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A matter of cause and effect

July 2nd, 2014


A matter of cause and effect

Not so long ago, I had a Middle Eastern female patient who was about 70 years old. She was only around 150cm tall, but she weighed 130kg. She suddenly felt short of breath about two months earlier and it was so severe that she could not lie on her back. She had to be sent to a hospital in her country, and it was found that there was fluid accumulation in the lungs (pulmonary edema) and she had mitral valve insufficiency.

Prior to this illness, she had never felt out of breath or tightness in the chest. However, she was not very active, due to her weight problem. Her knees hurt so she did not move around much except to go to the bathroom, the dining table and her bed. It had been that way for a couple of years. Later, her back started to hurt and her other joints began to get rusty from being inactive for too long.

The hospital in her country diagnosed her with acute mitral valve insufficiency caused by a tear in the connection between the heart and the heart valve. This connection is like a parachute string. The heart valve in this case is the parachute’s fabric, while the connection is the threads that hold the parachute together with the person. If one or two threads break, the parachute will be out of balance. The heart valve, likewise, cannot close properly.

The valve’s supportive structures can be torn due to many reasons, such as an infection, myocardial infarction, mitral valve prolapse, or in this case, an unknown cause which has yet to be figured out. Everything has a cause and an effect.

The mitral valve controls the flow of blood between the two chambers on the left side of the heart. The upper left chamber receives the oxygen-rich blood coming from the lungs, then sends it to the lower left chamber, the strongest chamber consisting of intertwined heart muscles that work the hardest among the four chambers.

The lower left chamber works the hardest as it has to send blood to every organ in the body. The mitral valve prevents blood that has been released from this chamber from reversing back into the upper left chamber.

In the case that the mitral valve gradually becomes loose, the patient will not show any symptoms and doctors normally would not want to perform any operation to change or fix it, as the risk might not be worth the benefit, particularly when there is no symptom in the patient (at the present time).

If that’s the case, doctors will monitor the heart closely, and if it is enlarged, an operation will be recommended, whether there are symptoms or not. This is because when left unattended for too long, operating when the leakage is already severe will not yield good results, and the patient will not benefit much from the operation. The heart might not revert to normal size.

For acute mitral valve insufficiency, such as in this case, all patients suffer from severe symptoms because the heart has a hard time adapting. Medication is not enough to treat the attack properly. This patient and I were worried that there could be complications following the operation because of her weight problem.

For an obese and inactive person, the muscles vital for breathing are also weak, and after the operation, she would need to rely on mechanical ventilation for a long time until she could get up and walk by herself.

While she was unable to breathe on her own and sit up, there were great risks of complications, such as infection in the lungs, bedsores and blood blockage in the legs and lungs.

I decided to enroll her on heart rehabilitation and respiration training programmes to help her exercise muscles for better breathing.

Meanwhile, I slowly adjusted her medication. She was very cooperative so her condition improved bit by bit until she was able to walk farther than before, something she hadn’t been able to do for two years. Soon she could walk without gasping for breath. The pain in her knees and joints reduced remarkably. Most importantly, her weight gradually decreased.

I felt that she was ready for an operation, so I checked her details just to make sure. I was surprised to find that her heart valve was still loose, but her heart was able to function well. The size of her heart had not changed (meaning it was not bigger than normal). By doing a colour test and heart and lung pressure tests, I found that the pressure was back to normal.

Her blood test results also appeared as NT ProBNP (which, if high, would indicate heart failure and risk of acute and severe complications in the future) was normal. Before the treatment and the programme, the number of this test was alarmingly high.

The latest result showed that it was down to normal levels, meaning that although her heart valve was loose, her body and her heart were able to adapt themselves to work with it.

This woman ended up coming to Thailand as a tourist, not as a patient. She did not need any operation, and her weight dropped by 8kg. From a person who was inactive because of her painful joints, she easily walked around Bangkok, shopping!

Dedication, determination and a strong will can achieve even the near-impossible.

Prof Nithi Mahanonda is consultant cardiologist and interventionist, Perfect Heart Institute.


หัวใจสัญจร (๑)
Heart-healthy food
The end of the heart
Live long and lively

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