Surgery for Multiple Valve Disease *

ALBERT STARR, M.D., COLIN W. MCCORD, M.D., JAMES WOOD, M.D.

RODNEY HERR, M.D., M. LOWELL EDWARDS, B.S.
From the Department of Surgery, University of Oregon Medical School,
Portland, Oregon

SUFFICIENT PROGRESS has been made in

the surgical treatment of isolated valve disease so that attention may now be directed
to the vast number of potential surgical
candidates with multivalvular involvement.
This report is based upon 27 such patients
all of whom had combined aortic and mitral
surgery. As with isolated valve disease, success is related to the proper application of
replacement and reparative procedures.
Some preliminary observations regarding
multiple replacement have been previously
described." With increasing experience the
risk of such procedures has been greatly reduced and the late clinical and hemodynamic results more clearly defined.
The Prosthesis
Since the first mitral replacement operation performed in September, 1960 12 our
experience with replacement procedures
has been confined to the ball valve prosthesis both mitral 8, 9 and aortic 3,10 developed in this laboratory (Fig. 1). These
are used in exactly the same manner as in
isolated replacement. The septal portion of
the mitral prosthesis is in the usual subaortic position and there is no impingement
of one prosthesis upon the other. Both
prostheses have undergone gradual improvement in design and this has been
pertinent to the problem of multiple replacement. The smaller size prostheses are

used more often in multiple valve disease

so that attention has been directed to an
appraisal of function of these sizes. No
major changes have been required in the
aortic series since even with the 8A prostheses, the smallest made for adult implantation, there is no significant pressure
gradient following proper implantation.
There is a small mean diastolic gradient
and end diastolic gradient across the old
style mitral prosthesis, however, and
changes have been made in internal geometry of this valve to improve hydraulic
function. These involve a more streamlined
inflow face, a larger diameter for flow
without increase in external diameter,
thinner struts, and a more compressible
margin due to the cushion-like effect of the
silicone foam rubber insert in the sewing
ring (Fig. 2, 3). These changes were of sufficient value as determined by late cathe-

Presented before the American Surgical Association, Hot Springs, Virginia, April 1-3, 1964.
*

FIG. 1A. Current aortic prosthesis size 8A. Note

the small ball to orifice ratio. B. The current mitral
prosthesis size 2M as revised in October, 1963.

This study was supported by Program Project

Grant HE 06336-03 of the USPHS.

596

Volume 160
Number 4

*I..i:-|x1im.s. ;A:-;r.,liSPX<o:5..;

SURGERY FOR MULTIPLIE VALVE DISEASE

:.. }!.. .. v

i.:s

FIG. 2. This demonstrates the progressive

changes made in the
mitral prosthesis since its
first clinical use in September, 1960. Stage 4
and 5 have a silicone
rubber foam insert in
sewing margin.

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ENT C.HART ..F NUMBER I UITRAL jEART VALVE

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terization studies so that they were subsequently applied to all sizes of the mitral
prosthesis for isolated as well as for multiple replacement.
Clinical Material
In June, 1962, the first patient in this
series with known severe aortic and mitral
disease underwent a double replacement
procedure. Since then 27 such patients
have been operated upon, 18 of whom had
replacement of two or more valves. Seven
patients had aortic replacement and repair
of the mitral valve. Two patients had mitral
replacement and repair of the aortic valve
(Table 1). All were severely incapacitated
despite the most extreme medical measures.
All had a history of past episodes of congestive failure and seven were in a terminal
state with treatment-resistant congestion at
the time of operation. Despite prolonged
preoperative bed-rest these patients had
hepatomegaly, peripheral edema, and in
three instances persistent ascites. Six patients, including the two patients with
triple replacement, had previous cardiac
surgery.
Important elements of the preoperative
work-up included fluoroscopy for valve cal-

cification, right and left heart catheterization, and careful evaluation of hepatic,
renal, and pulmonary function. The preoperative hemodynamic data is shown in
Table 2. Six patients are sufficiently remote
from surgery so that both pre- and postoperative studies have been completed and
are available for comparison (Table 3). No
patient was denied surgery on the basis of
catheterization findings. However, such
studies were crucial in defining multiple
valve disease in patients who from clinical
evaluation alone had isolated aortic or

FIG. 3. Starr-Edwards mitral valve size 1M pressure

gradient-steady state flow with water.

598

STARR AND OTHERS

Annals of

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Volume 160
Number 4

SURGERY FOR MULTIPLE VALVE DISEASE

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Annals of Surgery
October 1964

STARR AND OTHERS

600

TABLE 2. Surgery for Multivalvular Disease Preoperative Hemodynamics Data

(Average Pressures (mm. Hg.))

Pt.

ED

DM

V ED

ED

Index 1/
meter2/min.

Aorta

LV

LA

PA

RA

Rest Ex.

A. Multiple Valve Replacements

1
2
11
6
2
3
17 10
3
13
3
4
1
5
1
2
6
0
+1 -3
7
0
0
-1
8
6
9
10
5
11
3
4
3
12
1
2
13
0
14
4
5
15
4
16
1
1
3
17
2
3
3
18

29/10
35/15
36/18
41/18
50/18

21
24
30
35

24 34 27
25 35 18

B. Open Mitral Repair + Aortic

3
6
19
2
3
20
3
4
21
3
22
2
3
3
23
4
24
8
3
25

Replacement
24/9
54/26 38
27/14 24
30/3(rt. ventricle)
56/24 36
35/10 17
48/22 35

23
30 12
23 8
21 8
16 21 10
10 17 5
19 40 8

88/9
204/8
96/8
156/68
188/5
210/20

140/40 (BA)
216/44(BA)
114/60 (BA)
160/68 (BA)
100/56
95/40
124/62

2.02
3.1
2.2

24 37 19
26 48 18

230/0
140/2

110/60
104/56

3.38
1.24

40/24
48/20 29

25/10 14
30/10 17
31/10 18
32/15 23
42/18 26

60/28 (40)
50/32 38
34/13 20
17

C. Aortic Repair + Mitral Replacement

1
4
56/15 30
2.5
26
25 11
88/28 52
20
27

25 34 20
19 23 17
27 38 24
14 18 11
11 12 12
12 16 9
12 18 5
14 18 9
34 50 20
28 42 (wedge)
13 25 12
19 27 16
23 26 18
10 11 6
15 23 13

17 19(wedge)

12
18
15
10

mitral involvement. Some patients had relatively mild valve disease as determined by
pressure gradients and intracardiac pressures. However, with double valve disease
the combination of valvular abnormalities
resulted in marked restriction of performance as determined by cardiac output and
arterial venous oxygen difference with rest
and exercise.
Contrast visualization of the ascending
aorta was performed in most patients and
was helpful in assessing the magnitude of
aortic regurgitation. Coronary visualization was not performed if hemodynamic
data revealed serious valve disease as a

148/6
114/5
232/10
112/10
205/10
120/9
160/7

146/10
142/12
123/3
140/11

123/63 (BA)
156/56(BA)
90/68
104/54(BA)
100/60(BA)
140/48(BA)
108/60
116/64 (BA)
180/52
118/10

120/70
98/56
96/64
128/60(BA)
136/64(BA)
122/6
100/68
150/65

2.11

2.71 2.86
1.88
2.32
3.64
3.26
3.22
2.75
2.25
4.15
1.99
2.74
2.36
3.11
2.3
3.66
2.94
3.53

2.29
3.95

4.42

3.44
3.72
3.01

4.35
3.4
4.42

2.07
2.80

2.57 4.12
1.04 1.7

cause of symptoms. A second injection in

the abdominal aorta allowed evaluation of
this region as a perfusion pathway and
assessment of the degree of atherosclerosis
in elderly patients.
While no patient was denied the operation on the basis of the severity of cardiac
disability as determined clinically or by
hemodynamic studies, some patients with
serious associated diseases such as alcoholic
cirrhosis, chronic renal failure, and pulmonary fibrosis and emphysema were not
considered suitable candidates for multiple
valve surgery. Severe pulmonary hypertension was not in itself felt to be a con-

SURGERY FOR MULTIPLE VALVE DISEASE

Volume 160
Number 4

601

TABLE 3. Pre- and Postoperative Catheterization Data on Patients uith Muitiple Valve Surgery

Brachial
RA
M

Pt.

Double Replacement
4
Pre(3)
Post(4)

LA

PA

V ED

LV

Artery

Cardiac
Index

S ED

S D

Rest Ex.

V ED

S D

25/10 (14)
25/10 (17)

(14) 18 11
(9) 11 5(wedge) 130/5

104/54
115/75

2.32 2.29
2.56 3.56

PrePost-

(1)
(4)

30/10 (17)
25/10 (16)

(11) 12 12
(9) 13 8

148/6
130/6

100/60
130/80

3.64 3.95
2.56 3.74

PrePost-

(0)
(5)

1
9

-3
1

32/15 (23)
22/6 (13)

(12) 18
(7) 12

5
4

115/4

108/60
120/75

3.22 3.44
2.78 3.42

12

PrePost-

(3)
(3)

4
4

3
2

40/3 (RV pressure)

28/10 (18)

(19) 27 16
(8) 13 5

120/9
115/8

98/56*
125/75

2.74
2.66 3.55

13

PrePost-

(1) -

50/3
21/5

(13)

(23) 26 18
(5) 5 3

166/8
120/7

80/62*
115/72

2.36
2.01 3.96

Arotic Replacement; Mitral Annuloplasty

24/9
19
Pre(3) 6
28/7
(2)
Post-

(12)
(12)

(12) 23
(4) 8

88/9
102/4

140/40

2.07

100/63

2.29 3.85

* Aortic.
M: Mean pressure; ED: End diastolic pressure; S: Systolic pressure; D: Diastolic pressure.

traindication to operation. Patients over 60

years of age have not thus far been accepted for multiple valve surgery although
many patients in this age have had a spectacular result following correction of isolated valve disease.
Patients accepted for surgery were admitted to the hospital one to six weeks
prior to operation to be certain that the
maximum benefit of medical therapy had
been obtained. Advantage was taken in
this period of preoperative preparation to
control the patient's staphylococcal flora
and search for foci of infection. Thus if
dental examination and x-rays were not
part of the initial workup these studies were
performed and followed by appropriate
treatment prior to operation. Urine cultures
were performed routinely and surgery was
not done in the presence of a positive culture. Culture of the external nares provided
useful information regarding the presence
of coagulase + hemolytic staphylococci. All
patients whether their nasal cultures were

positive or negative were started soon after

hospital admission on a rigid program of
prophylaxis with daily installation of 5 per
cent ammoniated mercury ointment into
the nasal vestibule, showers or bed baths
with surgical soap twice daily, and shampoo
every other day.
Patients not allergic to penicillin were
given methylcillin, 4 Gm. daily, beginning
on the day before operation. The remainder
were treated prophylactically with Chloromycetin and Erythromycin in a similar
manner.
Operative Findings
All patients in this series had rheumatic
heart disease except Patient 25 who had
cystic medial necrosis of the aorta with resultant aneurysmal dilatation of the sinuses
of Valsalva and aortic regurgitation. Mitral
regurgitation in this case was due to ruptured chordae tendinae.
Repair rather than replacement of the
aortic valve was possible in only two pa-

602

STARR AND OTHERS

FIG. 4. This preoperative chest film on Patient

17 shows calcification of the aortic and mitral
valves as a unit involving intervening tissue.

tients in this series. These (Patients 26, 27)

had pure aortic stenosis with fusion of the
commissures and only mild thickening of
the leaflets. Both were in severe failure at
the time of operation and it was felt that
palliative surgery was justified. The aortic
pathology in the remaining cases were quite
similar. There were varying degrees of
fusion of the commissures, loss of leaflet
substance, and thickening of the leaflets,
especially at the attached margins. Massive
calcification of the aortic valve was uncommon in this group of patients occurring
only in Patients 13, 17 and 24. Of great interest is that when this occurred the calcification involved the aortic and mitral
valves as a single unit, as if the rheumatic
process extended from one valve to the
other without regard for functional boundaries (Fig. 4). Once this concept of rheumatic involvement of the aortico-mitral

Annals of Surgery
October 1964

complex as a unit was appreciated it became apparent even in the absence of significant calcification that the inflammatory
process in most cases involved the intervening tissue between the aortic and mitral
valves, a point of some significance in the
technic of resection.
Most of the patients having mitral resection had a mixed lesion, massive calcification, or both (Fig. 5). The remainder fulfilled other criteria for mitral resection at
this clinic.4 Patient 9 had pure mitral regurgitation with normal sized annulus and
Patient 12 had pure stenosis without calcification but with irreparable subvalvular
fusion. Thus, in only seven of the patients
in this series was it possible to adequately
repair the mitral valve. The type of repair
is described in Table 1. The decision for
repair in these cases was made within a
few seconds after seeing the valve and it
was determined by no other consideration
than the anatomic findings. Open commissurotomy was performed only for flexible uncalcified valves with a good subvalvular mechanism. Annuloplasty was performed only in the presence of a dilated
annulus. Leaflet plication procedures were
performed only for flexible leaflets with
acquired clefts or flail free margin due to
ruptured or stretched chordae tendinae.
In no case in this series was the mitral
disease simple dilatation of the annulus as
the result of left ventricular failure. While
we have operated upon many such patients,
none in our experience required mitral
valve surgery. The mitral regurgitation in
such cases along with the elevated left
atrial pressure disappears following aortic
valve surgery alone.
Operative Technic
The technic of isolated mitral and aortic
valve replacement has been previously described. Attention is directed here to those
features peculiar to multiple valve surgery
concerning 1) operative approach; 2)
technic of prolonged cardiopulmonary by-

Volume 160
Number 4

SURGERY FOR MULTIPLE VALVE DISEASE

603

pass; 3) protection of the myocardium during aortic cross-clamping; and 4) sequence

of implantation.
All patients were operated upon with
midline sternotomy incision. Heparin is
given in the amount of 3 mg./Kg. and
both cavae are cannulated for a venous return. The left external iliac artery is isolated
for inflow and the patient is placed on
cardiopulmonary bypass at an initial flow
of 2.5 L./m.2 of body surface/min.
The extracorporeal circuit consists of a
rotating disc oxygenator and roller pumps
adjusted to complete occlusion. Hemodilution technics are not used, the prime consisting of heparinized blood drawn 18
hours prior to surgery. Mannitol is added
to the pump prime in a 20 per cent solution at a dose of 2 Gm./Kg.5. Additional
heparin is given after three hours of perfusion if bypass will continue beyond 31/)
hours. Light fluothane anesthesia is administered during perfusion and relaxants are
used to prevent muscular activity during
electrical defibrillation. Shortly after the
onset of bypass the patient is cooled to
300 C. and when this temperature is
reached flow is reduced to 1.8 L./m.2 of

body surface/min. provided that perfusion

pressures remain 65 mm. Hg or above.
While cooling is in progress pericardial
adhesions over the ventricles are divided
so that the apex may be elevated for insertion of a left ventricular vent. Attention
is directed first to the mitral valve. Exposure is facilitated by a long left atriotomy,
decompression of the aortic root, and relaxation of the myocardium. The pericardial
reflection between the inferior vena cava
and the right inferior pulmonary vein is
divided. The posterior interatrial sulcus is
widely opened by sharp and blunt dissection and the right atrium and inferior cava
retracted sharply to the left. A small stab
incision is then made in the exposed anterior wall of the left atrium and the mitral
valve palpated in the beating heart. The
ascending aorta is cross-clamped and the

u
M
Tuz>rh
i

FIG. 5. Operative specimen of Patient 3. Note

the advance mitral pathology with massive calcification. There is marked loss of leaflet substance of the tricuspid valve.

left atrial incision extended downward between the inferior cava and the right inferior pulmonary vein to reach the back of
the heart. It is then possible to extend the
incision around the posterior wall of the
left atrium to reach the left inferior pulmonary vein if necessary for adequate exposure. As the heart relaxes the mitral valve
comes into view. Momentary release of the
aorta clamp provides an indication of the
degree of aortic regurgitation. Decompression of the aortic root during mitral surgery is achieved by intermittent crossclamping of the aorta if aortic regurgitation
is not too severe. This was possible in 11 of
the 18 multiple replacement procedures and
in four of the combined replacement and
reparative procedures. In the remainder
continuous cross-clamping was necessary
because of loss of perfusion pressure or
flooding of the operative field with blood
upon release of the aortic clamp. Under
these circumstances the myocardium is protected by intermittent coronary perfusion
with cold blood. This is obtained from the
oxygenating chamber, passed through a
heat exchanger with circulating ice water
and delivered to the coronary ostia by a
foot pedal control pump at a combined
flow of 350 to 400 cc./min. After five
minutes of perfusion the cannulae are removed and mitral surgery is continued.
Coronary perfusion is repeated for three

STARR AND OTHERS

604

Annals of Surgery
October 1964

FIG. 6. A. Left ventricular view of the mitral

and aortic prosthesis. The
mitral prosthesis is too
large and its sewing mar-

Aft
dL.,

gin appears to narrow the

left ventricular outflow

tract (Patient 6). B. This

demonstrates the proper
positioning of both mitral
and aortic prostheses (Patient 2).

minutes every 15 to 20 minutes. Myocardial

temperature is thereby reduced to 80 C.
and a maximum drift upward during the
period without perfusion is 0.50 C./min.
Iced Ringer's solution is not used in the
pericardium.

With intermittent coronary perfusion

there is sufficient myocardial relaxation so
that retraction is possible without injury
to the heart. A useful maneuver is to place
a traction suture in the mitral valve or annulus to help pull this area close to the
left atrial incision. If resection is necessary
care must be taken to excise the septal
leaflet as close as possible to the aortic
root. A stump of thickened leaflet if left
behind will impinge upon the limited space
available for the two prostheses. Following resection of the mitral valve and division of the chordae tendinae sutures may be

placed in the liberated mitral annulus with

surprising

ease.

Special care must be devoted to the

selection of a proper size mitral prosthesis
in patients with combined aortic and mitral
disease (Fig. 6). With aortic stenosis concentric hypertrophy may encroach upon
the left ventricular cavity diminishing available space for the cage. Septal hypertrophy
may also diminish the space available for
the fixation ring of the mitral prosthesis
which occupies a subaortic position. For
these reasons the smaller sized mitral prostheses have been used in the majority of
cases.

Following mitral surgery the left atriotomy is partially closed and aortic replacement is performed exactly as in isolated
aortic disease. In one patient (Patient 2)
the aortic valve was replaced before the

Volume 160
Number 4

SURGERY FOR MULTIPLE VALVE DISEASE

mitral. Subsequent exposure of the mitral

valve was quite difficult and this error in
sequence was never

repeated. A transverse

aortotomy is used to avoid narrowing the

aorta by closure of a longitudinal incision.

This insures the largest possible area for

flow around the ball, a critical factor for
optimal prosthetic function. After removal
of the aorta clamp while rewarming is taking place the left atrium is closed. The
left ventricular vent is placed on passive
drainage and following removal of all air
from the heart electrical defibrillation is
performed. The left ventricular vent is not
removed until it is apparent by palpation
of the closure clicks that both prostheses
are functioning.
Attention is then directed to the tricuspid
valve. In Patients 3 and 11 severe tricuspid
regurgitation was present as a result of
marked loss of leaflet surface area rather
than passive right ventricular dilatation
(Fig. 5). Tricuspid annuloplasty was performed but both patients were unable to
maintain adequate systemic pressures. Palpation of the tricuspid valves and pressure
tracings revealed massive residual regurgitation. Bypass was resumed and tricuspid
replacement performed with the mitral
prosthesis. Care must be taken to avoid
heartblock by placing the sutures in the
septal area through leaflet tissue rather
than through annulus. In both cases it was
then possible to discontinue perfusion without progressive deterioration of the circulation and with evidence that tricuspid function was significantly improved. In two
patients (7, 13) tricuspid regurgitation was
present but this was not sufficiently severe
to warrant correction. One patient (27)
had tight tricuspid stenosis treated by commissurotomy. There was considerable resid-

ual tricuspid regurgitation but again this

was well tolerated and nothing further was
done.
The bypass time in this series of patients
varied from two hours and six minutes to
five hours and eight minutes with a mean

605

of three hours and 17 minutes for all cases.

This was significantly less for the combined
replacement and repair group. However, no
consideration was given to perfusion time
as a cause of mortality or morbidity and
patients were given extended periods of
pump support following the establishment
of a satisfactory rhythm.
Results

Of the 27 patients operated upon for

multiple valve disease at this clinic 20 are
still alive and in good condition, a total
mortality of 26 per cent. If one excludes
the first three patients, in 24 subsequent
consecutive cases there were four deathsa total mortality of 12 per cent.
Pertinent data concerning morbidity and
mortality is shown in Table 1. Patient 1
could not be resuscitated in the operating
room. While autopsy disclosed serious coronary artery disease there was also some
leak around the aortic prosthesis requiring
reopening of the aortotomy. Patient 2 was
about to be discharged from the hospital
three weeks after surgery when he suddenly developed coma, jaundice, and died
within 48 hours. Autopsy revealed acute
yellow atrophy of the liver. Patient 6 had
a technically perfect operation and was returned to the recovery room in good condition. During the second postoperative day
she complained of shortness of breath and
expired shortly after tracheostomy that
night. In retrospect the earlier use of artificial ventilation in this patient may have
changed the outcome. Patients 9 and 11 required vasopressor drugs in the operating
room and despite all supportive therapy including prophylactic tracheostomy and artificial ventilation expired on the third postoperative day of progressive low cardiac
output. Both patients were 52 years of age
and were in congestive failure at the time
of operation. Patient 22, a 54-year-old lady
with massive aortic regurgitation and
marked dilatation of the left ventricle, also

Annals of Surgery
STARR AND OTHERS
606
October 1964
died of progressive low output despite eight
Postperfusion Status
hours of left atrial to iliac artery bypass
Within a few hours after return to the
performed 36 hours following valve imroom most patients had easily
recovery
plantation. Patient 26, the second patient
warm extremperipheral
palpable
operated upon in this series, died of a ities, and excellent pulses,
this
Indeed,
color.
supraventricular tachycardia not respond- were not the case a careful searchif was
ing to all medical measures on the night of
for the cause. An intravenous drip
operation. She had been subject to these made
of
or noradrenalin was used
epinephrin
attacks frequently prior to operation.
hesitation
to buy time until blood
without
Noteworthy is that all of the deaths oc- volume deficits could
be corrected or digicurred in patients over 45 years of age and
regulated.
talis
dose
with one exception (Patient 6) the patient
Most of the patients had a variety of
was in functional Class IV. The seven padisturbances requiring constant atrhythm
tients in congestive failure at the time of
Nodal rhythm with atrial ventricutention.
operation accounted for four of the seven
was the most common arlar
dissociation
deaths.
occurring
in about half the parhythmia
Complications were common in the early
tients.
drip proved
Isuprel
by
intravenous
cases surviving multiple valve replacement.
most
of this
in
the
management
effective
Patient 3 required exploration for tamponbeats
ectopic
Frequent
ventricular
problem.
ade on the first postoperative day and durusually
disappeared
common
and
were
ing the first week had multiple attacks of
ventricular fibrillation. Reoperation for leak without definitive therapy. If not, small
around the mitral and tricuspid prostheses doses of Pronestyl, provided the blood pressure was normal, were of value in their
was successfully performed eight months
following implantation. Patient 4 required control. Some patients in sinus rhythm prereoperation for late cardiac tamponade on operatively developed atrial fibrillation.
the tenth postoperative day. She also de- This did not seriously alter their cardiac
status clinically and usually would revert
veloped febrile splenomegaly with abnor- to
sinus rhythm spontaneously or with a
mal lymphocytosis and fever.6 However,
little
help from Quinidine during the third
she was never in serious difficulty and left
week after operation. Heartblock
fourth
or
the hospital six weeks after operation in
in this group of patients.
did
not
occur
excellent condition. Patient 5 had transient
tracheostomy and artificial
Prophylactic
aphasia on the 14th postoperative day with
with
a volume cycled respirator
ventilation
good recovery of function. Patient 10 was
of the patients
in
three-fourths
was
used
slow in awakening and was suspected of
to
for
seven ten days after
having mild air embolism. He posed no and maintained
cardiac problems, however, and was dis- operation. The importance of this type of
There
charged four weeks after operation. Patient support cannot be overemphasized.
from
this
treatno
were
complications
12 developed sudden ventricular fibrillation
had
No
ment.
pneupostoperative
patients
on the eighth postoperative day and was
one case was bronchossuccessfully defibrillated. She recovered monia and in only
for
removal of bronchial
required
copy
completely and had an excellent result.
plugs.
This episode occurred while the patient
Serum hemoglobin measured immediately
was out of bed for mealtime. In subsequent
after bypass varied from 44 milligrams per
patients overexertion during this period
cent in Patient 13 to 560 mg. % in Patient
has been carefully avoided.
There were no late deaths in this series 1 who was given pump support for ten
hours. The mean value was 117 milligrams
and no infections.

Volume 160
Number 4

SURGERY FOR MULTIPLE VALVE DISEASE

607
_ -

FIG. 7. Pre- and postoperative chest films on

Patient 4.

per cent. Hemoglobinuria was common,

but urine output on the day of surgery was
at least 60 to 75 cc./hr. and this was used
as an index of the adequacy of cardiac output. Temporary decrease in urine flow
responded always to blood transfusion or
Digitalis or both except in the four patients
dying of the low cardiac output syndrome
in this series.
Many patients became slightly jaundiced
after surgery and all had elevation of the
serum transaminase. The height of the rise
in serum bilirubin correlated best with
evidence of hepatic dysfunction prior to
operation and with the duration of cardiopulmonary bypass. Except for one patient
dying of acute yellow atrophy jaundice
subsided in all patients and did not present
a significant clinical problem. The relative
role of prolonged anesthesia, prolonged
perfusion, hemolysis, and pre-existing liver
disease remains to be determined.

Perhaps most striking in the immediate

postperfusion period was the mental clarity
of all but one of the patients. This was
despite a mean pump time of three hours
and 19 minutes. Psychosis occurred later in
the postoperative period, usually after the
third postoperative day, and was always
followed by complete recovery prior to
discharge from the hospital.' This was a
common complication, occurring in more
than one-half the patients.
Late Results
Within a few months following operation
most surviving patients noted improvement
in their exercise tolerance. These over four
months postoperatively have had no cardiac
symptoms despite full activity and normal
diet. There have been a few exceptions.
Patient 24 has a small leak around the
aortic prosthesis and murmurs at the apex

608

STARR AND OTHERS

Annals of Surgery
October 1964

7.-...:U.'.
.

FIG. 8. Pre- and postoperative chest films on

Patient 3.

of residual mitral valve disease. The diastolic pressure is normal and the murmur
of aortic regurgitation is short so that a
decision for reoperation has not yet been
made. Her activities have been limited to
avoid increasing the leak until firm healing has taken place. The patient with triple
valve replacement is normally active without cardiac symptoms but remains on a
moderate low salt diet and Digitalis. He
continues to improve and an excellent result is anticipated. The chest x-ray in all
patients shows a decrease in pulmonary
congestion and if cardiomegaly was present
before operation, a decrease in heart size
(Fig. 7, 8). Phonocardiogram shows the
findings of combined aortic and mitral replacement with an ejection click of the
aortic prosthesis followed by a short systolic
ejection murmur (Fig. 9). The opening
snap of the mitral prosthesis occurs between 0.08 and 0.10 seconds after the
pulmonic closure. No diastolic murmurs are

present. The patient following triple replacement shows a split first sound with
tricuspid closure preceding the mitral closure. A double opening snap is present.
One patient (3) in this group developed
severe hemolytic anemia in the postoperative period requiring multiple transfusions,
and corticosteroid therapy. After many
months of such treatments steroids were
discontinued and hemoglobin and hematocrit were well maintained at normal levels.
The mechanism for hemolysis following
valve replacement is not clear but it has
occurred sporadically in patients following
isolated aortic valve replacement and responds to medical management as outlined.
Six patients are sufficiently remote from
surgery so that postoperative cardiac catheterization has been performed. A comparison of these findings with the preoperative
catheterization data is shown in Table 3.
Those patients with pulmonary hyperten-

V'olume 160
Number 4

SURGERY FOR MULTIPLE VALVE DISEASE

609

FIG. 9. MC-Mitral
closure; TC-Tricuspid
closure; EC-Aortic ejection click; MOS-Mitral
opening snap; TOS-Tricuspid opening snap.

sion prior to operation demonstrated

a fall
pulmonary artery pressure and in all
cases there was a profound fall in the mean
left atrial pressure. The end diastolic pressure in the left atrium following replacement was universally normal at rest despite
the fact that in most patients the smaller
sized mitral prostheses were used. Left
ventricular and brachial artery or aortic
pressures reveal no significant gradient
across the aortic prosthesis (Fig. 10). Cardiac outputs at rest fell into the normal
range for this laboratory and each patient
was able to increase his cardiac output with
exercise in a normal manner. These findings
are similar to postoperative studies performed after isolated valve replacement.2
in

AORTIC AND MITRAL VALVE REPLACEMENT

Pt. G.Y.

2 mitral valve,

8 aortic valve

10_

20

Simultaneous left ventricular and left atrial pressure

100 Simultaneous left ventricular and brachial artery pressure

Cardiac
Mean

output

diostolic

4.42 liters
mitral

(2.66 L/M2)

gradient

No systolic gradient

across

Co/cu/aofed

volve areo.....

mitral

FIGURE 10.

3mmHg

aortic volve

/. 6 cm,2

610

STARR AND OTHERS

Anticoagulant Therapy
All patients except the wife of an itinerant farm worker are receiving long-term
anticoagulant medication. This was initiated on the seventh postoperative day with
the use of heparin given deep subcutaneously every eight hours. During the second
or third postoperative week heparin is discontinued as long term oral anticoagulant

started.
Only one patient in this series had an
embolus and this occurred on the fourteenth
postoperative day while the patient was receiving heparin. There have been no late
emboli in this group of patients.
treatment is

Discussion
In many patients the need for surgical
exposure of both valves is obvious. In others
with severe aortic disease serious mitral
disease might be completely missed unless
careful hemodynamic studies are performed. In such cases mitral surgery must
be done at the time of aortic replacement
if the patient is to survive operation. A
more difficult problem in surgical judgement is posed by the patient with obvious
mitral disease associated with mild aortic
stenosis or regurgitation. In such cases the
aortic systolic gradient may be only 10 to
15 mm. Hg. If aortic regurgitation is present it may be associated with a normal
peripheral arterial pressure tracing. One
may be tempted to ignore the aortic disease in the hope that significant palliation
may be obtained by mitral surgery alone.
While occasionally successful, this limited
approach to multiple valve disease may be
dangerous. Aortic regurgitation interferes
with operative exposure during open mitral
surgery. Should the patient survive operation the late functional result may be poor.
It is our experience that even small degrees
of aortic regurgitation are poorly tolerated
by patients following mitral replacement.
It has been known for some time that mild
aortic stenosis may assume real significance
after mitral surgery. At the time of explora-

Annals of Surgery
October 1964

tion of such valves one may be surprised by

the far advanced pathology associated with
hemodynamically mild aortic stenosis. To
have any gradient at all across the aortic
valve there must be a critically small orifice.
Once this size orifice is reached small
changes in anatomy may be reflected in
very large changes in pressure studies. The
only late death in our series of isolated
mitral valve replacements occurred in a patient who died suddenly with aortic stenosis
one year after operation. At the time of
surgery there was no significant gradient
across the aortic valve but aortic stenosis
was noted on the angiocardiogram. Thus to
achieve a good long term result careful consideration must be given to the anatomic
deformity of the aortic lesion as well as to
the hemodynamic deficit it imposes upon
the circulation (Fig. 11). In general it is
best to be prepared to expose both the
aortic and mitral valves in patients with
multivalvular disease and to replace these
valves if necessary.
The decision for replacement versus repair is based upon the same principles as
in isolated valve disease. Replacement is
performed when it is apparent, uisually immediately after exposure of the valve, that
long term function cannot be restored by a
reparative procedure. The emphasis is
placed upon a projection of anticipated
late results and not upon considerations of
other features such as operating time or
short term improvement. The late results
of isolated valve replacement remains sufficiently good so that in marginal situations
when one cannot be sure of the late results
of reparative surgery replacement is done.
In most cases the decision is easy to make.
Of 57 valves operated upon in this series,
47, or 82 per cent, were replaced.
Summary
Multiple valve surgery has been performed on 27 patients, 16 of whom have had
aortic and mitral replacement. Two had
triple replacement and nine had combined
replacement and repair.

V'olume 160
Number 4

SURGERY FOR MULTIPLE VALVE DISEASE

611

FIG. 11. Preoperative

supravalvular angiocardiogram and postoperative

chest film of Patient 8
demonstrating incomplete
opening of aortic valve
and aortic regurgitation
of mild degree. This patient had no gradient
across the aortic valve
prior to operation but at
surgery had significant
aortic stenosis associated
with severe valvular deformity and aortic re-

gtirgitation.

The replacement procedures were performed with the ball valve prostheses as
designed for isolated replacement except
that the smaller sizes are more frequently
used. Essential features of operative technic are: 1) sternal-splitting incision; 2) replacement of the mitral valve before the
aortic valve; and 3) myocardial protection
during aortic cross-clamping by intermittent
coronary perfusion with ice cold blood.
The over-all mortality in this series consisting of our total experience with multiple
valve surgery is 26 per cent. Twelve of the
16 patients undergoing mitral and aortic
replacement survived operation and one patient undergoing triple replacement has had
a dramatic restoration in normal activity.
Seven of the nine patients undergoing com-

bined replacement and repair survived operation. The first three patients operated
upon account for three deaths in this series,
and 24 subsequent patients were operated
upon with four deaths, a mortality of 12
per cent. The last seven consecutive patients with double replacement survived
operation and are doing well. The late
hemodynamic results in those patients sufficiently remote from surgery to have such
studies have been presented and document
the remarkable improvement obtained clinically.
Thus with increasing experience the risk
of surgery for multiple valve disease has
approached that of surgery for isolated
valve disease and patients are selected for
surgery on

the

same

basis.

STARR612AND OTHERS

612

Addendum
Since submission of this paper 13 additional patients have undergone surgery for
multiple valve disease including three triple
replacements, eight combined mitral and
aortic replacements, one aortic replacement
with open mitral commissurotomy, and one
mitral replacement with aortic commissurotomy, with no deaths. Thus, in the multiple replacement group there has been no
mortality in the last 18 patients. More
lengthy follow up on previously reported
cases has revealed no late death or significant complications in our entire series.
Acknowledgment
The authors are indebted to the engineering department of Edwards Laboratories,
Santa Ana, California, for their collaboration in valve design and testing.
References
1. Blachly, P. H.: Post-Cardiotomy Delirium.
Am. J. Psychiatry. To be published in 1964.
2. Bristow, J. D., C. McCord, A. Starr, L. Ritzman and H. E. Griswold: Clinical and Hemodynamic Results of Aortic Valve Replacement with a Ball Valve Prosthesis. Supplement to Circulation, April, 1964.
3. McCord, C., A. Lui, M. L. Edwards and A.
Starr: Aortic Valve Replacement: The Semirigid Self-Sealing Ball Valve Prosthesis. Sur-

DISCUSSION

DR. JOHN W. KIRKLIN (Rochester, Minnesota):

We are indebted to Dr. Starr for his usual magnificent presentation and for his truly pioneering
contributions to the surgery of acquired heart disease.
I would like to emphasize merely one point in
the surgical management of patients with severe
aortic valve disease who appear to have moderate
incompetence of the mitral valve but who may not
require any operative procedure on the mitral
valve. Preoperatively these patients are those who
have symptoms of pulmonary venous hypertension. That is, they have dyspnea and orthopnea,
and have full-blown evidence of severe disease of
the aortic valve and clinical evidence of apparent
moderate incompetence of the mitral valve in the
form of some modest enlargement of the left
atrium; an apical systolic murmur and on angiocardiography the passage of some dye from the
left ventricle to the left atrium. If one measures

Annals of Surgery

~~~~~~~~~~~~~~~~~~~

gical Forum, American College of Surgeons,

13:213, 1962.
4. McCord, C. W. and A. Starr: Treatment of
Mitral Insufficiency by Reparative and Replacement Methods. Trans. XIV Congress of
the International College of Surgeons, May
1964, pp. 177-186.
5. Porter, G., D. W. Sutherland, C. McCord, A.
Starr and H. E. Griswold: The Prevention of
Excess Hemolysis During Cardiopulmonary
Bypass by the Use of Mannitol. Circulation,
27:824, 1963.
6. Seaman, A. J. and A. Starr: Febrile Postcardiotomy Lymphocytic Splenomegaly: A New
Entity. Ann. Surg., 156:956, 1962.
7. Starr, A., M. Edwards and H. E. Griswold:
Mitral Replacement: Late Results with a
Ball Valve Prosthesis. Progress in Cardiovascular Diseases, 5:298, 1962.
8. Starr, A.: Total Mitral Valve Replacement:
Fixation and Thrombosis. Surgical Forum,
11:258, 1960.
9. Starr, A. and M. L. Edwards: Mitral Replacement: The Shielded Ball Valve Prosthesis. J.
Thorac. Cardiovasc. Surg., 42:673, 1961.
10. Starr, A., M. L. Edwards, C. McCord and H.
E. Griswold: Aortic Replacement: Experience with a Semirigid Ball Valve Prosthesis.
Circulation, 27:779, 1963.
11. Starr, A., M. L. Edwards, C. W. McCord, J.
Wood, R. Herr and H. E. Griswold: Multiple
Valve Replacement. Circulation, 29:30, 1964.
Supplement, April.
12. Starr, A. and M. L. Edwards: Mitral Replacement: Clinical Experience with a Ball Valve
Prosthesis. Ann. Surg., 154:726, 1961.

left atrial pressure at surgery in such patients it

may be found to be severely elevated and with a
markedly accentuated V-wave. It is well to bear
in mind, however, that these patients with severe
aortic valve disease can have markedly elevated
left atrial pressures and very high V-waves without any incompetence of the mitral valve at all.
We have had the experience in the last few
years of leaving alone the mitral valve in some of
these patients with severe aortic valve disease and
a mitral valve which has by palpation no intrinsic
disease but is modestly incompetent and postrepair
and postoperatively have had evidences of this
incompetence completely disappearing. There is
no apical systolic murmur, and the long-term and
result is good. So, merely a word of caution about
those patients with obviously severe aortic valve
disease and evidence of only moderate incompetence of the mitral valve.
This does not detract, certainly, from Dr.
Starr's results, which are excellent. I would quote
our own material to support his view that patients