Brief Comunication |
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Concurrent diagnosis of rheumatic mitral stenosis and aortoarteritis: |
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Introduction Case Report At that time, her shortness of breath had worsened, with occasional episodes of paroxysmal nocturnal dyspnoea, palpitations and a general feeling of tiredness. On examination, her pulse was 96 beats per minute and blood pressure was 156/90 mmHg. Cardiovascular examination revealed a left parasternal heave, a tapping apex, with loud and palpable 1st and 2nd heart sounds as well as an opening snap. There was a grade 3 mid-diastolic murmur at the apex – all findings consistent with her primary diagnosis of mitral stenosis. ECG showed normal sinus rhythm with right axis deviation, right ventricular hypertrophy with strain and biatrial enlargement. The chest X-ray showed signs of pulmonary venous hypertension. Routine blood investigations were within normal limits. |
Her transthoracic echocardiogram showed a pliable, non-calcific mitral valve with a typical rheumatic appearance. The mitral valve area was 0.7 cm2 with gradients of 31/22 mmHg. There was trivial mitral and tricuspid regurgitation. The estimated pulmonary artery systolic pressure was 100 mmHg. However, routine pulse wave doppler of the abdominal aorta showed continuous flow. There was an apparent narrowing at the lower end of the thoracic aorta on colour doppler with a gradient of 65/9 mmHg. Since a balloon mitral valvotomy was planned a trans-oesophageal echocardiogram was done, which showed the absence of clot in the left atrium and atrial appendage. Posterior rotation of the probe allowed closer examination of the descending aorta, which confirmed a narrowing at the junction of the thoracic and abdominal aortae. The irregularity of this narrowing was suggestive of type IV aortoarteritis, based on a newer system of classification of this condition.1 Treatment was carried out at two separate catheterisations. Being the distal lesion, the aortic narrowing was dilated first. This was to prevent increased pressure on the previously unexposed left ventricle, had the mitral stenosis been treated first and the aortic narrowing remained. The stenosed aortic segment was visualised on angiography (Fig. 1). There were no lesions seen in any other arteries. Pre-dilatation pressures were measured, and found to be 148/88 mmHg in the thoracic aorta and 77/63 mmHg in the abdominal aorta (distal to the narrowing), with the peak gradient calculated as 73 mmHg. The lesion was successfully stented with a 12 by 20 mm self-expanding Symphony nitinol-coated stent (Medi-tech, Boston Scientific Corp., Natick, MA) (Fig. 2A). This led to an improvement in flow through the aorta (Fig. 2B). Post-stenting pressures almost equalised in the ascending (129/81 mmHg) and descending aorta (119/80 mmHg). |
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Correspondence: Suneil Kumar Aggarwal, Department of Cardiology,Sri Sathya Sai Institute of Higher Medical Sciences
Prashantigram, Andhra Pradesh,India |
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Indian Heart J. 2009; 61:375-376 |
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Seuneil Kumar Aggarwal et al |
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A second cardiac catheterisation was performed 2 days later for the balloon mitral valvotomy (BMV). The mitral valve was dilated to 24 mm using a 23-26 mm Accura balloon (Vascular Concepts Pvt. Ltd., Bangalore, balloon size based on height of 151cm), leading to a fall in left atrial pressure from 34 to 15 mmHg. Post-BMV echocardiogram 6 hours later showed a mitral valve with both commisures split, a mitral valve area of 2.2 cm2 and trivial mitral regurgitation, confirming the success of the procedure. The patient was discharged the following morning. |
Discussion Our report highlights the importance of thorough echocardiography in a patient, regardless of the underlying aetiology of their principal disease. This patient had no history suggestive of either active aortoarteritis or lower limb circulatory deficiency. There was however a relatively high upper limb blood pressure for a patient with mitral stenosis. Of course, thorough examination of the lower limb pulses would also have raised the possibility of the diagnosis prior to echocardiography. Retrospectively they were examined and found to be weak. The treatment in this case was straightforward. Stenting for aortoarteritis is well established,6 while balloon mitral valvotomy is the most commonly performed percutaneous intervention in our institute. It is possible that the two procedures could have been carried out at the same time, although we felt the potential bleeding risks during septal puncture while using heparin (needed for the aortic stenting) were not worth taking. One possibility would be to perform the septal puncture, then stent the aorta quickly, followed by the BMV. This could be considered if such a case was to arise again. References
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Indian Heart J. 2009; 61:375-376 |
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