John B. Barlow

Barlow syndrome- 1960

Chinese saying goes

“when drinking the water, think of the men who dug the well”

Rare Snap

• with the house staff of the Johannesburg Hospital, autographed by each, following a lecture by the author.

How do we remember him

• Most complete and accomplished cardiologist of his generation, not only in South Africa but also in the world at large

• Innovative mind

• Limitless energy

• Lifelong enthusiasm

• Great sense of humour

• Selfless dedication to principles

Affiliation

• University of the Witwatersrand, from which he was graduated in 1951 and where he was a Professor and Director of Cardiology and its Research Unit and Physician-in-charge, Cardiac Clinic, Johannesburg Hospital since 1971.

Known for

• Barlow entered the international cardiology scene in 1963 with publication of his landmark paper on the mid-systolic click and late systolic murmur associated with billowing of the mitral valve leaflets and mitral regurgitation , which was subsequently known as the Barlow syndrome. It was Barlow's efforts to clarify the features of non-ejection systolic click and late systolic murmur that started the whole “mitral valve prolapse” saga.

The greatest also put into test

• This auscultatory phenomenon up till then was generally considered to be extracardiac in origin caused by pleuro-pericardial adhesions. Barlow's discovery was so controversial at the time that it did not win acceptance easily. In fact, Barlow's paper was not accepted for publication in the journal Circulation , to which it was first submitted . When Barlow later visited Baltimore, Victor McKusick, who was the “Heart Sounds” editor of Circulation during the time when Barlow's original article was rejected, graciously offered Barlow the Conjoint Clinic Forum at the Johns Hopkins Hospital and subsequently published Barlow's presentation in theJournal of Chronic Disease . Also, it was during Barlow's visit to the Johns Hopkins Hospital in 1964 that he met John Michael Criley who introduced the term ‘prolapse’ of the mitral valve 10 . Although Barlow never liked using the term ‘prolapse’ and preferred the term ‘billowing’ mitral leaflet ,he had the highest respect for Criley.

Tsung O. Cheng’s comment on Barlow

“Barlow and I visited each other frequently, oftentimes with our family . His office in Johannesburg Hospital had a rather cluttered desk , just like mine in the George Washington University Medical Centre . He always reminded me of what Albert Einstein said about a cluttered desk: “If a cluttered desk is a sign of a cluttered mind, of what then is an empty desk?”.

Privacy

In his memory

Barlow was adamant

• Barlow syndrome is also called mitral valve prolapse syndrome, although Barlow never liked the term ‘prolapse’. The term ‘prolapse’ was introduced in 1966 by Criley of Johns Hopkins Hospital — where he was a medical resident while I[Tsung O. Cheng] was a fellow in medicine (1957–1959) —based on the characteristic cine-angiographic appearance of the prolapsing mitral valve leaflet into the left atrium following left ventricular injection of the contrast substance in patients with a mid-systolic click and a late systolic murmur . Barlow was adamant about the distinction between the term ‘prolapsing mitral valve’, which he disliked, and ‘billowing mitral valve’, which is the term he preferred . “‘Billowing’ and ‘floppy’ describe the anatomical or pathological status of the mitral valve, whereas ‘prolapse’ and ‘flail’ describe function. Thus a prolapsed or flail mitral valve may be due to other causes (e.g., trauma, rheumatic carditis, infection, papillary muscle dysfunction or displacement) besides the prevalent degenerative condition”.

His letter-to-the-editor published in Circulation in 1998 - aortic stenosis• “….We wish to endorse the crucial but neglected role of exercise testing in the

management of patients with “asymptomatic” hemodynamically significant aortic stenosis. Stress testing is particularly pertinent before a decision is made to postpone surgical treatment. It is not only in the United States, as stated by Carabello but also in the United Kingdom and in our own environment that there is some reluctance “to exercise patients with aortic stenosis for fear that such patients were at high risk for complications during the test.” That philosophy is illogical when it is realized that such patients will inevitably exert themselves during their everyday lives, such as when late for an appointment or running for a bus. It is surely much safer to risk ‘complications’ during or after a supervised treadmill test when adverse events can immediately be managed by experts and with appropriate facilities available. Several years ago we were referred an elderly colleague with calcific aortic stenosis who insisted that he regularly played 18 holes of golf without a golf cart. Exercise was stopped early on the treadmill because of depressed ST segments. Three minutes after effort, the heart rate decreased dramatically, the ST segments were depressed 6 mm, and the blood pressure was unrecordable. Elevation of his legs, administration of intravenous isoproterenol, and other measures reversed his parlous state. What would have happened on the golf course? This is anecdotal, but anecdotes remain instructive.”

Withstand criticism

• Barlow in his medical practice had patients from all walks of life ranging from the under-privileged black children from Soweto (an acronym, which stands for South West Township, a city situated southwest of Johannesburg ), to the late South African President Nelson Mandela, to whom Barlow was a personal physician . Barlow in 1972 undertook a large epidemiological study to determine the clinical prevalence of rheumatic heart disease in over 12,000 Soweto schoolchildren . The overall rate of rheumatic heart disease was the highest reported in the world at that time, with an overall prevalence of 6.9 per 1000 and a peak rate of 19.2 per 1000 in those aged between 15 and 18. This survey remains a landmark with respect to rheumatic heart disease. However, he was criticised badly for stating evidence of the poor socio-economic condition in the South African Black community when this work published in BMJ

The quote he likes most

• Barlow enjoyed teaching, at which he was very good and to which he was fully and enthusiastically committed. He often quoted the Chinese proverb, about which I mentioned to him during one of my visits with him, “If you are planning for a year, sow rice; if you are planning for a decade, plant trees; if you are planning a lifetime, educate people.”

We have more remember him in echo era

• Echocardiography in the 1980s that propelled Barlow syndrome into its current prominent status of vast worldwide interest

• One of the two most common congenital anomalies of the heart

• The commonest cause of mitral regurgitation in developed countries , we should never forget the primary role of Barlow in introducing this entity in the.

You always with us

• He died from respiratory failure on December 10, 2008 in Johannesburg, South Africa at the age of eighty four