I am saddened that Elizabeth Taylor died recently of heart failure. In his appreciation of her, film critic Roger Ebert said in the Chicago Sun-Times, “Of few deaths can it be said that they end an era, but hers does.”
She is a star that many of us felt we knew. She was a great actress and a woman of great beauty who was a hard working champion of people with AIDS and always seemed to be a determined person who knew herself. Yet she always had a vulnerable side. So many marriages, so many illnesses, so many, many surgeries, over 40, I’ve read. And then her heart problem developed. Which leads me to talk a little about that problem, mitral valve leakage.
The heart’s mitral valve
The heart has four chambers and four valves that open to let blood through to the next chamber of the heart and on out to the body and back. The valves, acting as gates, then immediately close to prevent the blood from running back where it just came from. The mitral valve looks like a mouth with leaflets that look like lips that open and close. When I saw it in action on an echocardiogram, a test that uses sound waves to show moving pictures of the heart, I thought it looked like a very sensuous mouth. Each of the valves looks different. But because it looks like a mouth, the mitral valve stands out. Blood has just left the lungs carrying oxygen and arrives at the left atrium of the heart. The mitral valve’s mouth opens to let the blood pour through into the left ventricle. As the left ventricle contracts, the mitral valve closes and the aortic valve opens to allow blood to leave the heart and get out to the body.
A mitral valve can start to leak. This can range anywhere from a condition that is minor and does not need treatment to a serious problem that leads to a weakened heart and heart failure. In Elizabeth Taylor’s case, it led to heart failure and her symptoms must have included difficulty breathing and fatigue.
I asked Edward K. Kasper, M.D., director of clinical cardiology at Johns Hopkins Hospital, to talk a little about what can go wrong with a mitral valve. I should mention for disclosure that Ed is my cardiologist and co-authored with me the book Living Well with Heart Failure, the Misnamed, Misunderstood Condition:
A leaky mitral valve – mitral regurgitation, is common and has many causes. Most people tolerate a leaky valve well, but some need surgery to correct the leak. Repair is preferred to replacement. The MitraClip (which was used for Elizabeth Taylor) is a new technique to try and fix mitral regurgitation in the cath lab rather than in the operating room. There are no long-term comparison studies of this technique compared to standard OR repair – that I know of. Repair is currently the gold standard for those who have severe mitral regurgitation and symptoms of heart failure. Outcomes are better including improvement in symptoms and survival in patients with repair rather than replacement.
What takes a person from a leaking mitral valve to heart failure?
The leakage back into the left atrium increases the pressure in the left atrium. This increased pressure in the left atrium is passed back to the lungs, causing fluid to leak into the lungs, leading to heart failure. With time, the demands of severe mitral regurgitation on the left ventricle will lead to a weakened left ventricle, a dilated cardiomyopathy (disease of the heart muscle). We try to prevent this by operating before it gets to that point.
Mitral regurgitation can also be a consequence of a dilated cardiomyopathy – the orifice of the mitral valve enlarges as the left ventricle enlarges. The leaflets of the mitral valve do not enlarge. Therefore, they no longer close correctly, leading to mitral regurgitation.
It’s easy to see why anyone would want to opt for the Evalve MitraClip over open heart surgery. The MitraClip is little different from a common test known as an angiogram in which a catheter is passed through the femoral vein in the groin up to the heart. In this repair procedure, however, the catheter guides a clip to the mitral valve where the metal clip covered with polyester fabric is positioned over the leakage and brought down below the open flaps and back up, fastening the valve’s open leaflets together. The manufacturer, Abbott, shows in a video here how blood still is able to pass through on either side of the fastening.
Elizabeth Taylor got her MitraClip repair a year and a half ago, so it must have worked for awhile. Then about six weeks ago she was hospitalized with heart failure at Cedars-Sinai Medical Center in Los Angeles where she died with her family at her bedside. For more on mitral regurgitation, see this NIH site.
Heart failure has many other causes. High blood pressure can damage the lining of blood vessels leading to deposits of cholesterol. Coronary artery disease causes heart attacks. A heart attack kills part of the heart muscle, forcing the rest of the heart to work harder and in doing so, get large and weak. Only about half the people who develop heart failure have a weak heart. In another cause of heart failure, the left ventricle becomes stiff and the heart does not fill properly. And in some heart failure, the heart itself is normal but connecting blood vessels are not or a valve may be too narrow. In all of these cases, a person is said to have heart failure because the heart and vascular system are not able to provide the body with the blood and oxygen it needs.
*This blog post was originally published at HeartSense*
For years I have avoided Medicare breast reductions for a number of reasons:
(1) Poor pay for hours of work. An average breast reduction when done to a high standard usually takes 3-4 hours. I do not staple the closure.
(2) Medicare patients due to their age are at higher risk for wound healing problems.
(3) 90 day global fee period – These patients routinely need follow-up care and that care is not billable.
Recently I ignored my better judgment and performed the operation for a lady in whom back pain (ICD-9 724.5) and back surgery had been long term problems. She also had a pretty nasty rash (ICD-9 692.89 Dermatitis and eczema [in the infra-mammary fold]) under her right breast that just wouldn’t go away. These of course were all in addition to the usual diagnosis of large breasts (ICD-9 611.1 Hypertrophy of breast.)
Medicare showed me yet another reason for my hesitation to do these cases when they denied payment for the operation saying it was not medically indicated. They will probably pay on appeal, but the thought that I should have to appeal the case adds insult to injury.
*This blog post was originally published at Truth in Cosmetic Surgery*
Everyone has their own perspectives about life and death, often based on life experiences and their worldly views. Doctors are no different, except to say that doctors deal with life and death every day of their lives. For medical doctors, death perspectives are more likely to be defined by their disease specialty.
Here are a few examples of death perspectives from the different medical specialties
If you’re a pulmonologist, nobody dies without first getting a bronchoscopy.If you’re a cardiologist, nobody dies without first getting a heart catheterization.If you’re a nephrologist, nobody dies without first getting a run of dialysis.If you’re an oncologist, nobody dies without first getting a course of chemotherapy.If you’re a neurologist, nobody dies without first getting an EEG and an MRI. If you’re a gastroenterologist, nobody dies without first getting a colonoscopy.If you’re a rheumatologist, nobody dies from lupus, because the answer is never lupus. If you’re an infectious disease doctor, nobody dies without first getting a course of doxycycline.If you’re a family practice physician, nobody dies without getting a consult.If you’re an internist, nobody dies without first admitting the patient to the hospitalist.If you’re a dermatologist, nobody dies. Period.
What’s the moral of the story? If you want to live forever, get a dermatologist as your primary care physician.
*This blog post was originally published at The Happy Hospitalist*
The Times ran an intriguing experiment on its Well blog yesterday: a medical problem-solving contest. The challenge, based on the story of a real girl who lives near Philadelphia, drew 1379 posted comments and closed this morning with publication of the answer.
Dr. Lisa Sanders, who moderated the piece, says today that the first submitted correct response came from a California physician; the second came from a Minnesota woman who is not a physician. Evidently she recognized the condition’s manifestations from her experience working with people who have it.
The public contest – and even the concept of using the word “contest” – to solve a real person’s medical condition interests me a lot. This kind of puzzle is, as far as I know, unprecedented apart from the somewhat removed domains of doctors’ journals and on-line platforms intended for physicians, medical school problem-based learning cases, clinical pathological conferences (CPC’s) and fictional TV shows. Read more »
*This blog post was originally published at Medical Lessons*
By Richard C. Hunt, MD, FACEP
Centers for Disease Control and Prevention
A 17 year-old athlete arrives on the sideline, at your office, or in the emergency department after hitting her head during a collision on the sports field and is complaining that she has a headache and “just doesn’t feel right.”
Can she return to play? If not, when can she safely return to school, sports, and to her normal daily activities? Does she need immediate care, a Head CT or MRI, or just some time to rest?
Do those questions sound familiar?
Each year thousands of young athletes present at emergency departments and in the primary care setting with a suspected sports- and recreation-related concussion. And every day, health care professionals, like us, are challenged with identifying and appropriately managing patients who may be at risk for short- or long-term problems.
As you know, concussion symptoms may appear mild, but this injury can lead to significant, life-long impairment affecting an individual’s ability to function physically, cognitively, and psychologically. Thus, appropriate diagnosis, referral, and education are critical for helping young athletes with concussion achieve optimal recovery and to reduce or avoid significant sequelae.
And that’s where you come in. Health care professionals play a key role in helping to prevent concussion and in appropriately identifying, diagnosing, and managing it when it does occur. Health care professionals can also improve patient outcomes by implementing early management and appropriate referral.
As part of my work at CDC, and as a health care professional, I am committed to informing others about CDC’s resources to help with diagnosing and managing concussion. CDC collaborated with several organizations and leading experts to develop a clinical guideline and tools for the diagnosis and management of patients with concussion, including:
For more information about the diagnosis and management of concussion, please visit www.cdc.gov/Concussion/clinician.html.
Also, learn more about CDC’s TBI activities and join the conversation at: www.facebook.com/cdcheadsup.