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J Thorac Cardiovasc Surg 2006;131:941-943
© 2006 The American Association for Thoracic Surgery

Editorial

Closed heart surgery: Back to the future

Division of Cardiac Surgery, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.

Received for publication December 23, 2005; accepted for publication January 3, 2006.

^_* Address for reprints: Samuel V. Lichtenstein, MD, PhD, Head, Cardiac Surgery, University of British Columbia, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6. (Email: slichtenstein@providencehealth.bc.ca).

The first 20% of the full text of this article appears below.

In 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 . . . [Full Text of this Article]

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