Case study in heart-brain interplay: A 53-year-old woman recovering from mitral valve repair
ABSTRACT
This article presents the case of a 53-year-old female attorney who underwent successful mitral valve repair for mitral valve prolapse. The patient's postoperative course was marked by refractory pain, fatigue, shortness of breath, refusal to ambulate, frequent episodes of tearfulness, and a postsurgical decline in ejection fraction through postoperative week 4. Her slow recovery prompted a psychiatric consult, during which she reported panic and a fear of "losing it." After respective presentations of the case from the cardiology and psychiatry perspectives, the article concludes with a moderated discussion of the case to explore insights it provides into heart-brain interactions.
CASE OUTCOME
Our initial approach with this patient was the path of least resistance. Very good points have been made by the discussants and members of the audience. This patient was attached to alprazolam because it was the only psychotropic medication that she had ever taken. For this reason, she was discharged on alprazolam even though it wasn’t the ideal medication. As pointed out by the audience, the patient was quite resistant to the concept of having depression superimposed on a history of anxiety. In the cardiac rehabilitation setting she was again reassured by the exercise physiologists that her heart was doing well. A cardiologist personally reviewed the echocardiographic reports and films with the patient, pointed out the absence of unusual abnormalities with her heart, and suggested that something else was causing her symptoms. This direct explanation and reassurance from the cardiologist facilitated the patient’s ability to entertain depression as a comorbid condition.
At the visit with the psychiatrist in the cardiac rehabilitation program, the patient finally accepted that her lack of confidence could also be a symptom of depression. We repeated the Patient Health Questionnaire, which still showed moderate depression, and we started her on an SSRI, citalopram. About 3 weeks later, she began to regain her confidence, and she was able to attend and host her son’s graduation. By 8 weeks after the start of antidepressant therapy, a repeat Patient Health Questionnaire showed no evidence of depression.
Her progress, both physically and emotionally, was quite pronounced during the 12-week cardiac rehabilitation program. Her physical stamina improved, her fatigue abated, and her sense of confidence was restored. She successfully returned to work and her family concurred that she had returned to her “old self.” She benefited from the stress management and lifestyle seminars that were offered in the cardiac rehabilitation program, and her exit SF-36 scores were much improved. The patient pleasantly surprised us all by taking the initiative of forming a monthly women’s support group for coping with heart surgery.
She completed a 9-month course of the SSRI, with the depression in full remission, and has continued to follow up with her cardiologist and her exercise regimen.
