Worsening Dyspnea in a 38-Year-Old Woman

Abstract

A 38-year-old Hispanic woman with longstanding exertional dyspnea sought medical attention because of the recent onset of paroxysmal nocturnal dyspnea. Cardiac physical examination revealed murmurs of mitral stenosis and regurgitation, a prominent a wave in the jugular venous pulse, and a loud pulmonic valvular closure sound. An electrocardiogram showed sinus rhythm, left atrial enlargement, right axis deviation of the QRS complex, and an R/S ratio in lead V1 > 1.0 with a negative T V1, suggesting right ventricular hypertrophy (Figure 1). Figure 1. Electrocardiogram soon after admission showed left atrial enlargement (negative terminal P-wave deflection in lead V1 ≥ 0.1 mV and 0.04 s in duration) (2) and right ventricular enlargement (right axis deviation of the QRS complex and R/S ratio ... At cardiac catheterization, the pressures (mm Hg) were 64/30 in the pulmonary artery, 65/8 in the right ventricle, a mean of 7 in the right atrium with a waves of 10 and v waves of 7, a mean of 26 with a waves of 17 and v waves of 38 in the pulmonary arterial wedge position, and 96/6 in the left ventricle. The cardiac output by thermodilution was 3.4 L/min, which together with a 16 mm Hg mean diastolic pressure gradient between pulmonary arterial wedge and left ventricle gave a calculated mitral valve area of 0.7 cm2 (Figure 2). Angiocardiography revealed mild mitral regurgitation, trivial tricuspid regurgitation, and no aortic regurgitation. Figure 2. Simultaneous pulmonary arterial wedge and left ventricular pressure tracings showing a 16 mm Hg mean diastolic pressure gradient across the mitral valve (MVG). The pressure scale on each side of the tracing is in mm Hg. DFP indicates diastolic filling ... Rheumatic heart disease is the cause of mitral stenosis in most adults. Because of the steady decrease in the incidence of acute rheumatic fever over the past 75 years in the United States, mitral stenosis is now uncommon here and is most often seen in older patients and, as in this patient, in immigrants from less developed countries (1). Clinical evaluation is usually sufficient for making a diagnosis of mitral stenosis (1). The electrocardiogram can be helpful in this regard, but the history, physical exam, chest radiograph, and especially the echocardiogram are usually more helpful. Nevertheless, electrocardiographic evidence of left atrial enlargement and right ventricular hypertrophy in a dyspneic young immigrant woman from an underdeveloped country puts mitral stenosis toward the top of the list of diagnostic possibilities.