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June 27, 2017
Pre CPB Dwight Emary Harken

Dwight Emary Harken (1910-1993)

The surgical treatment of mitral stenosis. 1. Valvuloplasty. New Engl. J. Med., 1948, 239, 801-09.

Dwight Emary Harken
Portrait of Dwight Emary Harken
Portrait of Dwight Emary Harken


Cesalpino Andrea
Reproduced with the permission of the publisher
  Cesalpino Andrea
Copyright 2011 From the collection of Farzan Filsoufi, M.D.

Dwight Emery Harken performed more than 140 cardiovascular procedures during World War II on the battlefield. They consisted of the removal of foreign bodies from the heart and great vessels including 17 from the cardiac chambers themselves. All these procedures were performed successfully without any mortality. This remarkable achievement allowed Harken to gain extensive cardiothoracic surgical experience.

After World War II and his return to Boston, Harken focused on the surgical treatment of mitral stenosis and studied the work of Cutler and Souttar.  Prior to proceeding with clinical experience, he was able to define some basic principles. Harken favored the atrial approach to the ventricular incision. He also believed that patients with associated mitral regurgitation were not appropriate candidate for surgical intervention. Finally, he attempted to define appropriate criteria for patient selection to validate his new surgical procedure. They included the absence of active rheumatic carditis or bacterial endocarditis, the presence of severe cardiorespiratory symptoms due to mitral stenosis. Harken also excluded patients with the involvement of other cardiac valves.

On June 1948, Harken performed his first successful direct transatrial mitral valvuloplasty using a cardiovalvulotome (see figure). Regarding the operative procedure, He wrote:

"The cardiovalvulotome was introduced [through the left atrial appendage] with the cutting edge directed at the lateral commissure, the valvulotome hook engaged, and the instrument closed.  The cutting sensation and sound were elicited, but the segment was not recovered. The maneuver was repeated with the instrument directed at the medial commissure.  Finally, a segment of the stenotic funnel was removed in a third maneuver directed at the posterior aspect of the lateral commissure."

Cesalpino Andrea
Reproduced with the permission of the publisher
  Cesalpino Andrea
Reproduced with the permission of the publisher
 

Following the completion of the procedure, the atrial pressure dropped significantly. The postoperative course was uneventful and the patient's clinical symptoms significantly improved. The patient was alive five months after the procedure.

In the conclusion of his work, Harken remarked four principles of surgery of mitral stenosis:

"1) The operation should be performed without dislocation of the heart from the position of optimum function.
2)  The button-hole opening of the stenotic mitral valve should be approached from the auricular side so that the
      funnel directs the cutting instruments to the leaflet margin.
3)  Surgical enlargement of the stenotic orifice should be so planned that there is minimal burden from the
      associated regurgitation (selective insufficiency) and maximum restoration of valvular function (valvuloplasty).
4)  In the presence of mitral obstruction or regurgitation a rapid heart rate must be avoided; tachycardia tends to
      increase pulmonary vascular pressure and is associated with attacks of pulmonary edema or "pulmonary
      decompensation."

The term valvuloplasty was coined by Harken and first used in this article. Later, Harken stated "The importance of a new word (valvuloplasty or Bailey's commissurotomy) was to indicate the restoration of valve function rather than trading mitral stenosis for regurgitation."

This successful procedure inaugurated the second phase of surgical treatment of mitral stenosis. Harken and his team performed the procedure of mitral valvuloplasty on several thousand patients over the years. Overtime, Harken abandoned the cardiovalvulotome and used a valvulotome as a  dilator and finally applied the technique of  digital dilatation or so-calld finger-fracture valvuloplasty.

Cesalpino Andrea


REFERENCES

Harken DE. The emergence of cardiac surgery. I. Personal recollections of the 1940's and 1950's. J Thorac Cardiovasc Surg 1989;98:805-13

Ellis LB, Harken DE. Closed valvuloplasty for mitral stenosis-a twelve year study of 1571 patients. New Eng J Med 1964;270:643

Harken DE. Heart surgery-legend and a long look. Am J Card 1967;19:393-400


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Sir Henry Sessions Souttar Charles Philamore Bailey


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