CUFF-RING DILATOR FOR MITRAL COMMISSUROTOMY
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Commissurotomy for mitral stenosis is generally thought to be one of the simplest, easiest, and most widely performed procedures in cardiac surgery. There are, however, some cases of mitral stenosis in which there is shrinkage of the auricular appendage or intraauricular thrombi. These cases make a surgeon's digital insertion through the auricle difficult. There are also other cases of mitral stenosis that, despite the easy digital insertion via the auricle, have severe pathological changes of the stenotic valve. Some are so involved at both commissures, that they prevent us from performing a complete or satisfactory commissurotomy. Thus, the procedure has inadequate results. The cases where digital manipulation alone gives us an adequate opening of the stenotic valve are few. In the conventional procedure of so-called "finger fracture valvuloplasty", the opening is usually obtained only up to the size in which the index finger is easily permitted. In these cases, only the anterolateral commissure is usually fractured and the subsequent opening is about 2 cm. in its diameter.The pathological nature of the stenotic valve, particularly at both commissures, is not always consistent with the severity of the clinical manifestations or the severity of the stenosis.The future prognosis of the valvuloplasty depends upon various factors. This is, however, influenced mostly by the size of the opening following the commissurotomy.As supplementary measures to the finger fracture method, many surgeons, throughout the world, have devised a large variety of knives and valvular dilators for the purpose of opening the stenotic mitral valve. None achieved in making the ideal device.Generally speaking, valvulotomy with a sharp knife is not without the danger of incising or damaging the valvular cusps, for this is a closed technique. In comparison, the regular valvular dilators are safer, for those are not sharp and are forcibly, but evenly, applied against the stenotic valvular opening. The weakest points, which are at both commissures, therefore, are more safely torn.Most valve dilators have been metal instruments until 1953 when C. S. Beck successfully originated a new device and maneuver. He wrapped a length of wet cotton tape around the distal phalanx of his finger, and covered this "dilaror" with a second glove; re-introducing the finger into the auricle, he passed it forcibly through the mitral orifice. The valvular orifice was adequately opened to the valvular annulus at both commissures and no regurgitation was produced. In 1953 and 1954, he employed this technique and procedure in about 200 cases of mitral stenosis with satisfactory results. Recently Péretz-Alvarez reported that he successfully applied this procedure in 78 cases of mitral stenosis. He also reduced the use of sharp valvulotomes in his series. The author has also employed Beck's procedure in over 20 cases with good results.The procedure is simple and good. It is true, however, that this, too, has some technical limitations. For instance, in cases with a very small auricle or old clots in the auricle, the finger alone can be passed but not the finger which is wrapped with tape. At times, there are such occasions that several separate digital dilatatory manipulations are required. Each time the finger must be removed from the auricle and more cotton tape wrapped around the finger tip before re-insertion . It would be desirable to eliminate the difficulties of increased seperate finger manipulations and the skillful selection of the appropriate size of taped finger for each occasion by the new invention of devices.The author has devised a new method to avoid such technical difficulties as mentioned above.
- 久留米大学医学部 The Kurume Medical Journal 編集部の論文
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