The management of aortic stenosis has dramatically changed over the last 60 years. We briefly describe these remarkable advances from the personal perspective of Anthony P C Bacon (APCB) who was one of the first physicians to observe the importance of this pathological process and who watched, first-hand, some of the first surgical aortic valve procedures being performed in the UK. He most recently benefited from treatment with transcatheter aortic valve implantation (TAVI) himself, and provides a personal perspective of his experiences.
Introduction
It may be invidious to write about oneself and one’s own disorders, but perhaps exception can be made when there is a gap of 60 years between writing about a condition and reporting one’s own case of it at the age of 94. In my case (APCB), the prospect of a general anaesthetic accompanied recurrent cholecystitis and dyspnoea, so I dusted off my stethoscope and on listening to my heart, I was somewhat taken aback to find that I had developed aortic stenosis.
Early career
Having qualified in 1947, and following 18 months in the Royal Army Medical Corps (RAMC) in Germany in 1948–9, I began work again in the 1950s at the London Chest Hospital and the Brompton. I remember watching Sir Thomas Holmes-Sellors, president of the Royal College of Surgeons, being guided through ground-breaking mitral valve procedures by his younger assistant Jack Belcher. Later at St. Thomas’s Hospital, I observed Norman ‘Pasty’ Barrett, performing mitral valvotomies with a blade attached to the fingertip.
Meanwhile in May 1954, the first mechanical valves were being used to treat aortic insufficiency across the pond by C A Hufnagel in Georgetown, United States. Open thoracotomy was performed under general anaesthesia and refrigeration, and a primitive valve, which consisted of a ball within a plastic bag, was inserted distal to the subclavian artery, enabling the preservation of 75% of the cardiac outflow.1 Ironically, surgeons noted that clamping the aorta for over half an hour was excessively dangerous, while only 100 or so miles away in Philadelphia, a primitive heart-lung bypass machine, was being piloted.2
In 1959, my senior colleague Mike Matthews and I reported the largest series to date of cases of aortic stenosis, some of which had developed in association with various congenital defects.3 We found evidence that aortic stenosis was caused by a calcific degenerative process that occurred in old age, and not as a result of post-rheumatic disease, as had been previously vigorously debated.4
Medical advances
Having subsequently worked as a consultant general physician since 1960, I saw 25 years of medical advances in cardiology, and introduced cardioversion and pacing to the region. Advancements in valve surgery blossomed over this time, the first mitral valve replacements being performed in the 1950s, pioneered by Dr Albert Starr and electrical engineer Lowell Edwards.5 The first aortic homograft was inserted in 1962 by Donald Ross at Guy’s Hospital, and he also began his pioneering work on the Ross procedure, which is still used today.
Since my retirement 33 years ago, there have been further remarkable developments in the field. Following the first successful transcatheter aortic valve implantation (TAVI) in 2002,6 the technology and expertise in this field have made significant advances over a short period, initially in high-risk surgical candidates, to now being explored in younger, lower-risk individuals.6
My own experience
During my career as a physician, the burden of a diagnosis with aortic stenosis was greatly different from what it is today. Indeed, aortic stenosis was an uncommon diagnosis, save at post-mortem, owing to the late hour at which it presented itself. As illustrated by Ross and Braunwald,7 before the advent of aortic valve replacement, the prognosis of aortic stenosis was poor, and so my feeling of alarm upon making the discovery of my own typical crescendo–decrescendo murmur was rightly justified.
Thus, in the autumn of 2018, I underwent extensive investigation confirming severe aortic stenosis with a peak gradient across the aortic valve of 80 mmHg and area of 0.5 cm2. TAVI was performed uneventfully under local anaesthetic via the right femoral artery in less than an hour, and I was well enough to be discharged 48 hours later to the care of my medical family, lost in admiration for the doctors who treated me and the smoothness of the procedure. I envisage that in physicians’ hands the future of the treatment of aortic stenosis is bright. All has been well since and I have been relieved of my dangerous aortic valve, aged 94, and 60 years after my interest in the condition of aortic stenosis developed.
Key messages
- The management of severe symptomatic aortic stenosis has dramatically changed over the last 60 years and, without intervention, is associated with a poor prognosis
- Transcatheter aortic valve implantation (TAVI) has facilitated the treatment of individuals who previously may have been deemed too high risk for conventional surgical aortic valve replacement
- The use of TAVI in the management of younger, lower-risk patients is now being explored and is the focus of ongoing clinical trials
Conflicts of interest
None declared.
Funding
None.
Consent
The patient APCB consented to publication of this work and is the first author of the manuscript.
References
1. Rose JC, Hufnagel CA, Freis ED, Harvey WP, Partenope EA. The hemodynamic alterations produced by a plastic valvular prosthesis for severe aortic insufficiency in man. J Clin Invest 1954;33:891–900. https://doi.org/10.1172/JCI102962
2. Zalaquett R. [Fifty years of the heart-lung machine. Report on the pioneers and heroes and about the circumstances that led to the great invention, which allowed the treatment, and in many cases, the cure of heart illnesses]. Rev Med Chil 2003;131:1337–44.
3. Bacon AP, Matthews MB. Congenital bicuspid aortic valves and the aetiology of isolated aortic valvular stenosis. Q J Med 1959;28:545–60.
4. Mohler ER. Mechanisms of aortic valve calcification. Am J Cardiol 2004;94:1396–402, A6. https://doi.org/10.1016/j.amjcard.2004.08.013
5. Starr A, Edwards ML. Mitral replacement: clinical experience with a ball-valve prosthesis. Ann Surg 1961;154:726–40. https://doi.org/10.1097/00000658-196110000-00017
6. Mack MJ, Leon MB, Thourani VH et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 2019;380:1695–705. https://doi.org/10.1056/NEJMoa1814052
7. Ross J Jr., Braunwald E. Aortic stenosis. Circulation 1968;38(1 suppl):61–7. https://doi.org/10.1161/01.CIR.38.1S5.V-61
