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May 26, 2017
Pre CPB Elliott Carr Cutler

Elliott Carr Cutler (1888-1947) &
Samuel Albert Levine (1891-1996)

Cardiotomy and valvulotomy for mitral stenosis. Experimental observations and clinical notes concerning an operated case with recovery. Boston Med. Surg J., 1923, 188, 1023-27.

Cutler EC, Levine SA, Beck CS. The surgical treatment of mitral stenosis: Experimental and clinical studies. Archives Surg, 1924, 1 -131

Elliott Carr Cutler
Portrait of Elliott Carr Cutler
Portrait of Elliott Carr Cutler


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

 

Elliot Cutler, an American surgeon, and Samuel Levine, an American cardiologist, had a great interest in the surgical management of mitral stenosis. After more than two years of laboratory experimentation, Cutler and Levine published the first successful report of surgical treatment of mitral stenosis in an article entitled, "Cardiotomy and valvulotomy for mitral stenosis. Experimental observations and clinical notes concerning an operated case with recovery,"  in 1923. 

The patient was a twelve-year old girl with "the chief complains of dyspnea and bloody sputum" and hospitalized for more than 6 months prior to surgery. Following a detailed account of the case , they remarked " In general, the picture presented was one of mitral stenosis in a child who had no cardiac reserve."

Cutler and Levine performed the procedure through a median sternotomy using a ventricular approach  on May 20, 1923 at Peter Bent Brigham Hospital . In their article, they wrote:

"rolling the heart out and to the right by the left hand, the valvulotome, an instrument somewhat similar to a tenotome or a slightly curved tonsil knife, and the one with which we were most familiar in our experimental work, was taken in the right hand and plunged into the left ventricle at a point about one inch from the apex and away from the branches of the descended coronary artery, where two mattress sutures had already been placed. The knife was pushed upwards about 2 1/2 inches, until it encountered what seemed to us must be the mitral orifice. It was then turned mesially, and a cut made in what we thought was the aortic leaflet, the resistance encountered being very considerable.  The knife was quickly turned and a cut made in the opposite side of the opening. The knife was then withdrawn and the mattress sutures already in place were tied over the point at which the knife had been inserted. There was absolutely no bleeding."

The procedure was performed successfully and the patient did well. The article was concluded with the following statement:

"...The experience with this case, however, is of importance in that it does show that surgical intervention in cases of mitral stenosis bears no special risk, and should give us further courage and support in our desire to attempt to alleviate a chronic condition, for which there is now not only no treatment, but one which carries a terrible prognosis. Unquestionable further attempts will be made."

This patient lived for more than 4 years and died from congestive heart failure and pneumonia.

Following this initial successful report, Cutler and Levine continued their investigation and reported a detailed description of their experimental and clinical experiences in four cases in an article published in 1924. This landmark article, of historical significance, is viewed as the most comprehensive publication on these authors' work.

Cesalpino Andrea
Copyright 2011 From the collection of Farzan Filsoufi, M.D.

 

Cutler and Levine used the knife-valvulotome (tenotome) in the first three cases. In the fourth case, they used the cardiovalvulotome which was designed to excise a portion of the mitral valve (partial valvulectomy).

Cesalpino Andrea
Copyright 2011 From the collection of Farzan Filsoufi, M.D.


Cesalpino Andrea
Copyright 2011 From the collection of Farzan Filsoufi, M.D.
Cesalpino Andrea
Copyright 2011 From the collection of Farzan Filsoufi, M.D.

 They believed that surgical treatment of mitral stenosis by inducing some degrees of mitral incompetence would be well-tolerated. Except for the first successful case which was mentioned in their 1923 article, the three other patients died within one week following the surgical procedure. A cardiac autopsy was performed in all three cases as shown below.

The three major problems of surgical approach and exposure, difficulty to orient precisely surgical instruments within the ventricle, and the assumption that induced mitral regurgitation would be well-tolerated, were at the origin of their failure.

Case 2

Cesalpino Andrea
Copyright 2011 From the collection of Farzan Filsoufi, M.D.

Case 3

Cesalpino Andrea
Copyright 2011 From the collection of Farzan Filsoufi, M.D.

 

Case 4

Cesalpino Andrea
Copyright 2011 From the collection of Farzan Filsoufi, M.D.

The authors concluded their article by the statement "We feel that the proposal that certain cases of mitral stenosis may be relieved by surgery has not been contradicted by our experiences, and we hope that similar opportunities in other cases will prove that the proposition is well founded and desirable."

The closing comments of the authors are reproduced here.

Cesalpino Andrea
Copyright 2011 From the collection of Farzan Filsoufi, M.D.


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