Origins of Aortic Valve Reconstruction “From Tuffier to Ross”

The first documented surgery for acquired heart disease was in 1896. A stab wound of the heart was successfully repaired by Rehn [1,2]. On July 13, 1912 Tuffier preformed the first aortic commissurotomy in a 26 year old patient with progressive aortic stenosis [3]. Tuffier had reported six experimental aortic and pulmonary valvulotomies prior to this. His first human commissurotomy was done without opening the ascending aorta. He dilated the aortic valve digitally by indenting the wall of the ascending aorta. The patient went home twelve days after surgery and was still alive 12 years later [4]. In 1923, Cutler and Levine attempted to perform mitral valvulotomy for mitral stenosis [5]. They believed that resection of part of the stenotic valve was a necessary part of the procedure. Although the first patient survived, the next several died from mitral insufficiency. The procedure was abandoned for some years in the U.S. In England, in 1925, Henry Souttar performed a digital commissurotomy on one patient and although the patient survived, no further patients were referred to him for this unusual surgical intervention. The field of cardiac surgery was quiescent for over 20 years [6]. Russell Brock on March 27, 1946, passed a cardioscope through the innominate artery and visualized the calcified aortic valve [7]. In this initial case he did not attempt a valvulotomy. He later abandoned the retrograde approach to the aortic valve due to poor outcomes. Charles Bailey and Dwight Harken independently worked at reviving the concept of digital commissurotomy for mitral stenosis. Charles Bailey performed the first successful closed mitral valvulotomy June 10, 1948 and this was followed six days later by Harken’s successful commissurotomy [8,9]. This ushered in an era of mitral valve surgery that spread throughout the world. However, due to the limited extent of relief of mitral stenosis achieved by digital commissurotomy, in 1959 a mitral valve dilator was developed in England by Tubbs, Logan and Turner [7]. This permitted a more extensive commissurotomy, but was sometimes attended by postoperative mitral insufficiency. On June 22, 1950, Charles Bailey performed a transventricular dilatation of aortic stenosis and over the next two years repeated this procedure eleven times [7]. Although he had a 33% mortality rate, some of the survivors were greatly improved. Because of the limitation in the relief of aortic stenosis using this technique, he turned to an expandable triradiate instrument which produced better and more predictable results. In 1954, William Muller described his experiences with the treatment of aortic valve stenosis in 16 patients who had aortic valve stenosis only, and an additional 9 patients who had either aortic and mitral valve disease or aortic stenosis and coarctation of the aorta [10]. There were four deaths in the aortic valve only group, and two deaths in the nine patients with dual deformities. By 1952, Brock was dilating the aortic valve with an instrument passed through the left ventricle [7]. Gibbons first use of the heart lung machine in 1953 paved the way for an explosion of cardiac surgical procedures [4]. In November of 1955, Henry Swann performed an open aortic commissurotomy through an aortic incision using hypothermia [7]. Five years later he reported in the British Medical Journal the outcomes of his series of patients undergoing aortic commissurotomy using hypothermia. Early in the series, in cases of severe aortic stenosis, there was a mortality between 25 and 50%. However, the overall mortality was about 5% with 75% of the survivors having a good result. In 1958, Dwight Harken documented his outcomes in 100 patients who had closed transaortic digital dilatation of the calcified aortic valves [11]. He used an Ivalon sponge tunnel or graft attached to the ascending aorta. Through this his finger was placed into the ascending aorta to do the valvular dilatation. There were 16 deaths in these 100 patients. There were 7 deaths in the first 20 patients, and only 5 deaths in the last 60 patients [11]. On January 31, 1956, Walton Lillehei used the heart lung machine with a bubble oxygenator. Lillehei opened the commissures to the annulus with stout dissecting scissors, and he trimmed off some of the calcium deposits helping to restore mobility to the leaflets [12]. The patient made a uneventful recovery.