Dear Doctors: At age 51, I was diagnosed with severe rheumatic mitral stenosis. After a second round of tests, treatment was changed from open-heart surgery to balloon valvuloplasty. What can I do to help the results last? Should open-heart surgery be considered instead?

Dear Reader: The heart is a powerful muscle with precisely timed contractions that deliver blood with oxygen to the lungs. It also sends blood and oxygen to vessels and tissues throughout the body. The entrances and exits of the heart’s four chambers seal with thin, flexible leaflets of connective tissue known as valves. Their purpose is to make sure blood flows one way. Valves can have structural problems that affect their function. Stenosis, or narrowing, is one of these problems. In your case, the stenosis is in your mitral valve. This valve separates the left atrium (upper left chamber) of the heart from the left ventricle (lower left chamber). When rheumatic fever causes valve dysfunction, as in your case, it’s called rheumatic mitral stenosis.

This narrowing of the valve impedes the flow of blood into the left ventricle. It forces the heart muscle to work harder and causes pressure to build upstream. This can lead to an enlarged left atrium, heart arrhythmia, high blood pressure in the lungs and heart failure. A decrease in blood flow can cause symptoms such as fatigue, dizziness and fainting. More serious symptoms include systemic fluid buildup known as edema, frequent respiratory infections, coughing up blood and the formation of blood clots, which can cause a stroke.

Treatment depends on the degree of damage to the mitral valve. If it is thin, flexible, with little scarring and minimal backflow of blood, valvuloplasty can be an option. Valvuloplasty is a catheter repair usually done by a cardiologist. They insert a thin tube into the heart through a vein, typically through the groin. Then they insert a tiny balloon through the tube. They inflate the balloon slowly to stretch and expand the mitral valve. If the valve leaflets are too thick or have fused together, the valve may need replacing. This requires open-heart surgery. Rheumatic mitral stenosis often causes this degree of valve damage.

To determine the best path forward, you need to work with a cardiologist. They will review the tests you had and can understand why your recommended treatment may have changed. They’ll likely order additional testing. If imaging tests confirm the mitral valve is in good condition, the minimally invasive catheter repair may be the best approach.

Whichever treatment path you follow, there are a few things you can do to make the repair last as long as possible. Take all prescribed medications exactly as directed, keep blood pressure under control and regularly follow up with your cardiologist. Treat infections such as strep promptly, prevent recurrent infections and maintain good dental hygiene. These steps will all help give your heart the best chance at longevity.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: I have problems with circulation in my hands. I came across information about something called Raynaud's phenomenon and want to know if that is happening to me. Where does one go to get the nail fold test that was mentioned? My rheumatologist does not do it.

Dear Reader: Raynaud’s phenomenon is an episodic circulatory condition. The small arteries that bring blood to the extremities suddenly contract. Also known as Raynaud's syndrome, the condition typically affects the fingers, but it can happen in toes as well. Cold temperatures trigger these spasms. They may also be a response to stress. The spasms make these vessels narrow enough to reduce or even temporarily stop blood flow to the area. This also affects flow to smaller blood vessels downstream.

This sudden loss of blood flow to the extremities often causes a feeling of numbness. It also makes the affected tissue turn white, or sometimes bluish-purple. When an episode is over, blood flow returns. The skin then often turns red. The person may experience a throbbing pins-and-needles feeling. In severe cases, the repeated loss of blood flow can cause sores to form on the fingers or toes. And while rare, it is possible for the repeated spasms to lead to tissue death.

Raynaud’s phenomenon falls into two categories of diagnosis. When there is no known cause, it is known as primary Raynaud's. This is the most common form. It typically arises between the ages of 15 and 25. When Raynaud's is linked to another disease or condition, it is known as secondary Raynaud's.

Secondary Raynaud's is often a sign of an underlying autoimmune or connective tissue disorder. These can include lupus, scleroderma and rheumatoid arthritis. Thyroid disorders, certain blood disorders and pulmonary hypertension can also play a role. Secondary Raynaud's has also been linked to physical damage to the affected tissues, as can occur due to repetitive actions, exposure to chemicals, the adverse effect of certain medications or medical treatments, and hand or foot injuries.

Because the presence of Raynaud's phenomenon can signal an underlying condition or illness, it is important to get an accurate diagnosis. This can be done with a nailfold capillaroscopy, the test you are asking about. It’s a microscopic look at the tiny capillaries at the base of the fingernail. The capillaries lie flat here and are easier to see. In primary Raynaud's, the vessels will appear normal. But because secondary Raynaud's arises from vascular injury due to an underlying disease, these vessels will show signs of structural damage.

Nailfold capillaroscopy is not a routine in-office test. As a result, many doctors, like your own, do not offer it. The test requires special magnification equipment and training to interpret the findings accurately. Look for a rheumatologist who specializes in connective tissue disease or a dermatologist with an interest in vascular or autoimmune skin disease. You’ll most likely find this test available at a large medical center, university hospital or specialty clinic with a focus in these diseases.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: My 31-year-old daughter has leg cramps, fatigue and brain fog. Her apartment tested positive for mold, and she was told she has CIRS. She started a treatment called the Shoemaker protocol. Are either of those medically recognized? Might other causes or cures be overlooked?

Dear Reader: Your daughter has been diagnosed with what some clinicians refer to as chronic inflammatory response syndrome, often called CIRS. Proponents of the diagnosis describe it as a systemic inflammation that involves multiple organ systems. They believe it’s an immune system response to exposure to mold, fungi or other toxins in the environment. This exposure can often occur in water-damaged buildings. However, CIRS is not widely seen as an established medical diagnosis. Almost everything about it remains the subject of research and ongoing debate. This includes the criteria for diagnosis, biomarkers and ways to treat it.

There is clear agreement on one point: Molds and other forms of fungal growth can pose serious health risks. This is particularly true when their growth is extensive or there’s long-standing exposure. Symptoms often vary a lot from person to person. This can make it hard to identify a mold-related illness. Symptoms can include nasal congestion; sore throat; and red, watery or itchy eyes. Respiratory symptoms include tight chest, wheezing and difficulty breathing. Skin symptoms include irritation like a rash or dermatitis. Even headache and fatigue can be symptoms.

Another challenge with mold-related illness is effective treatment. Fungi are more closely related to humans than bacteria. That makes it hard to develop drugs that can eliminate fungi without harming human cells. A few antifungal medications do exist. Often their use is limited to specific fungal infections. Many chronic or environmental illnesses from mold exposure rely on removing the source of exposure. Then it’s about managing symptoms, usually not relying solely on antifungal medications.

This gap in available treatments has opened the door to treatments like the Shoemaker protocol. It’s a multi-step approach that starts with testing for mold or moisture problems. Test results may signal exposure to fungal toxins. Then, it focuses on removing sources of exposure. The patient can be tested for certain biomarkers that are believed to signal the presence of CIRS. Then there’s a course of off-label treatment with medications. The idea is the medications bind to toxins so they can be excreted in the stool.

The Shoemaker protocol is as disputed as the syndrome it is meant to treat. One concern is that a focus on CIRS may delay other diagnoses. Other causes could be missed. In a more conventional medical path, a doctor would explore other causes for your daughter’s symptoms. These could include endocrine disorders, vitamin deficiencies, electrolyte imbalance, central nervous system disorders and peripheral neuropathies. Undiagnosed asthma, Lyme disease, sleep disorder and autoimmune conditions could also be checked. If your daughter's current approach doesn't bring relief, consider encouraging her to seek a broader medical evaluation.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

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