Bruce had malignant hypertension (dangerously elevated high blood pressure) in combination with a severely leaking mitral valve, which was causing breathlessness and lung congestion. He went on to have his valve fixed via a minimally invasive ‘mini’ mitral valve repair technique which does not require full open heart surgery. Following surgery he has no valve leak at all and if anything low blood pressure. This is his story . . .
Full case history:
I want to start by thanking Bruce, Linda & Fionna for supporting this post.
I met Bruce and Linda in the afternoon of the 20th of July 2016 at Circle Hospital Bath. They were visiting family (Fionna) from Canada and due to fly back the following morning. At that point we didn’t know that during the subsequent weeks we would develop a close doctor-patient-family relationship. The case is a good illustration of a modern team approach where an optimal outcome is achieved by having access to the right network of professionals in combination with close patient and family engagement and open medical access.
The story starts earlier that week when Bruce had started to feel breathless and visited the Emergency Department at the Royal United Hospital Bath where he was assessed by a friend and colleague, Dr Mahnaz Alsherif. Mahnaz had detected extremely high blood pressure (malignant hypertension) and a loud heart murmur and subsequently recommended a Cardiology consultation prior to travel back to Canada – this is how I came to meet Bruce.
At our first meeting, Bruce was extremely anxious about his blood pressure and felt that a major contributor to the elevated readings was a ‘white coat’ reaction, but it was immediately clear to me that this was genuine uncontrolled hypertension. In fact, initially he was reluctant for me to even take his blood pressure so we agreed to defer this until later in the consultation and in Bruce’s case this was an important part of the doctor-patient relationship that we would develop. In parallel it was obvious that he had a significant murmur and that the breathlessness was a likely consequence. Once Bruce had settled into the consultation and after a bit of gentle explanation and reassurance we did take his blood pressure and this revealed a systolic (top number) of 240mmHg!
I recommended an echocardiogram as the obvious next step, which we performed immediately in clinic and this confirmed severe mitral valve regurgitation [leak] as a result of valve prolapse. The mitral valve is made up of two leaflets that open and close with each heart beat, and it was quite obvious that the posterior leaflet was blowing back. This in combination with his very high blood pressure was transmitting pressure back into his lungs and the resultant congestion/ fluid was in turn the cause of his breathlessness.
Based on these finding I recommended that Bruce should not fly long haul the following morning and put in place an immediate plan to lower his blood pressure and relieve some of the lung congestion. He was started on blood pressure medications and diuretics (‘water’ tablets) with a view to a repeat assessment in a week. He was also describing transient episodes of visual disturbance and palpitations – the combination of problems would put him at risk of a heart rhythm disturbance (atrial fibrillation) which could cause blood clots and stroke. Therefore we monitored his heart rhythm for 72 hours and started anticoagulation with a new generation agent to protect him. I also asked Bruce to start documenting his blood pressure at home so we could monitor progress.
By the end of the first appointment it was clear that Bruce would need to have his mitral valve fixed but at that point in time our intention was initial stabilisation and return to Canada for completion of treatment. Bruce called me a few days later on Saturday to say he had thought about things and was worried both psychologically and physically about the prospect of flying before his treatment was complete. We agreed to talk about things further face-to-face at the next appointment.
The following week Bruce was better. His lung congestion had improved and his blood pressure was safer although still elevated. He had thought about things further and had detailed conversation with family (including medical contacts) – on reflection it became clear that for him the correct course of action was to complete his treatment prior to returning home.
We agreed to start the process of work-up for mitral valve repair and I highlighted my friend and colleague, Mr Paul Modi. Paul is a Cardiac Surgeon at the Liverpool Heart and Chest Hospital and we have known each other since our respective training overlapped at the Bristol Heart Institute. We see each other at least 3 times a year as faculty on various surgical skills courses that we teach. Paul has a relatively rare expertise internationally in minimally invasive ‘mini’ mitral valve surgery which does not require a traditional sternotomy (which is the usual route for most mitral valve surgery). I phoned Paul up and we immediately penciled in a date for surgery in 4 weeks, which would allow enough time for stabilisation, optimisation for surgery and work-up.
By the second week Bruce’s blood pressure had improved further and was nearly ‘normal’. I performed a radial coronary angiogram at the Royal United Hospital Bath which confirmed that he did not have any blocked arteries and would not require bypass as well as valve surgery. Another friend and colleague in Bath, Dr Dan Augustine, who is a superb contemporary imaging Cardiologist performed a transoesopageal echocardiogram and produced some beautiful 3D images which confirmed that the mechanism of Bruce’s mitral valve leak was related to ruptured chords [think of a parachute - if some of the lines that hold the canopy break then that part of the parachute will ‘blow back’ or prolapse]. As well as improvement in all his ‘numbers’, Bruce was also clearly improving psychologically in combination with our weekly consultations at Circle Bath and excellent family support.
Bruce underwent uncomplicated ‘mini’ mitral valve repair in Liverpool, through only a small incision on the right hand side of his chest, with re-attachment of 3 synthetic chords and a ring at the base of the valve to strengthen the valve foundation. The valve leak went from severe to zero immediately following surgery and Bruce made an excellent and prompt recovery. He stayed in hospital for 3 days after the operation and was discharged. Paul had phoned me post-operatively but Bruce also sent a nice email to confirm that everything had gone well.
I met Bruce a week following his discharge in Bath. The small scar on the side of his chest was healing well along with the drain sites. He had no pain and was essentially rapidly returning to full everyday functionality – very impressive stuff. Linda was putting him through his paces in a regime of rehabilitation walking around Bath and his blood pressure was now at the lower end of the spectrum and so we started the process of easing back his medications.
I saw Bruce one final time at Circle Hospital Bath before his return to Canada. He has since emailed me from back home and everything sounds excellent. In retrospect I think the probability of an adverse outcome would have been significant if he had flown home as originally planned.
For me this is the standard of healthcare that we should always aim for – a modern team approach where the patient receives contemporary diagnostics and treatments all delivered efficiently in a pleasant environment with a close patient-family-doctor relationship.
There are now lots of rapidly evolving minimally invasive techniques and options for patients with heart conditions but these are not always available or widely disseminated through the healthcare community. In the majority of cases worldwide, patients like Bruce would have full open heart surgery which is still a high quality procedure but with a longer recovery time.