Valvular heart disease.

Era Before 1950 In 1950, rheumatic valvular heart disease (VHD) was the most common cause of VHD. The link between streptococcal infection and rheumatic fever was established, and a successful trial of penicillin prophylaxis against rheumatic fever was reported.1 In 1944, Jones published a seminal article on diagnosis of rheumatic fever.2 The American Heart Association (AHA) and Circulation played an important role in communicating the importance of (1) penicillin prophylaxis, which resulted in a dramatic reduction of rheumatic fever and rheumatic VHD, and (2) diagnosis of rheumatic fever, by revising the Jones criteria in 1956, 1965, 1984, and most recently in 1992.3 It was well recognized that the mitral valve was the valve most commonly affected in rheumatic heart disease. As a consequence, closed-chest mitral commissurotomy for mitral stenosis (MS) was the most common early and successful cardiac surgical intervention. 1950 was the first year of Circulation, and one of the articles published that year described the surgical experience in 8 patients.4 The etiology of mitral regurgitation (MR) in 1950 was rheumatic carditis; mitral valve prolapse (MVP) was not even recognized. As late as 1958, the following quote reflects the lack of recognition of MVP: “midand late systolic clicks are commonly produced by the tensing of pleuropericardial adhesions”; thus, MVP was considered to be of extracardiac origin.5 Circulation in 1950 had a smaller number of articles regarding VHD than one might expect. Some of the articles are of interest: (1) There were several articles on subacute bacterial endocarditis. One of these included the Lewis Conner Lecture by Bloomfield, “The Present Status of Treatment of SBE.”6 (2) Levinson et al7 discussed the “Increasing Bacterial Resistance to the Antibiotics . . . ,” a recurring theme in today’s literature.7 (3) The absence of noninvasive diagnostic imaging and hemodynamic assessment of VHD is striking. Also, the limitations in surgical therapy of congenital VHD before the development of openheart surgery are obvious. An example of these 1950 realities is provided by Engle and Taussig’s article,8 which includes the early use of cardiac catheterization and angiocardiography to differentiate between tetralogy of Fallot and valvular pulmonary stenosis in other settings. This represented a critical distinction in those days before open-heart surgery. The former was treated with a Blalock-Taussig anastomosis, and the latter was treated with closed pulmonary valvotomy. (4) There were several articles on cardiac catheterization and other efforts to enhance diagnosis of VHD. These included one of the first articles on left heart catheterization via the retrograde crossing of the aortic valve.9 (5) There was a study of the electrokymograph in analysis of aortic and pulmonary valve regurgitation. A common cause of isolated severe aortic regurgitation (AR) in 1950 was tertiary syphilis.10 In summary, the state of knowledge in 1950 included (1) detailed and remarkably accurate bedside clinical descriptions and increasing understanding of the natural history of VHD; (2) an understanding of the pathogenesis of rheumatic fever, its diagnosis, and effective prophylaxis of rheumatic heart disease; and (3) recognition of the need to improve diagnostic precision in anticipation of the future development of open-heart surgery. In fact, it is the successful implementation of open-heart surgery that forced improvements and refinements in all aspects of cardiovascular medicine and surgery.