Very early complication of rheumatic heart disease (valvuloplasty for severe mitral valve stenosis for 6 year old male patient)

Abstract

Rheumatic heart disease continues to contribute greatly to the burden of cardiovascular disease in Yemen, It’s usual to see a lot of advance RHD cases in adult in Yemen but in pediatric it is rare to see such advance case specially under the age of eight. Case report A.M, a 6 year old Yemeni male child was seen in September 2012 with history of recurrent breathlessness which started about 4 years earlier. His symptoms worsened in the previous three weeks when he became breathless at rest, had paroxysmal nocturnal dyspnea, huge abdominal distention, bilateral leg swelling and cough productive of whitish sputum. Past history was not significant for recurrent sore throat but he was diagnosed to have RHD at age of 3 year old without any farther follow up and irregular using to long acting penicillin. He was the second child in his family; both parents are in a very low income group. There was no family history of the disease in any of his siblings. Examination revealed that the child looked marasmic, pale, was chronically ill, and had a tinge of jaundice with bilateral pitting pedal edema. A cardiovascular system examination revealed a pulse rate of 101 per minute, regular and small volume, blood pressure of 90/60 m mmHg, elevated jugular venous pressure, displaced apex beat which was located at 5th intercostal space anterior axillary line, loud first and second heart sounds opening snap and mid diastolic rumbling murmur with systolic murmur at left parasternal border. The respiratory rate was 26 cycles per minute and bilateral crepitations. Other examination findings were visible dilated abdominal vein, a tender, pulsatile hepatomegaly of 3 cm below the right coastal margin and massive ascites. An echocardiography showed densely thickened mitral valves with severe commissural fusion leading to doming of the mitral valve in diastole, markedly dilated left atrium, normal left ventricular eject ion fraction, markedly dilated right atrium and right ventricle. Colour flow showed severe tricuspid regurgitation and severe pulmonary hypertension. The calculated mitral valve area is 0.6 cm square and pressure gradient max/mean (14/6 mmHg) respectively. ECG sinus rhythm normal axis and dilated LA with RBBB Complete blood count showed low HB 9 mg/dl with normal a white cell count. The chest X-ray revealed cardiomegaly with a double cardiac shadow positive mitralization sign. He was placed on diuretics (furosemide and low-dose spironolactone) Angiotensin Converting Enzyme inhibitor (Lisinopril), intranasal oxygen, intravenous heparin and antibiotics. And was prepared for percutaneous mitral valvuloplasty On the third day of admission, The PMVP was done with good out come the mitral valve area increase from 0.6 to 1.8 cm 2 and decrease in the pressure gradient to 6/4 mmHg and the pulmonary hypertension to mild. After that patient condition get better with improving to the dyspnea, the child become more active start to eat and play more frequent than before with decrease to the abdominal distension and the patient discharge to home in good condition and advice to follow up the hospital after six month. Discussion Rheumatic heart disease, no doubt remains a disease with great morbidity and mortality in most low and middle income countries specially in Yemen despite been having almost eradicated in high income countries, it affects the young population of our community whom presented late most of the time with complication due to the shortage of the medical service in the most of the regain of Yemen specially the remote areas. The case being presented typifies the cost of late presentation in patients with rheumatic heart disease. its usual in our country to see such cases in late stage and complicated but it’s rare to see a 6 year old child presented with severe mitral stenosis and he needed PMVB even it is successful procedure that saved his live but all that could be prevented from happening in the first place by a simple preventive program which we do not have in our country.