THE SURGICAL TREATMENT OF PULMONARY STENOSIS

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Abstract
Experiences are presented in the treatment of 198 patients with pulmonary valve stenosis. A brief survey is made of the incidence of the condition, morbid anatomy, clinical significance, and indications for operation. The significance of cyanosis is discussed of the 198 patients 74 were cyanosed, 124 were not. The proportion with cyanosis is less than it was initially. In general, it indicates a more severe lesion. The need for closure of the atrial communication is discussed: although not essential in most cases, closure is certainly preferable. Closed pulmonary valvotomy is presented and it is shown that the results have been very satisfactory. However, the general principle of the superiority of open heart surgery applies in this condition, and the closed operation should be displaced by the open procedure except possibly in very poor risk cases, and more particularly in severely cyanosed infants. There were 8 deaths in 107 cases. Open valvotomy is discussed and it is pointed out that most cases can be operated on more simply and more efficiently under hypothermia than under total heart-lung by-pass, except when the case is complicated or in the presence of cyanosis. There were 5 deaths in 84 cases. The problem of persistent high right ventricular pressure after valvotomy is presented and discussed. This is one of the complex and difficult problems of operation for pulmonary stenosis. In most cases it is due to secondary hypertrophic infundibular stenosis. Occasionally the infundibular stenosis is fibrous and the congenital, and sometimes a functional stenosis may undergo permanent fibrous changes. We do not know yet what is the best management for these cases. The suggestion that routine infundibular resection should be done is not acceptable on the available evidence. Indeed evidence is put forward that this may carry an undesirably high mortality. Certainly in most cases spontaneous regression of muscular hypertrophy occurs over 1-2 years with spontaneous reversion of the high right ventricular pressure. Spontaneous reversion of pressure occurred in 36 out of 46 patients. Several of the 10 in whom the pressure is still variably raised may require secondary infundibular resection, but not all of them. It is necessary, if this problem is to be satisfactorily settled, that other surgeons should present a careful analysis of their cases and refrain from dogmatizing until this is done. Pure infundibular stenosis, a much rarer condition than valvar stenosis, is briefly discussed. Open operation under total body perfusion is obligatory. It is not possible to understand that natural history and problems of pulmonary stenosis if only the valve stenosis is considered. Of great importance is the myocardial factor. This becomes increasingly important with the severity of the stenosis and the duration of the disease. Permanent myocardial damage may exist even in the young, and is usual after the late teens. Even after a complete relief of valve stenosis the prognosis can be adversely affected by these myocardial changes. The significance of the myocardial factors underlines the need for early operation in almost all cases.