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J Thorac Cardiovasc Surg 1995;109:818-819
© 1995 Mosby, Inc.

LETTERS TO THE EDITOR

Aortic and aortic-mitral annular enlargement

Genfstr. 18a
37079 Göttingen, Germany

To the Editor:

The article by Kawachi, Tominaga, and Tokunage ¹ refers to two methods, namely, a patch enlargement of the aortic root into the anterior leaflet of the mitral valve with aortic valve replacement and an enlargement of mitral and aortic anuli by patching both rings with double valve replacement, both as Manouguian's technique. The epithet Manouguian's technique is a mistake and needs correction.

The first technique should be called Rastan-Manouguian to give the proper credit to the proper originators. The second one must be called Rastan's technique only and purely, because it was Dr. H. Rastan who developed the concept, tested it, first applied it clinically, and refined it, all without any other person's contribution. ^2,3 To clarify the point, I must relate the story behind these techniques as I have witnessed them so that firsthand information will be made available to the profession.

In the years 1969 to 1979, when Dr. Manouguian and I were in training at the University of Göttingen, Dr. H. Rastan was a senior and attending surgeon and guided us in our work. Dr. H. Rastan had at that time completed his aortoventriculoplasty, showing that incising and enlarging the aortic ring was feasible and safe. ^4,5 Dr. Manouguian, on the basis of Dr. Rastan's work, proposed that enlarging the aortic ring could perhaps also be done by incising the mitral ring, an idea that Dr. Rastan himself had earlier entertained but refrained from testing because of mitral regurgitation that he was sure would ensue. However, he decided to test it, led Dr. Manouguian in the design of experiments, applied the initial patches himself, and he, not Dr. Manouguian, did the first clinical case in 1976, which indeed resulted in mild mitral regurgitation. ⁶ Dr. Manouguian's contribution to that technique, if any, ended there.

The concept for the second technique for enlarging the aortic and mitral anuli was developed by Dr. H. Rastan when he was visiting professor at the Queen Pahlavi Foundation Hospital (QPFH) in Tehran in 1976, where he was faced with small, tight, rheumatic mitral valves that needed enlargement. There he developed the concept and tested it experimentally without publishing his work, although he published the first clinical cases he did at QPFH in 1978. An opportune occasion for publishing the work was lost during the Iranian revolution, and that publication was delayed until 1981. ^2,3

On his return from his initial visit to QPFH, Dr. Rastan told us about his new idea and experiments. Dr. Manouguian did not fail to work on that idea, and those experimental results were published by him with Dr. Rastan's name as coauthor. ⁷

In Dr H. Rastan's next absence from Göttingen to QPFH, when he was continuing his work refining his second technique, Dr. Manouguian convinced another senior surgeon in Göttingen to perform a second case with the first technique, which had been found inadequate because of the ensuing mitral regurgitation. A severe mitral regurgitation resulted, the patient was reoperated on quickly, the mitral valve was replaced, and the patch of the aortic root was sutured to the mitral prosthesis. The failure of this first technique was reported by Dr. Manouguian in 1980 as the first bonafide clinical application of the second technique, ⁸ although he knew the first patients had already been operated on by Rastan in 1978. To further mark the events, after Dr. Rastan's permanent departure from Göttingen to QPFH, Dr. Manouguian again reported his earlier animal experiments, but this time without Dr. Rastan's name. ⁹

The fact is that Dr. Manouguian did not perform a single operation of either technique, neither initially nor later. The irony is that the course of events he tipped with his name eventually led him to leave the university and his career in cardiac surgery permanently.

I do not know if any operative method can justifiably bear the name of a person who has not performed the operation and has also ignored medical ethics.

References

1. Kawachi Y, Tominaga R, Tokunage K. Eleven-year follow-up study for aortic or aortic-mitral anulus-enlarging procedure by Manouguian's technique. J THORAC CARDIOVASC SURG 1992;104:1259-63.[Abstract]
   
2. Rastan H, Atai M, Hadi H, Yazdanyar A. Enlargement of mitral valvular ring. J THORAC CARDIOVASC SURG 1981;81:106-11.[Abstract]
   
3. Rastan H. Aortic and mitral valve replacement in children or adults with small valvular annulus. Pediatrician 1981;10:123-32.
   
4. Rastan H. A new technique for treatment of left ventricular outflow tract obstructions. Nezame Pezeshki of Iran 1974;4:122-6.
   
5. Rastan H, Koncz J. Plastische Erweiterung der Ausflußbahn der linken Kammer. Eine neue Operationsmethode. Thoraxchirurgie 1975;24:169-75.
   
6. Manouguian S, Rastan H, Abu-Aishah N, Kirchhoff PG, Koncz J. A new method for patch enlargement of hypoplastic aortic annulus. Athens: Proceedings of the International Congress of Cardiovascular Surgery, 1977:94-9.
   
7. Manouguian S, Rastan H, Abu-Aishah N, Kirchhoff PG. Erweite rungsplastik des Mitralklappenringes. Eine experimentelle Studie. Acta Chir Austr Sondersuppl 1977/1978:890-6.
   
8. Manouguian S, Kirchhoff PG. Patch enlargement of the aortic and the mitral valve rings with aortic-mitral double valve replacement. Ann Thorac Surg 1980;30:396-9.[Abstract]
   
9. Manouguian S, Abu-Aishah N, Neitzel J. Patch enlargement of the aortic and mitral valve rings with aortic and mitral double valve replacement: experimental study. J THORAC CARDIOVASC SURG 1979;78:394-401.[Abstract]
   

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