Case study in heart-brain interplay: A 53-year-old woman recovering from mitral valve repair

DISCUSSION OF THE CASE

To explore management options in this case and discuss the insights it provides into heart-brain interactions, the case presentation was followed by an interactive discussion (moderated by Dr. James B. Young, Department of Cardiovascular Medicine and Chairman, Division of Medicine at Cleveland Clinic) between the physicians who presented the case and the Heart-Brain Summit audience.

Dr. James Young: Let’s begin by considering whether there were some red flags that may have been apparent up front to predict that this patient might have been challenging in the postoperative period. I think one red flag was the diagnosis of mitral valve prolapse itself, which has been known to occur in type A personalities, who tend to exhibit catecholamine excess and sympathetic nervous system arousal that activates the autonomic nervous system.

Also, I’d be interested to know a few more findings from the patient’s physical examination. Was she thin? Did she have a narrow anteroposterior diameter? Did she have pectus excavatum? Did she have arachnodactyly tendencies? These are important characteristics that might have flagged the anxiety up front, as psychosomatic manifestations of patients with mitral valve prolapse were identified—and hotly debated—20 to 30 years ago. Although the link between mitral valve prolapse and personality type has fallen out of favor in cardiology circles, it clearly seems to describe this patient. The history of anxiety, panic, and possibly agoraphobia has been well described in patients with mitral valve prolapse and excematous degeneration.

I’d like to pose the following questions to the audience. What do you do with this patient now? Do you push medication therapy? Do you push psychotherapy? What is the next step?

Comment from audience: You haven’t excluded the post-pump syndrome. This patient is very bright and it wouldn’t take much of an insult to impair her sufficiently so that she would interpret the world in a different way. From my point of view, she needs sophisticated neuropsychological testing soon.

Dr. Young: That’s a good point. We know that cardiopulmonary bypass is associated with difficulties and problems that have been underreported in the past.

Comment from audience: The last thing that this patient wants to admit or even allude to is a psychological problem. She is the last one who’s going to even hint at it, which makes it very easy to miss. Look at how she reacted when she heard that there was a psychiatrist in the room. These patients are not necessarily well disposed to completing screening tests because they recognize that somebody is trying to identify a psychological problem. I don’t know that I have the answer, but I think that we should avoid browbeating ourselves for the problem.

Dr. Young: I want to mention the cultural anthropology of physicians and how it affects our approach to treatment. I like being a cardiologist because I write prescriptions for drugs that have proven to be useful, such as beta-blockers and ACE inhibitors, among others. From this experience came my earlier question, “Should we give this patient a drug?” The cardiologist’s focus—perhaps excessive focus—on pharmacologic solutions may not be the best way to approach this patient. You allude to some important issues about screening a patient for diseases that can be more easily treated.

Comment from audience: I have seen such situations as a result of drug interactions; many of our patients are on multiple drugs when they leave the hospital. The other issue to consider is sleep deprivation, with or without sleep apnea.

Dr. Young: Many complications, particularly in patients with heart failure, are related to disordered sleep, which certainly causes some heart-brain dysfunction. What about the drugs?

Dr. Thomas Callahan: We considered the effects of her medications, which included an ACE inhibitor and her analgesics. We also considered the lingering effects of anesthesia or other medications that she might have been receiving.

Dr. Young: Remember, she was reporting considerable pain. I suspect that she was on a cocktail of pain medications that might have been contributing to her difficulties.

Comment from audience: Morphine’s effects tend to be stronger in women than in men. The other issue is the 10% drop in ejection fraction after the surgery. This patient may be thinking, “Why did I go through all of this if my ejection fraction is going to be worse?”

Dr. Callahan: A drop in the ejection fraction, especially after mitral valve repair, is common. We often address it with patients preoperatively, but perhaps not with everyone, and perhaps not clearly enough.

Dr. Young: Also, this is an example of a patient who had heart failure going into the operation, but “heart failure” would be the worst term to use with this particular patient. An ejection fraction of 50% is not normal for a patient with 4+ mitral regurgitation and, as Dr. Callahan suggested, when you take away the mitral regurgitation, you dump a little more load on the left ventricle, and the ejection fraction will go down. We see this all the time, although I admit that cardiologists or cardiac surgeons don’t necessarily do the best job of discussing these subtleties with patients. Something we can take away from this case is a sense of the importance of improving our communications with patients about what they might expect postoperatively, although it still needs to be tailored to the individual patient. If this patient had understood the pathophysiology behind the drop in ejection fraction, it may have helped her. Other patients, on the other hand, may not require detailed conversations about this phenomenon.

Comment from audience: It was mentioned several times that the husband said the patient was not herself. Did you interact with the husband and the son to get a sense of the long-term dynamics of this family? It seems that there may have been some issues with the family dynamics.

Dr. Ubaid Khokhar: That’s a good question, although no underlying dynamics seemed apparent. The husband and son’s primary concern was that the patient’s previous characteristics of perfectionism and always being “in control” were so much in contrast with the tearful episodes she was having now. “She is not the same,” is how they kept phrasing it. However, there were no other significant changes—no rumination about suicide, no overt unwillingness to go along with treatment, or anything like that.

Comment from audience: I believe strongly that this patient was depressed, although she did not admit it. She had four of the five symptoms. She did not admit to a depressed mood but was tearful, which you reported at every postoperative visit. This is a sign of depression. We know very well that anxiety and depression often are present in tandem, especially in patients with high baseline anxiety. When they have more stress in their lives, they tend to get depressed.

I agree with the preceding comments that drug interactions are a potential worry; however, a few of the SSRIs have favorable drug-drug interaction profiles. I would urge this patient to try SSRI therapy. If she rejected this by responding, “I’m not depressed,” you could point out that SSRIs work very well for anxiety. Alprazolam is not a good medication for anxiety because it has a very short half-life, which can leave patients with an increase in anxious feelings after the medication is cleared from their system but before their next dose.

In addition to SSRI therapy as a first-line approach, I would try stress management, biofeedback, or even psychosupportive therapy that relies on patient education to help this patient understand her condition and take back control.