albert Einstein College of Medicine,
Montefiore Hospital and Medical Center, Bronx, New York, USA
Richard Gray, MD
Associate Cardiologist, Cedars-Sinai Medical Center, Los Angeles, California, USA
William Grossman, MD
Professor of Medicine, Harvard Medical School; Chief, Cardiovascular Disease, Beth Israel Hospital,
Boston, Massachusetts, USA
S. Hagl, MD
Department of Cardiovascular Surgery, Deutsches Herzzentrum, Muenchen, Munich, West Germany
Laurence A. Harker, MD
Director, Roon Research Center for Arteriosclerosis and Thrombosis, Scripps Clinic and Research
Foundation, La Jolla, California, USA
Syed S. Hasan, MD, FRCS
Senior Registrar, The General Infirmary, Leeds, UK
Werner Heimisch, MSEE
Department of Cardiovascular Surgery, Deutsches Herzzentrum Muenchen, Munich, West Germany
A. Henze, MD
Associate Professor, Thoracic Surgical Clinic, Karolinska Hospital, Stockholm, Sweden
Marian I. Ionescu, MD
Cardiothoracic Surgeon, The General Infirmary, Leeds, UK
Stuart W. Jamieson, MD
Assistant Proffessor, Cardiovascular Surgery, Stanford University School of Medicine, Stanford,
California, USA
W. D. Johnson, MD
3112 W. Highland Blvd., Milwaukee, Wisconsin, USA
Daniel Kalmanson, MD
Director of Clinical Teaching; Chief, Department of Cardiology, CV Research Center ARNTIC,
Foundation A. de Rothschild, Paris, France
Contributors ix
Chuichi Kawai, MD
Third Division Department of Internal Medicine, Kyoto University Hospital, Kyoto, Japan
Philip Kay, FRCS
Brompton Hospital, London, UK
Kenneth L. Kayser, MS
St Mary's Hospital, Milwaukee, Wisconsin, USA
J. Ward Kennedy, MD
Chief, Cardiovascular Disease Section, Veterans Administration Hospital, Seattle, Washington, USA
E. Kreuzer, MD
Professor of Cardiovascular Surgery, Herzchirurgische Klinik der Universität München, West Germany
Robert Leachman, MD
Senior Cardiologist, Texas Heart Institute; Professor of Medicine, Baylor College of Medicine, Baylor
College of Medicine, Houston, Texas, USA
Maurice Lev, MD
Director of Laboratories, Department of Pathology, Congenital Heart and Conduction System
Laboratory, Deborah Heart and Lung Center, Brown Mills, New Jersey, USA
M. Liebhart, MD
Cardiovascular Surgeon, Clinical Assistant, Clinic for Cardiovascular Surgery, Tirgu-Mure§, Romania
D. Lindblom, MD
Thoracic Surgical Clinic, Karolinska Hospital, Stockholm, Sweden
Jack Matloff, MD
Director, Thoracic and Cardiovascular Surgery, Cedars-Sinai Medical Center, Los Angeles, California,
USA
Hans Meisner, MD
Department of Cardiovascular Surgery, Deutsches Herzzentrum Muenchen, Munich, West Germany
Nikolaus Mendier, MD
Department of Cardiovascular Surgery, Deutsches Herzzentrum Muenchen, Munich, West Germany
D. C. Miller, MD
Associate Professor of Cardiovascular Surgery, Stanford University School of Medicine, Stanford,
California, USA
David Olivera, MRCP
Brompton Hospital, London, UK
James H. Oury, MD
Head, Division of Cardiac Surgery, Scripps Clinic and Research Foundatin, La Jolla, California, USA
Philip E. Oyer, MD
Assistant Professor of Cardiovascular Surgery, Stanford Medical Center, Stanford, California, USA
Matthias Paneth, FRCS
Brompton Hospital, London, UK
P. M. Pedraza, MD
St Mary's Hospital, Milwaukee, Wisconsin, USA
Kirk L. Peterson, MD
Director, Cardiac Catheterization Laboratory; Professor of Medicine, University of California, San
Diego, California, USA
M. Poliac
Clinic for Cardiovascular Surgery, Tirgu Mures, Romania
B. Reichart
Department of Cardiac Surgery, University of Munich, Munich, West Germany
Robert Replogle, MD
Chief, Division of Cardiac Surgery, Michael Reese Hospital, Chicago, Illinois, USA
x Contributors
Donald N. Ross, DSC, FRCS
National Heart Hospital, London, UK
John Ross, Jr, MD
Professor of Medicine; Head, Division of Cardiology, University of California, San Diego, California,
USA
Shigetake Sasayama, MD
Second Department of Internal Medicine, Toyama Medical and Pharmaceutical University, 2630 Sugitami,
Toyama 930-01, Japan
N. Schad
Community Hospital, Passan, West Germany
Nelson B. Schiller, MD
Associate Professor of Medicine, University of California, San Francisco, California, USA
Fritz Sekening, MD
Department of Cardiovascular Surgery, Deutsches Herzzentrum Muenchen, Munich, West Germany
Pravin M. Shah, MD
Professor of Medicine, School of Medicine, School of Medicine, University of California of Los Angeles;
Chief of Cardiology, Wadsworth Veterans Administration Hospital, Los Angeles, California, USA
Norman E. Shumway, MD
Chief of Cardiovascular Surgery, Stanford University School of Medicine, Stanford, California, USA
N. Paul Silverton, MD, MRCP
Lecturer in Cardiovascular Studies, Leeds University, Leeds, UK
Albert Starr, MD
Professor and Chief, Cardiopulmonary Surgery, The Oregon Health Science University, Portland,
Oregon, USA
Edward B. Stinson
Department of Cardiovascular Surgery, Stanford University School of Medicine, Stanford, California,
USA
Travis E. Stripling, PhD
Brown and Root, Inc., Houston, Texas, USA
Tsukasa Tajimi, MD
Visiting Research Fellow, University of California, USA
Anard P. Tandon, MD, MRCP
Consultant Physician, The Royal Infirmary, Halifax, UK
Frans Van de Werf, MD
Division of Cardiology, University Hospital St Rafael, Leuven, Belgium
Colette Veyrat
Chargé de Recherche au CNRS, Paris, France
David W. Wieting, MD
10846 Half Moon Pass, Littleton, Colorado, USA
Edward L. Yellin, PhD
Professor of Surgery; Associate Professor of Physiology and Biophysics, Department of Surgery and
Physiology, Albert Einstein College of Medicine, Bronx, New York, USA
Chaim Yoran, MD
Director of Cardiology, Bronx-Lebanon Hospital Center; Associate Professor of Medicine, Albert
Einstein College of Medicine, Bronx, New York, USA
1
Introduction
James H. Oury and Carlos Duran
There are more things in heaven and earth, Horatio, than are dreamt of in your
philosophy'
(Hamlet, I.v. 166)
When faced with a new problem we search and probe its causes, mechanisms and
possible solutions. A certain degree of understanding is reached, this knowledge is
organized and conclusions for action are drawn. Once this plateau is achieved, we
move on to more demanding situations and assumed the initial problem has been
solved. Our understanding of the solution crystallizes to become 'established
knowledge'. This 'established knowledge' will be taught to new generations who
ignore the many unsuccessful attempts, side avenues, interrupted alternatives and
negative experiences. Even some well-established facts are considered irrelevant to
the solving of our daily problems.
New situations that challenge this 'established knowledge' and find it inadequate
are necessary to force us to rethink our initial attitudes, deepen our search and
reach a new level of cognition. This continuous process is essential to progress. The
interruption or negative attitude towards the demands of change result in a closed
and eventually sterile system. The assumption that a subject is closed, besides being
an oversimplification, condemns the mind to ankylosis.
In the case of mitral valve surgery, advances in open-heart technology have
displaced the simple solution of closed commissurotomy and opened the era of the
valve prosthesis. The surgical simplicity of implantation coupled with the superb
immediate results have overshadowed other possibilities often considered archaic,
complex and even suspicious. However, the emergence of new techniques for valve
repair have rekindled the interest in the mitral valve. It forced the development of
improved diagnostic techniques which in turn facilitate the search for basic
anatomic and physiologic facts. This situation led to the momentous symposium
organized by Dr Daniel Kalmanson and held in Paris in 1975. Its pluridisciplinary
approach covered most aspects of the mitral valve and stimulated as well as
distributed knowledge across the specialty barriers.
Since then, a number of factors have continued to sustain or even accelerate the
interest in the mitral valve. First was the reported data by many centers using the
bioprosthesis for 5-10 years. Unfortunately, their findings show that the long-term
results are far from perfect. Secondly, the new mechanical devices with improved
hemodynamic performances have also come of age resulting in a new entity which
could be term 'prosthetic disease'. Lastly, the conservative approach to valve repair
has gained numerous adepts and offers a valid alterntive in some patient groups.
Choosing the right surgical intervention encourages the need for better diagnostic
3
4 Introduction
accuracy available through new non-invasive methods. However, these methods
require a better understanding of the functional anatomy of the valve itself. In an
effort to gather and update it was felt that the time was ripe for a new symposium
for the exchange of accumulated knowledge. The opportunity was made possible
through the enterprising foresight of the Scripps Clinic and Research Foundation
and the generous backing of the most representative companies in the field. In
October, 1982, in San Diego, California, a panel of well-known authorities was
assembled in a magnificent setting which combined a certain European grandeur
with efficient American comfort. Thus, the International Symposium of the Mitral
Valve was born.
This book represents the proceedings of that meeting. It is divided into ten
sections covering 38 contributors. The first four sections deal with the latest
advances in the study of mitral valve function. Following the recommendations
made by Daniel Kalmanson after the first Mitral Valve Symposium, it was felt that
an integrated or systemic approach to the subject would be wiser. Here the mitral
valve is treated as a complex structure which includes the left atrium, mitral
apparatus and left ventricle. Its function is studied from different perspectives with
a strong emphasis on echocardiography, always keeping in mind the diagnostic
implications.
These preceding comments indicate the urgent need for the development of new
predictors of left ventricular function which are not load-dependent and are
essential for establishing the correct timing of surgery. Furthermore, accurate
preoperative studies evaluating the anatomy and function of the valve are essential if
a conservative surgery is envisioned.
Sections 4-8 deal with the surgical treatment of mitral valve disease and include
the different types of valve prostheses, repair techniques—with their inherent
surgical problems including anesthesia—associated lesions, and complications. The
necessity for a unified method of reporting results is also becoming increasingly
obvious. Section 9 presents a very comprehensive view of the problem of congenital
mitral valve disease. Section 10 includes eight research papers. Traditionally, all
symposia are structured by the organizers who select the subjects and the authors.
Aware of the possibility that some important work or aspect might be overlooked,
an opportunity was given authors to present their unpublished research. A prize
was set for the best research paper submitted. The eight papers published in this
book represent those selected and presented before a panel at the meeting. Dr
Siegfried Hagl from Germany was awarded the prize by the panel for his work on
papillary muscle function.
This book does not intend to cover the entire field of mitral valve disease but
rather represents an effort to bring together updated work on this complex subject.
Let us hope that its reading will stimulate further work with the conviction that
there is still much more to be understood than our earier philosophy suggested.
2
Historical perspective of surgery on the mitral
valve
Donald N. Ross
Before writing anything further I should define the terms 'historical' and
'perspective'. Strictly speaking, perspective is an art form but has come to mean an
overview or broad coverage of the subject matter. This allows appropriate latitude
in our otherwise historical dicussion of the mitral valve and will have to supply the
cloak or overmantle behind which shelter will be provided should there be some
deviation from the strictly narrow confines of my brief.
Tennyson's Ulysses correctly sûmes up our painfully slow progression along the
stony path of surgical progress by saying:
'Yet all experience is an arch
Wherethrough gleams the untravelled world
Whose margin fades forever and forever when I move.'
(Unless, of course, you are a Texan and live in that happy land beyond the arch.)
While that quotation puts cardiac surgery in its correct historical perspective, the
story of the diseased mitral valve antedates cardiac surgery by several years. While
Vesalius originally suggested the term mitral valve because it resembled a bishop's
mitre, it was Vieussens of Montpelier, in 1715, who supplied us with the earliest
and most lucid description of the symptomatology and pathology of calcific mitral
stenosis. He was followed by Lannec, who described the diastolic and pre-systolic
murmurs characteristic of that condition.
Subsequent investigators contributed little until Paul Wood's classic article in the
British Medical Journal in 1954—'An appreciation of mitral stenosis—Clinical
features'. Little of clinical value has been added since.
Two other eminent physicians had made contributions relating to our subsequent
surgical endeavours—one of these negative and one positive. The unintentionally
negative contribution was the disproportionate overemphasis placed on the
importance of the myocardium in mitral valve disease. This factor was identified
and highlighted by Sir James McKenzie but because of his eminence in the field of
cardiology, the pendulum swung away from the importance of the valve pathology
to the myocardium. Unfortunately this view persisted up to the time of the
introduction of cardiac surgery and beyond.
On the other hand, a very important positive medical contribution came in 1902
when Sir Thomas Lauder Brunton dramatically threw down the gauntlet in this
otherwise complacent scene with an article in the Lancet advocating surgical
5