CARDIAC CASE PRESENTATION
A 53-year-old woman, a malpractice lawyer, with a history of mitral valve prolapse was diagnosed with severe mitral regurgitation and referred for mitral valve repair.
History and examination
The patient had no other cardiac history. She reported jogging 2 to 3 miles daily and playing tennis regularly, but over the past few months she had become more fatigued during her jogs, to the point that she occasionally had to reduce her pace and even shorten the duration of her runs.
On her initial visit, she expressed surprise regarding the severity of her mitral valve disease, as she had always been healthy. She seemed somewhat nervous but appropriately concerned about the impending surgery, and questioned whether she would be able to return to her previous level of activity. She also mentioned that she hoped the timing of the surgery would permit her to attend her son’s college graduation in 9 weeks.
Her medical history was notable for mitral valve prolapse. She had a history of panic attacks, for which she occasionally took alprazolam. There was no family history of cardiac disease. She did not use tobacco and occasionally consumed alcohol. A review of systems was negative.
Her physical examination was unremarkable except for a grade 4/6 holosystolic murmur at the apex that radiated to the axilla, which was consistent with the mitral regurgitation.
A transthoracic echocardiogram demonstrated mitral regurgitation that extended through the left atrium back into the pulmonary veins. The left ventricular ejection fraction was 50%, which is considered low-normal. The degree of mitral regurgitation was 4+. No other significant valvular disease was observed.
An electrocardiogram revealed a normal sinus rhythm. Per our routine, the patient underwent cardiac catheterization, which showed normal coronary arteries.
An uncomplicated repair, but slow recovery
The mitral valve repair was performed without complications. The course in the intensive care unit was uncomplicated, and the patient was quickly extubated and transferred to a regular nursing floor.
On the nursing floor, controlling the patient’s pain was difficult. She refused to use her incentive spirometer and initially refused to ambulate or even move from her bed to a chair. She was quite tearful.
A postoperative transthoracic echocardiogram revealed a satisfactorily repaired mitral valve with no mitral regurgitation. Her ejection fraction decreased to 40%, which is not unusual after mitral valve surgery.
Her hospital course was notable for an episode of shortness of breath and tachycardia. Sinus tachycardia was evident on review of the telemetry strips. A repeat echocardiogram showed no changes compared with the prior postoperative echocardiogram. Spiral computed tomography was negative for pulmonary embolism.
Pain control remained difficult. The patient expressed concern about the postoperative decrease in her ejection fraction; she was reassured that a decrease in ejection fraction was not unusual, but she remained tearful. The family expressed concern because the patient “wasn’t acting like herself,” and her ambulation and use of her incentive spirometer continued to be minimal, which had the potential to hamper her recovery and rehabilitation. For these reasons, a psychiatric consult was requested and the patient was seen prior to discharge from the hospital on postoperative day 6.
Wound check at 1 week postdischarge
A routine wound check was performed 1 week after discharge, at which time the patient was still reporting pain that was more severe than would be expected at her postoperative stage. She reported concern about drainage from the incision. She said that she was unable to do much walking or stair climbing, and she reported sleeping in the guest bedroom on the first floor of her house because she was unable to negotiate the stairs to her bedroom.
A check of the wound showed minimal serous drainage at the inferior aspect and was consistent with normal wound healing. The slow progress of her recovery was a concern, as was the possible contribution of her anxiety to this slow progress, so we kept our psychiatric colleagues informed about the patient’s recovery.
Follow-up at postoperative week 4
At the follow-up visit at postoperative week 4, the patient reported still being in pain, although the pain had improved, and complained of constant fatigue and shortness of breath that prevented her from returning to work. She had been discharged on lisinopril and admitted to occasional medication noncompliance. She said that if she did not improve dramatically and quickly, she would not be able to attend her son’s graduation.
We considered the possibility of new ischemia, a large pleural effusion, postpericardiotomy syndrome, constrictive pericarditis, or a mitral valve leak as potential causes of her symptoms. A chest radiograph was obtained, which demonstrated a small left pleural effusion, and an echocardiogram showed that her ejection fraction remained at 40% and the mitral valve repair remained intact. The patient had a psychiatric visit scheduled later on the day of this follow-up visit and was referred to the cardiac rehabilitation program, to start on week 6 of her postoperative care.