Abstract 13819: Case Report of a Mitral Stenosis in a Young Growing Teenager After Rheumatic Mitral Regurgitation Valve Repair

Abstract

Background: Mitral stenosis (MS) is a well- defined slowly progressive complication after mitral valve repair for non-rheumatic mitral regurgitation (MR) in adults. The pubertal growth spurt has potential hemodynamic implications for a mitral valve prosthesis matched prior to surgery for a projected indexed effective orifice area (EOA) using the lower pre-surgical body surface area (BSA) that preceded the growth spurt. The peak height velocity usually occurs at Tanner stage 3 in females and 4 in males. To our knowledge, there are no reports highlighting a rapid increase in Trans-Mitral pressure gradient (TMPG) and decline in mitral valve area (MVA) after rheumatic MR valve repair in an early pubescent child. Case presentation: A 14-year-old female presented with orthopnea, abdominal distension and bilateral lower limb edema. She was cachectic with a BMI (Body Mass Index) in the first percentile, a high-pitched holosystolic murmur most prominent at the cardiac apex, bilateral basal crackles, tender hepatomegaly, pitting pedal edema and jugular venous distension. Her Tanner’s stage was 2. Anti-streptolysin O (ASO) titer was elevated. The transthoracic echocardiography (TTE) revealed loss of the mitral valve central coaptation with leaflet restriction and MR. There was an annular dilatation of the Tricuspid valve and Tricuspid regurgitation (TR). She had AHA/ACC stage D mitral and tricuspid regurgitation. Tricuspid annuloplasty and mitral valve repair for rheumatic MR were respectively performed utilizing Carpentier Edward numbers 30 and 34, appropriate for her pre-surgical BSA. Following the surgery, the murmur of MR resolved and her MVA was 4cm 2 . In the first year after surgery, she attained Tanner’s stage 3, a peak growth velocity of 8.4 cm during that year and her BMI rapidly increased to the 10th percentile. However, towards the end of the year she developed progressive increase in TMPG and a decline in the mitral valve area to 1.2 cm 2 . Conclusion: Growth spurts during puberty can potentially affect MR repair as the Mitral valve prosthesis based on a preoperative BSA is outgrown. There is a need for research for planning, prognostication and development of an optimal, individualized and adaptable approach to MR intervention in early pubescence.