The Howard Gilman Foundation Lecture. Where have we come from and where are we going? Valve management past, present and future

Abstract

Leonardo da Vinci's anatomical drawings of quadricuspid, tricuspid, and bicuspid aortic valves underscored the hydraulic superiority of a three leaflet valve with cuspal equality. William Harvey demonstrated that venous valves were designed for unidirectional flow and to prevent reflux from the heart, observations that served as the basis of his immortal de Mortu Cordis. Joseph Rouanet of Paris proposed that heart sounds originated from the closing movements of cardiac valves. The Cardiodynamics of Mitral Insufficiency by Wiggers and Feil was followed three decades later by Paul Wood's An Appreciation of Mitral Stenosis. The Bland/Sweet operation indirectly addressed mitral stenosis by means of a venous shunt. Sir Henry Souttar's early digital repair of mitral stenosis was later reintroduced independently by Harken and Bailey; Doyen, Sellers, and Brock employed surgical valvotomy for pulmonary stenosis, and Bailey employed surgical valvotomy for aortic stenosis. Management of abnormal cardiac valves includes repair (reconstruction), replacement with mechanical or biologic prostheses, and interventional catheterization. The first mechanical valve was inserted extracardiac by Hufnagel into the descending thoracic aorta of patients with severe aortic regurgitation. The Starr caged ball mechanical prosthesis was designed for intracardiac replacement of an abnormal cardiac valve. The peripheral flow ball valve was followed by hydraulically superior and less thrombogenic central flow monoleaflet or bileaflet mechanical valves, and by homograft and heterograft bioprosthetic valves. Improved methods of preparing exogenous bioprostheses and innovative techniques of aortic valve reconstruction are evolving. Cardiac catheterization as a therapeutic intervention is routinely applied to stenotic mitral, aortic and pulmonary valves, and transcatheter replacement of an abnormal pulmonary valve is now a reality.