Rheumatic Heart Disease and Its Surgical Repair

Wilson and associates evaluated 385 patients up to 49 years of age who had heart murmurs and had had rheumatic fever before the age of 20. Fully 89 percent were asymptomatic; 45 percent of the cohort had pure mitral insufficiency; 41.8 percent had combined mitral insufficiency and stenosis; 10.3 percent had both mitral lesions and aortic insufficiency; and 2.9 percent had double mitral and double aortic valve defects (Gordis et al. 1969). Of 78 fatal cases from the population of which those just mentioned were among the survivors, 15.4 percent had only mitral insufficiency, 37.2 percent had mitral insufficiency and stenosis, and 47.3 percent also had aortic insufficiency (Magida and Streitfeld 1957).

The surgical treatment of rheumatically damaged heart valves began in the late 1940s when Dwight E. Harken in Boston performed the first successful mitral commissurotomy (Harken et al. 1948). The procedure was improved by Charles P. Bailey of

Philadelphia a year later (Bailey et al. 1960). This was "closed" heart surgery. No attempt to repair a damaged aortic valve was possible until an oxygenating system to bypass blood temporarily around the heart was developed; this technique made "open" heart surgery possible. The first practical apparatus was employed by John W. Kirklin. The first valve operations to ameliorate aortic insufficiency were performed by Bailey in 1959 and to correct aortic stenosis in the same year by Donald G. Mulder in Los Angeles. The next technical phase was the replacement of an active valve. This began with the ball valve devised by Albert Starr and Lowell Edwards (1961). Such plastic valves, however, tend to destroy red blood cells, and thus valves were developed with leaflets of pig, cattle, or sheep tissue. This type of prosthesis was first inserted to replace an aortic valve in 1965, and a mitral valve in 1967, both by A. Carpentier in Paris.

In 1983 about 16,000 mitral and 33,000 aortic valve replacements were performed in the United States. However, the cause of the injury, particularly of the aortic valve, has gradually shifted from rheumatic to other varieties of heart disease (Gillum 1986).

Thomas G. Benedek

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