The early days of heart valve surgery.
Abstract: To the lay public, the very idea of an operation on that vital structure, the heart, seems to be out of the question. (In fact, the heart muscle is an incredibly tough machine that can go on pumping, without a single service, for 90 or more years!) Even to the surgeons of the end of the 19th century, who, thanks to the twin discoveries of anaesthesia and antiseptic surgery, were beginning to operate on all the other major organs of the body, heart surgery seemed to remain an impossible dream. Even that great pioneer of modern scientific surgery, Theodor Billroth, Professor of Surgery in Vienna, who had himself already performed the first successful partial gastrectomy for a stomach cancer and the first laryngectomy, wrote, in 1893, 'Any surgeon who would attempt an operation on the heart should lose the respect of his colleagues'.

KEYWORDS Heart valve / Heart surgery / Souttar / Souttar's tubes
Subject: Heart (Surgery)
Heart (History)
Author: Ellis, Harold
Pub Date: 08/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: August, 2011 Source Volume: 21 Source Issue: 8
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 272168032
Full Text: Just a year later, in 1894, Ludwig Rehn, Professor of Surgery in Frankfurt am Main, in Germany, reported the case of a young man who had been stabbed in the left chest and who was admitted to hospital breathless, pale and shocked. Rehn opened the chest through the left fourth interspace, resected the fifth rib and opened the pericardium. A large amount of blood was evacuated and a 1.5 cm wound of the left ventricle was exposed. The tear was repaired with three sutures, each placed and then tied while the heart was relaxed in diastole. The patient developed an empyema, which was drained, and then went on to make a full recovery.

Rehn reported this case both in Germany and in The Lancet. The following year, Parrozzani in Rome reported a second successful case, also in The Lancet. A writer in The Lancet commented 'Happily, it is only in Italy that surgeons have many opportunities of practising cardiac surgery--opportunities that they owe to the terrible frequency to which the dagger is resorted to in this country in the quarrels of the lower orders'. What would The Lancet correspondent have thought of the scenes in our streets today? Ten years after his success, Rehn could report no less than 124 recorded cases of operations on stab wounds of the heart with a recovery rate of 40%. The possibility of successful surgery on the heart was now established. By the beginning of the 20th century, there were a number of suggestions that stenosed heart valves might be operated upon surgically. In 1902, Sir Lauder Brunton, Physician at St. Bartholomew's Hospital, London, wrote in The Lancet that it might be possible to divide the constricted valve in the living patient, after showing that it could be performed in animals and human cadavers. In 1910 Alexis Carrel, at the Rockerfeller Institute, New York, carried out successful incision and suture of the ventricle, and digital exploration of the interior of the heart in dogs.

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It is important to remember that, until 50 years ago, it was common to see young patients, young men and women in their teens and twenties, crippled and, indeed, dying, with severe mitral stenosis, often with atrial fibrillation, as a result of rheumatic carditis. As a medical student and young surgeon, I saw many such cases, now rare in this country but still seen in emerging parts of the world.

At last, in the 1920s, two surgeons performed operations for mitral stenosis with recovery of the patient. The first of these was carried out by Elliot Cutler, of Harvard University, Boston, in May 1923. The patient was a girl aged 11, in heart failure with severe mitral stenosis. A slightly curved long scalpel was pushed through the wall of the left ventricle upwards to the atrioventricular junction and two cuts made through the stenosed mitral valve. The child lived for four years after surgery, but remained disabled by repeated episodes of heart failure. The operation could hardly have been regarded as a success. At autopsy, incision through the mitral valve was confirmed. The poor child was the first to survive an intracardiac operation. Two further patients submitted to the same procedure both died postoperatively.

The first successful transauricular mitral valvotomy was performed in 1925 by Henry Souttar at the London Hospital. His patient was a girl of 15 cyanosed and in heart failure, and referred by none other than the King's physician, Lord Dawson of Penn. The heart was approached through a large left sided skin flap, turned outwards, and a flap of three ribs turned inwards. The damaged mitral valve was stretched by a finger passed through the auricular appendage of the left atrium, which was then closed with a suture. The operation took one hour to perform. The child made a good recovery and lived in reasonable health for five years, before dying of a brain infarct, probably from a clot in the left auricular appendage.

Souttar was keen, of course, to repeat the procedure, but never did so; physicians at the time firmly believed that the features of valvular disease of the heart were produced by "exhaustion of the heart muscle" rather than the obstructing effects of the valvular disease. He lived long enough, however, to see the operation of mitral vavotomy reintroduced with great success in 1948. Many thousands of these 'blind' operations were performed all over the world until 1954, when cardiopulmonary bypass became available. Further advances were the development of artificial heart valves and 'biological valves' harvested from pigs and calves.

Henry Souttar (1875-1964) was a remarkable man. He first studied engineering and mathematics at the University of Oxford, where he obtained a double first. He then switched to medicine, and qualified from the London Hospital in 1912, later being appointed to its surgical staff. His engineering prowess was put to good use; he devised, and built in his own workshop, his ingenious coiled metal 'Souttar's tubes' which pioneered the intubation treatment of oesophageal cancers. He took an early interest in radium treatment for cancer, visited Madam Curie in Paris and devised a special introducer for the insertion of radon seeds. He was knighted in 1949.

No competing interests declared

Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication August 2010.

Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE11UL.

About the author

Professor Harold Ellis CBE, FRCS

Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London
Gale Copyright: Copyright 2011 Gale, Cengage Learning. All rights reserved.