My mom was recently dianosed as having a severly enlarged heart and with
heart failure. After being treated for bronchitis in mid-June, my mom's condition
improved and then deteriorated in mid-July. Her doctor began working to
determine the cause by sending her for another chest x-ray, sending her for a
breathing test and then a thalium stress test. Based on the results of
these tests, she referred my mom to a cardiologist. The cardiologist
performed an echocardiogram that led her cardiologist to conclude that she
has heart failure and a severly enlarged heart. He said this could be caused
by blockage, a virus, or an "unknown" cause if the first two causes are
ruled out. A heart catherization was performed earlier this week and the
cardiologist did not find any blockage, therefore, he has concluded that
the damage has been caused by a virus. He has indicated that she has lost
about 70% of her heart. I have several questions that I would appreciate
1. How can we determine that this extensive damage has been caused by a
virus and wasn't actually caused by an "unknown"? Are there any tests that
can be performed to prove it is actually a viral cause?
2. The cardiologist indicated that sometimes a virus enters the body and
a person's immune system continues to attack the body after the virus
leaves. He said that, in my mom's case, the immune system happened to
attack her heart but it could have just as easily attacked another organ.
Therefore, he is suggesting that it is my mom's immune system that caused
the damage and not actually a virus (if I am remembering all of this
correctly). Does this sound correct? If so, how common is this? Can you
provide or refer me to any information on why her immune system would
attack her heart and why it would attack her heart over another organ?
How can we know that the virus is actually gone? How can we know that her
immune system is not continuing to damage her heart or another organ for
that matter? Should she also see another specialist to make sure there
isn't a problem with her auto-immune system?
3. The cardiologist indicated the the only treatment at this time is to
put her on the medications (diruetics, potassium, cumaden, and something to
strengthen her heart) and closely monitor her condition. Is there any
chance that some of her heart will become functional again and that she
could be left with more than 30% of her heart? He also indicated that she
has equal chances of her condition improving, staying the same or getting
worse. If her condition worsens, he would then consider heart transplant.
What is the outlook for a heart transplant for her if she is 65 and in very
good physical shape otherwise (has only been treated for high blood
pressure, mild arthritis and underactive thyroid)?
I would greatly appreciate any information you can provide. Thank you.
Dear Fran, thank you for your question. I'll answer your questions in order.
1) Viral Cause: I agree with everything that your cardiologist has told you. There is no effective way to determine whether the immune system or a virus has caused your mother's cardiomyopathy. Myocardial biopsies used to be performed to evaluate the cause of cardiomyopathy with normal coronary arteries (called dilated cardiomyopathy - DCM), but biopsies were not found to be useful for making a diagnosis nor for dictating treatment. Thus, biopsies are no longer performed for DCM. The viruses that cause cardiomyopathy are difficult to identify through available tests and since anti-viral therapy doesn't help DCM, there's no reason to exhaustively search for a virus.
2) Immune System: I understand your confusion with this diagnosis. The incidence of DCM is 36 causes per 100,000 population so it is uncommon. It's hard to understand why the immune system would attack the heart and not other organs, but the answer to your question is quite complex. Organs have different tissues that are recognized as different entities by the immune system. So, the heart could be affected since it has cell surface receptors that are not on other organs and is thus recognized as "unique" by the immune system. If your mother had a general dysfunction of her immune system, then she would manifest other symptoms like fevers, skin rashes, pulmonary dysfunction, kidney dysfunction, etc. Her internist, who sounds very thorough, would have picked up these changes if they were present. Thus, it appears that she does not have generalized immune system dysfunction and she does not need to see an immunologist. Likewise, I'm sure that she has had enough tests to determine if she has dysfunction of other organs. Whether the virus is "gone" or not is not relevant to your mother since her symptoms are stable which indicate that there is no active myocardial damage occurring at this point.
3) Recovery/Transplantation: I cannot predict whether she will improve or stay the same, but again, I agree completely with her management by her cardiologist. What he told you is correct. At age 65, your mother is nearing the upper age limits for heart transplantation (usually 70 years old), but if she required this therapy, she sounds like an excellent candidate. However, I must emphasize that only time will tell if she needs transplantation. Thus, it would be best to defer discussion about transplantation unless she does require it in the future because transplantation is a complicated topic that would require a lot of explanation.
I hope you find this information useful, but don't hesitate to have further discussions with your mother's cardiologist about her condition and treatment.
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