Thursday, April 30, 2009


I read in the newspaper today that the Sultan of Selangor has decided to go to Stanford University Hospital, California, USA for his mitral valve surgery. I had heard from the grapevine that HRH was unwell one evening with acute heart failure and his physician rushed to the palace to attend to him. He was subsequently admitted to the Sime Darby Medical Center where he recovered well. He was diagnosed, I believe with acute heart failure from mitral valve incompetence. What is the cause. Well, at his age, ischemic heart disease will have to be excluded. Whether it be chronic ischemic heart disease or acute ischemic heart disease, I am sure that his attending physician will determine, with all the facilities at his disposal. I must say that I am concern that the mitral valve must have ruptured rather badly and suddenly ( making an acute process likely ). Usually, if there is a leaky mitral valve, the chamber before the mitral valve viz the left atrial chamber accomodates the regurgitant stream and heart failure sets in rather more gradually, as compared to the aortic valve, where a torn cusp will cause a severe leak and the left ventricle will decompensate very rapidly. Of course, the usual cause of mitral regurgitation, ie chronic rheumatic heart is unlikely here as we all know HRH to be a very fit man and he must have had many physical examination, by many prominent cardiologist, in the past. For the same reason, I think that congestive cardiomyopathy, though should be considered is also unlikely.
Going to Stanford, would be a good decision for two very good reasons. I would not wish to speculate as to why he chose to go to Stanford. I can only say that the Stanford Cardiothoracic Surgical Unit was established by Dr Norman Shumway, of heart transplant pioneering fame. The unit is very competent, and has a very good research arm, that researches all the newest and the best. By the way, Prof Alan Yeung, is a cardiologist and head of the department of Cardiology in Stanford University, and not a cardiac surgeon as reported in some newspaper. Dr Yeung is a very competent and pleasant cardiologist, a friend whom I know and also a frequent visitor to the East, especially China. He also likes to come by here whenever invited. The Stanford Unit is also good, because they do have a very good coronary artery by-pass team ( should that be necessary ) and also they have a cardiac surgeon, who can do mitral valve repair surgery, as oppose to mitral valve replacement surgery, that many of our surgeons here, prefer to do. If the cause of the acute mitral regurgitation is ischemia, and the coronary angiogram shows significant coronary artery disease, then he may nee coronary artery bypass surgery ( CABG ) in addition to mitral valve surgery. Many of us feel that whenever possible, the mitral valve should be repaired, as opposed to replacement, as mitral valve repair have been shown to preserve left ventricular function better, and it also avoids the need for long-term anticoagulation. Mitral valve replacement witha mechanical mitral valve has the problem of affecting left ventricular function and also requires long term anti-coagulation, something the very energetic Sultan may prefer to avoid if possible. By going to Stanford with their expertise, all the options are open.
I wish HRH a very speedy recovery, and a return to the best of health, quickly. I can safely say that the whole state, and also the country is praying for him.

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