12 September 1964 S.A. TYDSKRIF VIR GENEESKUNDE 721 THE PRE-OPERATIVE ASSESSMENT OF MITRAL-VALVE DISEASE* v. ScHRlRE, M.Se., PH.D., M.D., F.R.C.P.E., F.R.C.P. AND C. N. BARNARD, M.D., M.MED., M.S., PH.D., FA.C.S., Departments of Medicine and Surgery, University of Cape Town, CSIR Cardiovascular Pulmonary Research Group, and the Cardiac Clinic, Groote Schuur Hospital, Cape Town The diagnosis of mitral-valve disease can readily be made for corrective surgery, but the fact that the medical staff, at the bedside. Careful palpation and auscultation, surgical beds and operating time has not kept pace with together with the electrocardiogram and roentgenogram, the development and demand for cardiac surgery. generally provide such precise information that an accurate A full history and examination was performed in every estimate of the haemodynamic state can usually be de­ patient, usually repeated on several occasions. Phonocardi­ duced without recourse to cardiac catheterization and ography was used in almost every patient for record pur­ angiocardiography. The latter procedures, however, are of poses and for study, but did not influence the selection of particular value in quantitating the degree of stenosis and cases in any way. It was invaluable in promoting accuracy incompetence, and in measuring the pulmonary resistance. of auscultation, and was constantly used to check the Furthermore, in the presence of multiple valve involvement clinical findings. Electrocardiography included the stan­ they provide, in our experience, the only reliable data. dard, the unipolar-limb and the praecordial leads VI to From 1951 until April 1963, 450 patients were seen and V7. Most of the patients (75%) were screened by one studied in the Cardiac Clinic, Groote Schuur Hospital, and of us (V.S.) in the Cardiac Clinic and a barium swallow referred for mitral-valve surgery. There were 441 closed­ was routine. Roentgenograms were taken independently in heart and 48 open-heart procedures; several patients the radiological department. requiring two or more operations. In this paper we wish The haemodynamic disturbance was classified into four to report the pre-operative clinical data and their relation groups according to the findings at surgery: to the findings at surgery. The study is concerned with the A. Pure mitral stenosis (356 patients) meant narrowing problem of mitral-valve disease without significant aortic of the mitral valve, without any palpable evidence of valve involvement, particularly aortic stenosis. mitral incompetence. In 95% of the patients the valve area measured less than 2 sq. cm.7 MATERIAL AD METHODS B. Trivial mitral incompetence (38 patients), indicated The 450 patients in this series have been selected from a slight jet felt during systole and regarded by the surgeon 2,500 rheumatic patients referred to the Cardiac Clinic for to be of no haemodynamic consequence, often described assessment and treatment. AII patients were seen by one as a 'purr' rather than as a jet. In 72% the valve area was of us (V.S.) before operation. With few exceptions, less than 2 sq. cm. surgery was performed at Groote Schuur Hospital. 14% e. Mixed stenosis and incompetence (34 patients), im­ of the patients were catheterized, but the findings are not plied a significant degree of both stenosis and incompet­ discussed in this communication. ence; each component varied considerably from case to With the development of cardiac surgery, and increased case, no attempt being made to assess which was dominant. experience, there has been a rise in the number of patients Attempts at quantitation were not possible at surgery. 89'10 on whom surgery has been performed (Table I). had valve areas between 1 and 3 sq. cm. D. Pure mitral incompetence. In 21 of the 22 patients TABLE 1. MITRAL VALVE SURGERY in whom the valves were inspected during bypass surgery, Closed heart Open heart no stenosis was present. 1951/1952 4 1953 30 RESULTS 1954 40 1955 22 The patients were analyzed according to age, race and sex, 1956 39 in Table H. There was no racial difference, the incidence 1957 16 of rheumatic heart disease being proportionate to the 1958 25 1959 46 6 relative number of patients of each racial group attending 1960 68 2 the hospital.s The youngest patient in the series was 10 and 1961 61 14 the oldest 62 years. The female dominance of almost 3: 1 1962 71 19 is in keeping with the world experience. Severe rheumatic­ 1963 65 23 valve disease appears to manifest itself at an earlier age Total 487 64 in the non-White races and is probably more lethal. Most patients over the age of 40 were White. As cardiac-bypass procedures have improved in our The diagnosis made on clinical grounds and the findings uniP-5 and prosthetic valves have been developed,4-6 more at surgery are shown in Table Ill. patients are now being submitted to mitral-valve surgery. Of the 356 patients with pure mitral stenosis (group A) At present practically no patient is too ill for surgery, the diagnosis was correctly made in 345 (97%), which is provided renal function is satisfactory, and any type of in keeping with the experience of others.9 Errors were mitral-valve deformity can be improved or corrected. The made in both directions. Of 8 patients regarded as having present limitation is not the number of patients suitable pure mitral stenosis, 7 had trivial mitral incompetence (B) 'Presented at the 44th South Mrican Medical Congress, Johan- and 1 mixed mitral stenosis and incompetence (C). Ten nesburg, July 1963. patients regarded as having trivial mitral incompetence 722 S.A. MEDICAL JOURNAL 12 September 1964 TABLE 11. RACE, AGE AND SEX OF 450 PATIENTS WITH MITRAL-VALVE DISEASE SUBMITTED TO SURGERY Group A* Group B Group C Group D Tota/ABCD Sex Race Sex Race Sex Race Sex Ra~e Age (Yeors) No. M F No. M F W C B No. M F W C B No. M F W C B No. M F W C B 10--19 53 14 39 43 11 32 6 21 16 5 2 3 I 4 2 I 1 2 3 3 I 2 20--29 140 41 99 112 27 85 31 64 17 10 8 2 1 7 2 9 4 5 3 3 9 2 7 6 I 30--39 130 40 90 106 30 76 54 40 12 8 4 4 4 3 1 9 5 4 4 5 7 I 6 7 40--49 89 28 61 65 21 44 45 14 6 12 3 9 8 2 2 10 3 7 8 1 2 I 1 2 50--59 36 9 27 28 8 20 24 2 2 3 3 1 2 4 1 3 4 1 1 I 60+69 2 I 1 2 1 I 1 1 Total 450 133 317 356 98 258 161 142 53 38 17 21 14 15 9 34 14 20 21 9 4 22 4 18 17 • For classification of groups see text and 1 as having mixed stenosis and incompetence, had for a history of rheumatic fever, chorea, or equivalents, for emboli, anginal pain, haemoptysis, fatigue, palpitations, syn­ pure stenosis. cope on effort, swelling of feet, and for bacterial endocarditis. Of the 38 patients with trivial mitral incompetence The effect of pregnancy on the symptomatology was also (group B), the diagnosis was correctly made in 29 (80'10)' always noted. There were 12 errors. Ten had pure stenosis and 2 mixed A. Rheumatic fever. A history of rheumatic fever was present in a little more than a third of patients with mitral stenosis TABLE Ill. CLINICAL DIAGNOSIS AND SURGICAL FINDINGS (groups A and B). A far higher incidence was noted in Group A Group B Group C Group D patients with mixed stenosis and incompetence. In pure mitral pure MS MS + triv, MI MS+MI pure MI incompetence, most patients (87%) had a history of rheumatic Surgically proven 356 38 34 22 fever. Clinical diagnosis 353 41 35 21 It is worth noting that chorea never occurred with pure Clinically correct 345 29 31 21 A-I B-2 mitral incompetence, whereas an incidence of 3·6% was noted Clinical errors .. B-7 C-I A-IO C-2 in other forms of mitral-valve disease. The severity of the stenosis and incompetence. For practical purposes groups rheumatic process could be assessed by the age at which the patients became aware that they had murmurs, or suffered A and B (both of whom are suitable for closed-heart from valve disease. Most patients with pure mitral incom­ surgery) can be taken together, i.e. there were 394 such petence were aware of heart murmurs or heart disease in their patients, the clinical diagnosis being correct in 391. 'teens' (average 16 years, range 3 - 45) and symptoms gene­ Of the 34 patients with mixed stenosis and incompetence, rally dated from an early age. Patients with pure mitral stenosis, on the other hand, were often unaware of any heart 31 (91%) were confirmed at surgery. There were 4 errors, disease until severe symptoms requiring surgery had developed, one patient having pure stenosis, one pure incompetence, (average age when murmurs were discovered 28, range 6 - 61). and 2 trivial incompetence. All 21 patients diagnosed as 'fhe figures obtained for dominant stenosis and trivial incom­ pure mitral incompetence had this lesion at surgery. petence were 27 (6· 46) and for mixed stenosis and incom­ petence 30 (6 - 46) respectively. DISCUSSION B. Emboli. The incidence of systemic embolism is shown in In the following analyses groups A to D are separately con­ Table IV.