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Amaurosis following mitral commissurotomy
AMAUROSIS
FOLLOWING
MITRAL
COMMISSUROTOMY
O.HENRYJANTON, M.D., RICHARD A. BRUNNER, THOMAS J. E. O'NEILL, M.D., AND ROBERT P. GLOVER, M.D.
M.D.,
PA.
PHILADELPHIA,
reports concerning the results and the postoperative M ANY following mitral commissurotomy have been written.‘e6
complications The case described below of amaurosis following mitral commissurotomy is the first in our experience in 750 such operations and the first such complication reported to date. CASE REPORT A 34-year-old white male was admitted to the Presbyterian Hospital, Philadelphia, Pa.? on Jan. 18, 1955. The pertinent history indicated a rheumatic infection during childhood, otherwise the history was not remarkable. The present hospital admission was due to rapidly progressive pulmonary dysfunction during the past eight months, so that at the time of admissiou There had been numerous instances of the patient was barely able to walk half a city block. nocturnal dyspnea. The physical examination revealed a slender, cooperative and seemingly intelligent white male who was not orthopneic or cyanotic. There were no abnormal cervical vessel pulsations. Temperature was 98.2” F., pulse 76/min., respirations 20/min. and the blood pressure 118/80 mm. Hg. The heart was not enlarged to percussion, but there was a prominent apical impulse. The rhythm was regular, 76/min. A mitral diastolic thrill accompanied a Grade 3 mitral diastolic rumble with presystolic accentuation. A Grade 2, early, mitral systolic murmur was audible. MI and Pz were accentuated. The lungs and abdomen were normal. The peripheral vessels of all extremities were accessible and of normal volume, and no abnormal neurologic reflexes were noted. The laboratory data were as follows: with a normal differential; sedimentation negative; urinalysis was negative.
hemoglobin, 13.9 grams; white blood rate 6 mm. in one hour (Westergren).
*An electrocardiogram showed regular sinus Fluoroscopy and cardiac x-rays showed moderate tricle and calcification of the mitral valve.
rhythm and right ventricular enlargement of the left atrium
count, Serology
7600, was
hypertrophy. and right ven-
The patient was considered an excellent surgical risk for operation, and a mitral commissurotomy was done on Jan. 13, 1955. No thrombotic material was detected in the left atrium or appendage. The mitral orifice barely admitted the tip of the index finger of the surgeon (RPG). The cusp margins were heavily beaded with calcium, and the valve leaflets were greatly thickened The commissures were heavily scarred and the posteroand little, if any, mobility was felt. Both commissures were opened medial one was the site of maximum deposition of calcium. From
the Departments Philadelphia, Pa. Received for publication
of
Cardiology,
Neurology,
Hospital,
May
2. 1955. 948
and
Thoracic
Surgery.
The
Presbyterian
JANTON
ET
AL.
:
AMAUROSIS
AFTER
MITRAT,
COMMISSITROTOMY
949
with considerable difficulty using the guillotine knife, although the resulting enlargement of the mitral orifice was but 1.5 cm. It was speculated at this time that “a piece of calcium might have been dislodged.” The procedure was well tolerated, and the operating time was one and one-half hours. Postoperatively the patient awakened with a left hemiplegia, the signs of which disappeared in the first four hours except for some loss of coordination of the movements of the fingers. Rut his most persistent and striking complaint was, “I am blind; I can’t see anything.” The patient seemed rational and cooperative, and at first it was conjectured that a cerebral embolus might be the cause of this symptom. The likelihood of this being true was most improbable in view of a normal ophthalmologic examination, the relatively normal neurologic findings, and the physical condition of the patient. However, the patient continued to complain that he was unable to see; thus, somewhat in desperation a psychiatrist was consulted. The psychiatric examination on Feb. 18, 1955 revealed the patient to be irritable but only mildly indisposed by his visual deficit. He appeared to be in good contact with his surroundings, and his answers were coherent and relevant. Of singular note was his spontaneously expressed idea that he would be “better off dead.” There was little affective correlation of this idea. Questioning evoked a denial of tension, irritability, anxiousness, or nervousness either at present or in the past. He specifically stated that he had not been disturbed in any way by his heart condition or his recent cardiac surgery. His reaction to his amaurosis was one of almost complete indifference. There was evidence in his personality make-up of marked passive dependent traits sharply evidenced by the way he related himself to others and his failure to take responsibility for his own welfare. Additional history elicited from the family disclosed that the patient had ality change a few months prior to surgery. He suffered from disturbance had frequent anxiety attacks, and had become more morose and irritable. of alcohol was a major problem in married life and irascibility had increased dissolution of marriage appeared imminent.
undergone a personof his sleep pattern, His intemperate use to such a point that
It was evident that this patient was returning to a state of complete dependence on his mother, and psychiatric hospitalization was recommended. However, this was energetically declined. Worthy of note was the patient’s description of visual impressions that he “sees” on the blank wall of his room. These appeared hypnagogic in type. Recent communications indicate that his cardiac has persisted unchanged for the past three months. psychiatric treatment. DISCUSSION
AND
status is excellent, but The patient steadfastly
his visual complaint avoids and refuses
SUMMARY
It has frequently been pointed out that one of the dread complications of mitral commissurotomy is that of cerebral embolism, and in this instance the transient hemiplegia was most probably caused by dislodgement of a piece of calcium during the procedure. However, there has been no documentation of amaurosis as a complication with or without hemiplegia. In view of the fact that this complication had never presented itself after some 750 operations and the fact that much conjecture and speculation arose as to the possible cause, we felt such a report was worthwhile. It was only after the disappearance of the hemiplegia and the continuation of normal ophthalmologic findings that the patient was considered to have a severe psychic disturbance. SUMMARIO
IN
INTERLINGUA
Es presentate un case de amaurosis occurrente coma complication operative immediatemente post le execution de commissurotomia mitral.
postNulle
950
,\MI
HEART
JOIJRNAI.
altere tal case se trova in le litteraturn. In lor experientias con 7.50 rommissurotomias mitral le autores non ha incontrate ulle case comparabile. Le report0 es publicate proque le case ha provocate multe speculationes e conjecturas in re su possibile etiologia e etiam proque illo esseva accompaniate de transiente hemiplegia sinistre. Al tempore de1 presente reporto, i.e. tres menses post le operation, le patiente exhibi un excellente resultato cardiovascular, sed su amaurosis persiste. Since the submission of this paper for publication another missurotomy has been brought to the attention of the author.
of
following
mitral
REFERENCES 1. 2. 3. 4. 5. 6. 7.
Janton,
0. H., Glover, R. P., O’Neill, T. J. E., Gregory, J, E., and Froio, G. F.: Results of the Sureical Treatment for Mitral Stenosis (Analvsis Consecutive \ , of One Hundred Cases), C&ulation 6:321, 1952. Soloff, L. A., Zatuchni, J., Janton, 0. H., O’Neill, T. J. E., and Glover, Ii. P.: Reactivation of Rheumatic Fever Following Mitral Commissurotomy, Circulation 8:489, 1953. Glover, R. P., O’Neill, T. J. E., Harris, J., and Janton, 0. H.: The Indications for and the Results of Commissurotomy for Mitral Stenosis, J. Thoracic Surg. 25:.5.5, 1953. Harken, D. E., Ellis, L. B:, Dexter, L., Farrand, R. E., and Dickson, J. F., III.: The Responsibility of the Physician in the Selection of Patients With Mitral Stenosis For Surgical Treatment, Circulation 5:349, 1952. Ellis, L. B., and Harken, D. E.: The Clinical Results in the First Five Hundred Patients With Mitral Stenosis Undergoing Valvuloplasty, Circulation 11:637, 1955. Fox, H. M., Rizzo, N. D., and Gifford, S.: Psychological Observations of Patients Undergoing Mitral Surgery, AM. HEART J. 48:645, 1954. Haring, Olga M.: Personal communication.
FOLLOWING
MITRAL
COMMISSUROTOMY
O.HENRYJANTON, M.D., RICHARD A. BRUNNER, THOMAS J. E. O'NEILL, M.D., AND ROBERT P. GLOVER, M.D.
M.D.,
PA.
PHILADELPHIA,
reports concerning the results and the postoperative M ANY following mitral commissurotomy have been written.‘e6
complications The case described below of amaurosis following mitral commissurotomy is the first in our experience in 750 such operations and the first such complication reported to date. CASE REPORT A 34-year-old white male was admitted to the Presbyterian Hospital, Philadelphia, Pa.? on Jan. 18, 1955. The pertinent history indicated a rheumatic infection during childhood, otherwise the history was not remarkable. The present hospital admission was due to rapidly progressive pulmonary dysfunction during the past eight months, so that at the time of admissiou There had been numerous instances of the patient was barely able to walk half a city block. nocturnal dyspnea. The physical examination revealed a slender, cooperative and seemingly intelligent white male who was not orthopneic or cyanotic. There were no abnormal cervical vessel pulsations. Temperature was 98.2” F., pulse 76/min., respirations 20/min. and the blood pressure 118/80 mm. Hg. The heart was not enlarged to percussion, but there was a prominent apical impulse. The rhythm was regular, 76/min. A mitral diastolic thrill accompanied a Grade 3 mitral diastolic rumble with presystolic accentuation. A Grade 2, early, mitral systolic murmur was audible. MI and Pz were accentuated. The lungs and abdomen were normal. The peripheral vessels of all extremities were accessible and of normal volume, and no abnormal neurologic reflexes were noted. The laboratory data were as follows: with a normal differential; sedimentation negative; urinalysis was negative.
hemoglobin, 13.9 grams; white blood rate 6 mm. in one hour (Westergren).
*An electrocardiogram showed regular sinus Fluoroscopy and cardiac x-rays showed moderate tricle and calcification of the mitral valve.
rhythm and right ventricular enlargement of the left atrium
count, Serology
7600, was
hypertrophy. and right ven-
The patient was considered an excellent surgical risk for operation, and a mitral commissurotomy was done on Jan. 13, 1955. No thrombotic material was detected in the left atrium or appendage. The mitral orifice barely admitted the tip of the index finger of the surgeon (RPG). The cusp margins were heavily beaded with calcium, and the valve leaflets were greatly thickened The commissures were heavily scarred and the posteroand little, if any, mobility was felt. Both commissures were opened medial one was the site of maximum deposition of calcium. From
the Departments Philadelphia, Pa. Received for publication
of
Cardiology,
Neurology,
Hospital,
May
2. 1955. 948
and
Thoracic
Surgery.
The
Presbyterian
JANTON
ET
AL.
:
AMAUROSIS
AFTER
MITRAT,
COMMISSITROTOMY
949
with considerable difficulty using the guillotine knife, although the resulting enlargement of the mitral orifice was but 1.5 cm. It was speculated at this time that “a piece of calcium might have been dislodged.” The procedure was well tolerated, and the operating time was one and one-half hours. Postoperatively the patient awakened with a left hemiplegia, the signs of which disappeared in the first four hours except for some loss of coordination of the movements of the fingers. Rut his most persistent and striking complaint was, “I am blind; I can’t see anything.” The patient seemed rational and cooperative, and at first it was conjectured that a cerebral embolus might be the cause of this symptom. The likelihood of this being true was most improbable in view of a normal ophthalmologic examination, the relatively normal neurologic findings, and the physical condition of the patient. However, the patient continued to complain that he was unable to see; thus, somewhat in desperation a psychiatrist was consulted. The psychiatric examination on Feb. 18, 1955 revealed the patient to be irritable but only mildly indisposed by his visual deficit. He appeared to be in good contact with his surroundings, and his answers were coherent and relevant. Of singular note was his spontaneously expressed idea that he would be “better off dead.” There was little affective correlation of this idea. Questioning evoked a denial of tension, irritability, anxiousness, or nervousness either at present or in the past. He specifically stated that he had not been disturbed in any way by his heart condition or his recent cardiac surgery. His reaction to his amaurosis was one of almost complete indifference. There was evidence in his personality make-up of marked passive dependent traits sharply evidenced by the way he related himself to others and his failure to take responsibility for his own welfare. Additional history elicited from the family disclosed that the patient had ality change a few months prior to surgery. He suffered from disturbance had frequent anxiety attacks, and had become more morose and irritable. of alcohol was a major problem in married life and irascibility had increased dissolution of marriage appeared imminent.
undergone a personof his sleep pattern, His intemperate use to such a point that
It was evident that this patient was returning to a state of complete dependence on his mother, and psychiatric hospitalization was recommended. However, this was energetically declined. Worthy of note was the patient’s description of visual impressions that he “sees” on the blank wall of his room. These appeared hypnagogic in type. Recent communications indicate that his cardiac has persisted unchanged for the past three months. psychiatric treatment. DISCUSSION
AND
status is excellent, but The patient steadfastly
his visual complaint avoids and refuses
SUMMARY
It has frequently been pointed out that one of the dread complications of mitral commissurotomy is that of cerebral embolism, and in this instance the transient hemiplegia was most probably caused by dislodgement of a piece of calcium during the procedure. However, there has been no documentation of amaurosis as a complication with or without hemiplegia. In view of the fact that this complication had never presented itself after some 750 operations and the fact that much conjecture and speculation arose as to the possible cause, we felt such a report was worthwhile. It was only after the disappearance of the hemiplegia and the continuation of normal ophthalmologic findings that the patient was considered to have a severe psychic disturbance. SUMMARIO
IN
INTERLINGUA
Es presentate un case de amaurosis occurrente coma complication operative immediatemente post le execution de commissurotomia mitral.
postNulle
950
,\MI
HEART
JOIJRNAI.
altere tal case se trova in le litteraturn. In lor experientias con 7.50 rommissurotomias mitral le autores non ha incontrate ulle case comparabile. Le report0 es publicate proque le case ha provocate multe speculationes e conjecturas in re su possibile etiologia e etiam proque illo esseva accompaniate de transiente hemiplegia sinistre. Al tempore de1 presente reporto, i.e. tres menses post le operation, le patiente exhibi un excellente resultato cardiovascular, sed su amaurosis persiste. Since the submission of this paper for publication another missurotomy has been brought to the attention of the author.
of
following
mitral
REFERENCES 1. 2. 3. 4. 5. 6. 7.
Janton,
0. H., Glover, R. P., O’Neill, T. J. E., Gregory, J, E., and Froio, G. F.: Results of the Sureical Treatment for Mitral Stenosis (Analvsis Consecutive \ , of One Hundred Cases), C&ulation 6:321, 1952. Soloff, L. A., Zatuchni, J., Janton, 0. H., O’Neill, T. J. E., and Glover, Ii. P.: Reactivation of Rheumatic Fever Following Mitral Commissurotomy, Circulation 8:489, 1953. Glover, R. P., O’Neill, T. J. E., Harris, J., and Janton, 0. H.: The Indications for and the Results of Commissurotomy for Mitral Stenosis, J. Thoracic Surg. 25:.5.5, 1953. Harken, D. E., Ellis, L. B:, Dexter, L., Farrand, R. E., and Dickson, J. F., III.: The Responsibility of the Physician in the Selection of Patients With Mitral Stenosis For Surgical Treatment, Circulation 5:349, 1952. Ellis, L. B., and Harken, D. E.: The Clinical Results in the First Five Hundred Patients With Mitral Stenosis Undergoing Valvuloplasty, Circulation 11:637, 1955. Fox, H. M., Rizzo, N. D., and Gifford, S.: Psychological Observations of Patients Undergoing Mitral Surgery, AM. HEART J. 48:645, 1954. Haring, Olga M.: Personal communication.