MITRAL VALVE PROLAPSE SYNDROME.

The name is very familiar now but was not known before the late sixties and early seventies. With the advent of echocardiography newer diseases came to light! I still remember the days when we were playing with a simple mid-line echo. machine used in neurology delineating the mid-line shift in the brain. We tried that on the heart and had to struggle for a long time to get at the anterior mitral leaflet. My paper on echocardiography in the Karnataka Medical Journal was possibly the first one in India.1 I have not been able to get any earlier reports so far. I had made a reference to this new syndrome in that paper and had stressed the need for caution in the diagnosis, since the technic of echocardiography had to be perfect to get the correct diagnosis. Even if the echo. did show any change in the configuration of the mitral valve, that, by itself, does not make it a serious disease.



In a beautiful editorial in The Lancet it was shown how epidemics of diseases could be caused by epidemiologists themselves.2 Labelling gives rise to awareness and the latter in turn results in overdiagnosis! The same holds good for vascular diseases like coronary artery disease these days. Medicine revolves round anxiety-patient anxiety of death and disability and doctor anxiety of having to do the right thing and also to do it right. The new labels increase anxiety in the population. While our whole effort in medicine should aim at reducing anxiety, here is an effort to increase anxiety. Thousands of young men and mostly women have been frightened out of their wits by the new breed of cardiologists with their newly acquired echo. machines. The more the merrier and newer the better is the slogan in this field now. A big cardiologist was telling me recently that the latest in the line is the best and he has to have that to join duty in our institution as he wishes to delineate the endocardium correctly!



I am reminded of a personal anecdote. I was reviewing a middle aged woman in the out patient cardiac clinic at the Middlesex Hospital, London in 1974. This lady was seen as a school girl thirty years earlier by a great cardiologist, Even Bedford, in the same clinic. The referral letter from the GP said: “ I hear a peculiar sound at the apex. Please clarify if this is due to cardiac disease?” The wise old man had written: “ I do not think that this short mid-systolic murmur with a click is due to any cardiac pathology. You could reassure her on that count. However, to be on the safer side she could be reviewed here once in five years.” The letter was still there in the file! I echocardiogramed her that day and found mitral valve billowing. It was then called Billowing Mitral Leaflet Syndrome (BMLS) by Prof. Barlow of South Africa. He, along with his able assistant Wendy Pocock, had contributed a lot to clear this mystery.1





The middle aged lady that was refered to earlier was in the pink of her health and had two children by the time I reviewed her. Of course, I had to reassure her again. The wisdom of the wise old man struck me then.



Since then lot of water has flown under the bridge and people have made mountains out of mole hills of this minor alteration in the size of the chordae tendinae. How I wish we had appreciated Nature’s ways better! People are told these days that any one with this kind of a change is in for serious problems in life like sudden death, infective endocarditis, mitral leaks with attendant consequences and so on and so forth. I do not think any one has given as much as a small thought to the anxiety and torture that are induced in the poor victims of our technological attacks on them. It may not be a bad idea for cardiologists to get into such unfortunate people’s shoes and think of their own lives with that kind of a death warrant given to them by their doctors.



Now comes some relief for those poor victims. A large prospective and long term follow up study from the USA in the recent New England Journal of Medicine confirms the wisdom of Late Evan Bedford that this minor change in the mitral valve is very innocuous and is not the devil that it is made out to be by the echocardiographers and the many small and short term studies in the past.3 Barlow’s original studies had thrown some light on this, but the present study is better conducted with better resources. Less than 2% of those with the so called mitral Valve Prolapse syndrome get into any trouble. This is not higher than the ordinary population.4 This study clearly acquits MVP as the culprit. This should, at least, make our doomsday doctors wake up from their deep slumber! May the hapless victims of their attack breathe a sigh of relief. The study also points out to the significant overdiagnosis of the condition because of the faulty technic of echocardiography.5 Today cardiologists believe that echo. is like a tomogram, and could be easily interpreted, howsoever done. Far from it, very far! The technic still is the key to correct diagnosis. In fact, I have described a new auscultatory method of diagnosing this condition even without the help of echocardiogram. 6,7



Many a person suffers because of bad technic. I have seen patients being angiogrammed with an echo. diagnosis of thinning of the ventricular wall ( due to silent infarcts etc.,.), while the fault was the original technic. Like the abdominal scans throwing up lots of young women with ovarian cysts of the diameter of a millimeter, creating the scare of cancer and then surgery, echocardiograms have made life miserable for quite a few in society. The above study in the NEJM could not have been more timely.



Even the king of sciences, physics, is not without such fallacies. Recently Richard Marsdon, Harvard astronomer, came up with his computer data that on the 26th October 2028, at 12.10 p.m. Central time in America there would circle the earth an asteroid of the size of a mile diameter, at a distance of 30,000 miles from earth. This has a fifty-fifty chance of hitting the earth. This prediction was very scary indeed! Similar asteroid, half its diameter, had hit the earth millions of years ago. The dust that it threw up closed off the sun from the earth for months that not a blade of grass grew here and the dinosaurs disappeared from the earth. People then got so scary that they started making all the arrangements, including insurance policies, to be on the safer side. Two days later another equally great astronomer, Donald Yeoman of NASA, could get similar data on his computer. The only difference was that the asteroid would be circling at 6,00,000 miles away from the earth and that there would not be a ghost of a chance that it would hit the earth. Insurances were then cancelled and people breathed a sigh of relief! This is not called mistake in science, the latter word is a taboo in science. It is called uncertainty! Similar is the story of mitral valve prolapse syndrome.



Would the great cardiologists pay any heed and read the NEJM report for the good of humanity at large? The greatest discovery of the twenty-first century would be the discovery of man’s ignorance!







Bibliography:



1) Hegde BM. Echocardiography-Its role in Clinical Medicine. Karnataka Med. Jr 1983; 50:49-54.



2) Editorial. Do epidemiologists cause epidemics? Lancet



3) Freed LA, Levy D, Levine RA, et. al. Prevalence and clinical outcome of mitral-valve prolapse. N.Engl.J.Med. 1999; 341:1-7.



4) Gilan D, Bounanno FS, Joffe MM, et. al. Lack of evidence of an association between mitral-valve prolapse and stroke in young patients. N.Engl.J.Med 1999; 341: 8-13.



5) Nishimura RA and McGoon MD. Perspectives of mitral-valve prolapse. N. Engl.J.Med 1999; 341:48-50.



6) Hegde BM. Auscultation for MVP. Lancet 1994; 344: 1446-47.



7) Hegde BM. Mitralklappen-Prolaps. German Medical Tribune 1995; 17: 36.

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