Download rheumatic stenoses of all four cardiac valves: a case report

Anatol J Clin Investig 2008:2(2):86-87
RHEUMATIC STENOSES OF ALL FOUR CARDIAC VALVES: A CASE REPORT
TÜM KALP KAPAKLARININ ROMATİZMAL STENOTİK TUTULUMU: VAKA RAPORU
Ednan BAYRAM1, Hasan KOCATÜRK2, Mehmet Cengiz ÇOLAK3, Murat MERİÇ1
1
2
3
Numune Hastanesi, Kardiyoloji Servisi, Erzurum, Türkiye
Şifa Hastanesi, Kardiyoloji Servisi, Erzurum, Türkiye
Şifa Hastanesi,kardiyovasküler Cerrahi Servisi, Erzurum, Türkiye
Abstract
Affection of all four valves is extremely uncommon feature of rheumatic heart disease. The few reports in the
literature of patients with rheumatic lesions of all four heart valves correspond to cases diagnosed at autopsy or
by cardiac catheterization, but reports of echocardiographic diagnosis are much rarer. Echocardiography is useful
for confirming clinical findings and allows assessment of the severity of valvular stenosis and regurgitation. (Anatol
J Clin Investig 2008:2(2);86-87).
Özet
Romatizmal kalp hastalıklarında kalbin dört kapağının da birlikte tutulması oldukça nadir bir durumdur. Bu konuda
literatürde çok az sayıda vaka vardır. Bu vakaların çoğunluğun tanısı otopsi veya kardiyak kateterizasyonla
konulmuştur, ancak ekokardiyografik olarak tanı konulan sayı oldukça azdır. Ekokardiografi kapakların yetersizliği
/ darlığını ve ciddiyetini saptayan klinik bulgularla uyumlu bir araçtır. (Anatol J Clin Investig 2008:2(2);86-87).
Introduction
Quadrivalvular rheumatic damage is more rare[1].
The few reports are available in the literature
describing of patients with rheumatic lesions of
all four heart valves [2,3]. To our knowledge, only
12 cases have been reported in the literature [110].
Echocardiography
provides
crucial
information in the evaluation of a patient with
suspected significant heart valve dysfunction,
and is can contribute to earlier diagnosis. Also
there are a few reports of echocardiographic
diagnosis of stenotic involvement of all four
cardiac valves [4].
Case report
A 41 year old man presented with exertional
dyspnea, palpitations and fatigue of 8-year
duration. He had New York Heart Association
class IV symptoms. Clinical findings suggested
severe stenosis of the mitral, aortic and tricuspid
valves with a history of rheumatic fever in
childhood. Chest X-ray radiography showed
gross cardiomegaly and was consistent with
pulmonary
arterial
hypertension.
The
electrocardiogram suggested severe left atrial
overload and right ventricular hypertrophy and
was in sinus rhythm. There were opening snaps
in the apex and in the lower left sternal border. A
grade 4 ejection murmur in the aortic area
conducted to carotids. Liver was palpable 3 -cm
below the right costal margin.
Transthoracic echocardiography revealed severe
aortic, mitral, and tricuspid valve stenoses and
calcium deposition on the tips of the pulmonary
valve with doming. The mitral and aortic valve
areas were 1 and 0.9 cm2, respectively. The
mean gradient across the mitral and tricuspid
Ednan BAYRAM
Numune Hastanesi, Kardiyoloji Servisi, Erzurum, Türkiye
E-mail: [email protected]
valve were 16 and 14 mm Hg, respectively. The
peak systolic gradient was 105 mm Hg across
the aortic valve and 57 mm Hg across the
pulmonary valve. There was minimal aortic and
pulmonary regurgitation and moderate tricuspid
regurgitation but no regurgitation over the mitral
valve.
Discussion
Affection of all four valves is an uncommon
feature of rheumatic heart disease, with stenosis
in all valves being still rarer [1]. The few reports
in the literature of patients with rheumatic lesions
of all four heart valves correspond to cases
diagnosed
at
autopsy
or
by
cardiac
catheterization, but reports of echocardiographic
diagnosis are much rarer [2-4]. Before the
development of echocardiography, cardiac
disease was diagnosed with a loud heart murmur
and clinical signs of congestive heart failure
(coughing, edema, venous distention, jugular
pulsations) detected on physical examination.
Earlier, pulmonary valve involvement was
diagnosed only at surgey [5]. This case
highlights the importance of preoperative
diagnosis of pulmonary valve involvement. The
late recognition of pulmonary stenosis on the
operating table extended the bypass time, which
probably contributed to the fatal complication of
disseminated intravascular coagulation [5].
There are a few reports of echocardiographic
diagnosis of rheumatic lesions of all four heart
valves [4]. Preoperative echocardiographic
diagnosis the involvement of all four cardiac
valves and successful surgical management has
also been reported [6].
Echocardiography is useful for confirming clinical
findings and allows assessment of the severity of
Rheumatic stenoses of all four cardiac valves: a case report
valvular stenosis and regurgitation [7,8], and can
contribute to earlier diagnosis. Also operator
awareness regarding possible involvement of all
four valves is essential for appropriate diagnosis
[9]. It is possible that by the time
echocardiography came into common use, the
incidence as well as the severity of rheumatic
heart disease had already been drastically
reduced. This could explain the rarity of
echocardiographic detection of quadrivalvular
rheumatic involvement, which seems to be the
case even in developing countries [10].
We reported in this patient with quadrivalvar
involvement by rheumatic disease, diagnosed
preoperatively by echocardiography, which
underwent successful surgical correction.
Figure 1. Transthoracic echocardiogram showing thickened and doming mitralvalve (A) and thickened aorta valve
(B).
Figure 2. Transthoracic echocardiogram showing thickened and doming tricuspid valve (A) and thickened
pulmonary valve (B).
References.
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