Bruce's Journal

Meeting the Surgeon Initially, I thought this valve could be repaired using GoreTex(TM) chordae tendineae ("heartstrings") replacements in open heart surgery. (Ah naivety) I read all the available literature about this repair process, prepped questions about details, and studied the study proposed for comparing this repair with the temporary catheter-placed clip (MitraClip) that was the alternative to the definitive repair. I thought I had a possible game plan, and I was willing to forgo the less invasive but non-definitive MitraClip for the longer recovery open heart direct repair of the chordae. I did not know the valve had so much calcium. This was discovered just 2 days before today's kickoff meeting and appeared in the heart CT angiogram. The cardiothoracic surgeon who would have done the repair ruled the calcium too much and in an unanticipated move, removed himself from the case! Unexpected? Yes! But that is the way biology and medicine operate. Just when you think you understand the situation there appears another factor. The Calcium What is this calcium which caused the surgeon to withdraw from the case? Not everyone knows, that the heart has a "skeleton". These are rings of fibrous tissue similar to cartilage that surround each of the valves giving them structure for the valve leaflets to attach to. That sounds like a good thing. But thinking back on embryonic development, our real skeleton starts out as cartilage, and over time calcium sets down within this fibrous matrix to create bones. You may be beginning to see a potential problem. How does biology know that calcium belongs to skeletal bone cartilage and not to heart cartilage? Well, it doesn't. I was awarded the "impressive" accolade by the surgeon. "I mean you have got some impressive ... look at that! ... that's 1 1/2 centimeters!" pointing to a bright white blob on the CT scan display. "That's my valve??" I said. "Oh yeah!". You may recall my regurgitation was "large". I have lost my taste for superlatives. The surgeon, a very personable, polite, considerate, and well-spoken young man explained that the mortality figures in the first month for direct repair that he does is 1-2% but reported repairs for a calcified valve, like mine, at more like 20% and he does not do them. What comes next?

The TransEsophageal Echocardiogram (TEE) I don’t have to explain to this group that a TEE is not the first part of a tee-hee giggle. It was a significant procedure and produced detailed results and the team put me under and brought me back without any problem. The anesthesiologist in charge of the procedure introduced herself saying "I am your bartender today ...". I woke up slurring my speech for a few minutes, and with a slightly sore throat, but otherwise no worse for the wear. What does Mitral Valve Leakage look like? This is a link to a very good cartoon representation of the heart valves specifically the mitral valve when it fails. Mitral Valve Regurgitation - YouTube The TEE results confirmed that I have severe mitral regurgitation and they were able to estimate the effective area of regurgitation is about 1 square centimeter and the volume of regurgitation at 98 ml. Both of those are considered large The flail leaflets and ruptured chordae tendineae (heart strings) were also seen. 2/3rds of my posterior leaflet is "incompetent" and not doing its job closing the valve. Later the same week, I had a cardiac CT Angiogram scheduled to quantify how much calcification I had on my mitral valve. This is important in planning any correction of the leak. Will the defect be too large to repair by catheter? Will it be too large to repair with a Gore-Tex(tm) chordae replacement? Will I have to get a pig valve? Or a mechanical valve? Will the amount of calcium deposits play a big role in the path that I take? 

First Listen When something big happens in your life, it can seem like a bolt out of the blue. On reflection sometimes we discover hints and allegations (to quote Paul Simon) of precedent events. When I found out that I had mitral valve prolapse and regurgitation, it felt like the floor had fallen out from under me. I was sitting in the exam room after a very nice conversation with the new nurse practitioner. She was doing the basic heart and lung exam when she stopped and said “You didn’t mention you had a murmur! It’s kind of loud! You want to listen?” We had just finished the part where I told her I was a retired primary care physician. She took her stethoscope off and handed it to me. As I fitted the earpieces into my ear canals and checked the chest piece by tapping it I felt time disappear and I entered provider mode listening to another patient’s chest. Placing the chest piece over my heart I heard the familiar sound of a leaking valve. I froze. I was listening to my heart make a sound I had never heard it make. All healthcare workers who have a stethoscope listen to their own heart. It had been many years since I had listened to the relaxed lub and dub of healthy valves closing. I don’t know how long I listened transfixed by the waterfall roar of blood going the wrong way. I became conscious of sitting and listening with my provider’s tool while she stared questioningly. I snapped back into the provider role and said “Yes. That sounds like a 3 or 4 (out of a scale of 6) – pretty loud!” We discussed the initial workup with an echocardiogram. Echocardiography is the process of sending high-frequency sound waves through the heart and recording the bounced-back waves or echoes. The concept had been around since the 1950s and was getting wider use and inevitable overuse in the 1970s. I thought about the first echocardiogram I ever had.  I think it may have been in residency in the late 70’s. I was hanging out with other internal medicine residents after a case presentation, and I was herded into the echocardiogram lab by a cardiology fellow to be part of his study of this new “click-murmur syndrome” which would later be called mitral valve prolapse. Later he approached me with a paper strip of the results and excitedly told me I had it. It’s a common phenomenon that when something is new and everyone is searching for it, we “find” a little more and sometimes a lot more of what we are looking for compared to subsequent somber academic surveys. In later years, I would mention it to my physicians, and they would admit they could not hear anything abnormal. Eventually, I forgot about it and stopped mentioning it. That recent day sitting with my provider, the enthusiasm of the cardiology fellow from 45 years ago flooded back and I thought “Huh! That guy must have been right!”