Recurrent Mitral Stenosis: Problems of Management

Abstract

Abbreviation: TEE 5 transesophageal echocardiography A 44-year-old woman was evaluated for the primary complaint of the sensation of rapid and irregular beating of the heart, which was intensified by exertion. This sensation had been apparent for approximately 2 months and was associated with increased fatigability. Her previous history disclosed that elsewhere, 21 years previously, she had undergone aortic valve replacement combined with mitral valvotomy, but the records of this event were unavailable. She had never previously noted a rapid or irregular heart rhythm, and the remainder of the history and review of systems was completely negative. Three weeks previously, her referring physician had initiated regular oral treatment with digoxin and warfarin. On examination, the BP was 130/80 mm Hg, and the pulse rate was estimated at 85 beats/min and irregular. Physical findings included a displaced apical impulse to 1 cm lateral to the midclavicular line. An accentuated first heart sound and a soft mitral opening snap were audible. Opening and closing sounds were compatible with a mechanical aortic prosthetic valve. There was a grade 2/6 apical pansystolic murmur together with a grade 2/6 mid diastolic rumbling murmur consistent with combined mitral stenosis and regurgitation. A grade 3/6 early systolic ejection murmur was noted at the base together with a soft, high-pitched (blowing) diastolic decrescendo murmur (grade 1/6) heard maximally at the mid-left sternal border and consistent with aortic regurgitation. The lungs were clear to auscultation, and the findings of the remainder of the examination were normal. The ECG disclosed atrial fibrillation with a ventricular response rate of 75 beats/min; ST-T abnormalities were consistent with the effect of digitalis. An echocardiogram disclosed an enlarged left atrium (diameter, 4.8 cm). The mitral valve was thickened and stenotic, with a valve area estimated by both direct planimetric measurement and Doppler echocardiographic assessment to be approximately 1.1 cm 2 . Mild-to-moderate mitral regurgitation was demonstrated. A mechanical prosthetic valve in the aortic position was visualized, and peak systolic gradient of 47 mm Hg across this structure was derived by Doppler echocardiographic assessment. Mild regurgitation was noted across this orifice. The left ventricular size and systolic motion were normal. There was mild-to-moderate tricuspid regurgitation, from which the right ventricular systolic pressure was estimated to be in the range of 30 to 40 mm Hg. Chest radiography disclosed a cardiac silhouette indicative of left atrial enlargement, but the lung fields were clear. A mechanical prosthetic aortic valve was present together with evidence of a previous sternotomy.