I have been seeing Mr. S in my office for almost 20 years. This 77-year-old man has had lifestyle-limiting chest discomfort for a long time. Several heart catheterizations showed no role for a stent or bypass surgery, so he was stuck taking multiple medications to control his symptoms.
He needed to take 20 to 30 nitroglycerin tablets under his tongue each month in addition to his long list of regular medications.
His case has always been a bit of a conundrum for me, and after 30 years of practice in the field of cardiology, I don’t like puzzles that do not fit. Situations like this can usually be fixed by some kind of intervention, but there were no answers about why he was so symptomatic.
He became even more short of breath eight years ago when he developed atrial fibrillation. He felt back to his baseline after beginning a blood thinner and having an electrical cardioversion. This brief electrical shock to the heart, done under anesthesia, quickly restored him to a normal rhythm.
An echocardiogram (or cardiac ultrasound) at that time showed normal heart function and mild mitral regurgitation. The mitral valve, which separates the left atrium from the left ventricle, is a two-leaflet structure designed to stop backflow of blood when the valve closes. A small amount of leaking is normal, but more than this can lead to shortness of breath.
He continued to do the same clinically for a couple of years but then developed anemia. His hemoglobin fell as low as 8.7 grams, suggesting a possible internal bleed (normal is 12-14 grams) but a gastrointestinal workup did not show signs of that. His blood thinner was cautiously restarted, his anemia improved, and his usual symptoms persisted.
Almost two years ago, everything changed. He had to go to the hospital because he suddenly became short of breath and had congestive heart failure. He was treated with intravenous furosemide — used to reduce swelling in the body caused by heart failure — and felt better. He did not have atrial fibrillation, his anemia was stable, but he did have a slightly louder heart murmur.
An echocardiogram showed normal heart function with an increase in his degree of mitral regurgitation when compared with a study one year earlier. What had been mild regurgitation was now moderate to severe. A cardiac catheterization was done, which again showed non-critical coronary blockages, but new pulmonary hypertension — an elevation of the pressures in the lungs, which can cause shortness of breath. In this case, the findings suggested that it was being caused by worsening mitral regurgitation.
He was at very high risk for heart surgery because of his history of anemia and multiple other medical problems. He was sent home from the hospital on adjusted medications and I saw him in the office the next week. He was breathless after walking less than 100 feet and not feeling well.
Since his mitral regurgitation had been mild and now was somewhat worse, I thought that it might be possible at least to address this issue, and referred him to an interventional cardiologist. I wasn’t expecting great improvement, but wanted to give my patient the best option I could think of.
What happened next, however, truly amazed me.
I sent him to see Brian O’Murchu, the head of interventional cardiology at Temple, to see whether he was a candidate for a mitral valve clip. This is a relatively new procedure in which a clip is attached to the mitral valve without the need for open-heart surgery. It is entirely done through a catheter placed in the femoral artery of the leg; the catheter is removed after the procedure.
In order to see whether this procedure was possible, he arranged a special kind of echocardiogram, called a 3D transesophageal echo, which revealed that Mr. S had a ruptured posterior mitral valve leaflet, a small piece of muscle that normally attaches the valve to the heart. Valve leaflets can rupture spontaneously, which can then cause the valve to not close properly, and suddenly leak. This causes blood to back up, raises the pulmonary pressures, and results in the exact symptoms Mr. S had been experiencing.
The traditional approach is to suggest open-heart surgery to repair the torn leaflet, but he was too sick with other medical issues, so after a multidisciplinary conference, the decision was made to proceed with a clip.
The mitral valve clip, or MitraClip, has been used for more than five years on more than 80,000 patients. The results in this case were amazing. He felt dramatically better the next day, and could walk blocks before becoming winded. He has been feeling remarkably well for almost two years.
In addition, his chest discomfort has essentially gone away.
The results post-procedure were nothing short of miraculous and have persisted. At a routine appointment last month, he said he can now walk more than three blocks and has not taken a single nitro under his tongue in months.
I cannot explain this, as his mitral regurgitation was never more than mild when he was so symptomatic. He remains a bit of a conundrum, but a much happier one. He told me that he feels that he has his life back, and was happy to allow me to share his story.
David Becker is a board-certified cardiologist with Chestnut Hill Temple Cardiology in Flourtown. He has been in practice for more than 30 years.