Closed heart surgery: Back to the future (original) (raw)

2006, The Journal of Thoracic and Cardiovascular Surgery

I n 1912, a famous thoracic surgeon, Theodore Tuffier, was presented a young patient with disabling symptoms caused by aortic stenosis. He planned to treat the patient by using inflow occlusion cutting the aortic valve leaflets with a knife. About to snare the cava, he noted that the aortic wall was flaccid, so he used his finger to invaginate the anterior aortic wall through the valve orifice. Immediately the palpable systolic vibration of the aortic wall was diminished. When examined 12 years later, the patient was alive and well. 1 Tuffier had performed the first successful closed heart surgery. Aortic stenosis of the senile calcific variety is today the most common valvular disease in the Western World, occurring in 2.9% of adults aged more than 65 years. 2-4 Its hemodynamic precursors include congenital bicuspid malformation and acquired insults such as rheumatic heart disease, endocarditis, myxomatous proliferation, and trauma, which progress to a combination of stenosis and regurgitation. 2 Once symptoms, in particular left ventricular dysfunction, become manifest, the prognosis is poor and medical therapy is not likely to modify the course of the disease. 4 Balloon valvuloplasty has been attempted but with only transient modest improvement and is reserved for palliation only. 5 Open surgery therefore remains the treatment of choice for symptomatic aortic stenosis, and open aortic valve replacement is exceedingly effective in eliminating symptoms and improving prognosis. 6 Open surgery, however, necessarily entails the risks and morbidity associated with cardiopulmonary bypass, clamping of the aorta, myocardial preservation, and median sternotomy, with operative mortalities as high as 20% reported in elderly patients and those with concomitant left ventricular dysfunction. 7,8 Because senile aortic stenosis is a disease of the elderly, comorbidities are a frequent concern and render some patients inoperable. Ironically, nearly 100 years after Tuffier's pioneering work, closed procedures are again being reconsidered by cardiac surgeons as an option for aortic stenosis. 9 Catheter-based aortic valve implantation in animal models was introduced in 1992, 10,11 and 10 years later Cribier and colleagues 12 described the first successful human aortic valve implantation using the venous antegrade transeptal approach. More recently at our institution, Webb and colleagues 13 reported on patients treated by retrograde arterial implantation of prosthetic aortic valves. Ye and colleagues 9 reported on the deployment of an aortic valve prosthesis for severe aortic stenosis through the apex of the left ventricle in a 75-year-old patient (a closed heart surgery procedure). This report of successful implantation of an aortic valve prosthesis through the apex of the left ventricle without sternotomy or the use of cardiopulmonary bypass in a human 9 provides a glimpse of an indispensable future role for cardiac surgery with this modality. At present this procedure is offered to patients deemed to be nonsurgical candidates, but we can fully expect the indications in the future to be expanded to high-risk surgical candidates and likely even further, depending on the proven clinical durability of the device. Although clinical experience is obviously limited, in vitro valve durability has been repeatedly documented to 200 million cycles or more than 5 years of life. Before the development of cardiopulmonary bypass by Gibbon in the 1950s, 14 cardiac surgeons were ingenious in developing instruments for closed heart surgery. Examples include the valvulotome and dilating forceps for pulmonary valvulotomy and the infundibular punch for right ventricular outflow tract obstruction. 1,15 Indeed, now a lost art, the past era of cardiac surgeons were very comfortable with the