Henry Souttar, of England, performed the first successful surgical relief of mitral stenosis using digital dilatation and an atrial approach via the left atrial appendage on May 6, 1925. The patient was a 19 year-old female with severe symptomatic mitral stenosis including dyspnea, cyanosis, and hemoptysis.
The procedure was accomplished with the use of intratracheal anesthesia and a left chest incision which allowed excellent exposure of the left atrial appendage.
After the clampage of the base of the left atrial appendage, an incision was made with scissors and a finger was inserted. Souttar remarked:
"The whole of the inside of the left auricle could now be explored with facility. It was immediately evident from the rush of blood against the finger that gross regurgitation was taking place, but there was not so much thickening of the valves as had been expected. The finger was passed into the ventricle through the orifice of the mitral without encountering resistance, and the cusps of the valve could be easily felt and their condition estimated.
The finger was kept in the auricle for perhaps two minutes, and during that time, so long as it remained in the auricle, it appeared to produce no effect upon the heart beat or the pulse. The moment, however, that it passed into the orifice of the mitral valve the blood pressure fell to zero, although even then no change in the cardiac rhythm could be detected. The blood stream was simply cut off by the finger, which presumably just fitted the stenosed orifice. As, however, the stenosis was of such moderate degree, and was accompanied by so little thickening of the valves, it was decided not to carry out the valve section which had been arranged , but to limit intervention to such dilatation as could be carried out by the finger. It was felt that an actual section of the valve might only make matters worse by increasing the degree of regurgitation, while the breaking down of adhesions by the finger might improve the condition as regards both regurgitation and stenosis. It was now decided to withdraw the finger and close the appendage."
The patient did well postoperatively and was discharged.
In his follow up notes, Souttar wrote "...at the end of three months she declared that she felt perfectly well, although she still became somewhat breathless on exertion." The existence of concomitant mitral regurgitation was the likely explanation for the persistence of symptoms in this young patient.
Souttar concluded his article as follows:
"It appears to me that the method of digital exploration through the auricular appendage cannot be surpassed for simplicity and directness. Not only is the mitral orifice directly to hand, but the aortic valve itself is almost certainly within reach, through the mitral orifice. Owing to the simplicity of the structures, and, oddly enough, to their constant and regular movement, the information given by the finger is exceedingly clear, and personally I felt an appreciation of the mechanical reality of stenosis and regurgitation which I never before possessed. To hear a murmur is a very different matter from feeling the blood itself pouring back over one's finger. I could not help being impressed by the mechanical nature of these lesions and by the practicability of their surgical relief."
Surprisingly although the case was successful and the patient did well, Souttar did not get any further referral from his cardiologists.
Souttar's historical article is reproduced here.
In 1929, The Brigham group reviewed the entire experience with the surgical treatment of mitral stenosis. Out of ten patients, their first patient and the one operated by Souttar had only survived surgery. These disappointing results led to the end of the first era of valvular heart surgery. These early steps, however, had a major impact on the future of cardiac surgery.
Cutler EC, Beck CS. The present status of the surgical procedures in chronic valvular disease of the heart. Arch Surg 1929;18:403-416