ABC | Volume 111, Nº2, August 2018

Anatomopathological Session Case 4 – A 59-Year-Old Woman with Rheumatic Mitral Valve Disease (Severe Stenosis and Regurgitation), Severe Dyspnea, Shock and Pulmonary Condensation Desiderio Favarato e Vera Demarchi Aiello Instituto do Coração (InCor) HC-FMUSP, São Paulo, SP - Brazil Mailing Address: Vera Demarchi Aiello • Avenida Dr. Enéas de Carvalho Aguiar, 44, subsolo, bloco I, Cerqueira César. Postal Code 05403-000, São Paulo, SP – Brazil E-mail: demarchi@cardiol.br , anpvera@incor.usp.br Mansucript received July 04, 2018, revised manuscript July 31, 2018, accepted August 06, 2018 Keywords Mitral Valve/complications; Heart Murmurs; Mitral Valve Insufficiency; Arrhythmias, Cardiac; Pulmonary Embolism. Section editor: Alfredo José Mansur (ajmansur@incor.usp.br ) Associate Editors: Desiderio Favarato (dclfavarato@incor.usp.br ) Vera Demarchi Aiello (anpvera@incor.usp.br ) DOI: 10.5935/abc.20180157 A 59-year-old female patient with double mitral lesion was hospitalizedwith fever, cough andworsening dyspneawith shock. At 58 years old, the patient reported onset of dyspnea in medium exertions for five months, associated with dry cough at night with dyspnea, which was relieved with orthostatism. Cardiac murmur was detected and the patient was referred to InCor, a heart specialist hospital, for treatment (17/Sept/2010). There was no reference to rheumatic outbreaks in the past, and the patient had arterial hypertension and hypothyroidism. Physical exam when the patient was first examined (17/ Sep/2010) showed the patient weighed 73 Kg, was 1.55 m tall, body mass index was 30.6 kg/m², cardiac frequency was 88 bpm, arterial blood pressure 140 x 90 mmHg; pulmonary auscultation resulted normal; cardiac auscultation revealed hypophonic 1 st heart sound, hypophonic pulmonary component of 2 nd heart sound and mitral holosystolic murmur ++++/6+; abdomen exam resulted normal; there was no edema in the lower limbs and pulse palpation was normal. The ECG (14/Sep/2010) showed sinus tachycardia, with 127 bpm frequency, PR interval 200 ms, dQRS 92 ms, SÂQRS + 150º reverse, QTc 459 ms, overload of the left atrium and indirect signs of overload of the right atrium (Peñaloza‑Tranchesi signal), low-voltage front plane and overload of the right ventricle (Figure 1). Laboratorial exams (14/Sep/2010) showed red blood cells 5.0 million/mm 3 , hemoglobin 14.6 g/dL, hematocrit 45%, creatinine 1.08 mg/dL (FG = 55L/min/1.73 m 2 ), potassium 4.4 mEq/L and sodium 142 mEq/L. The echocardiogram (25/Aug/2010) revealed aortic diameter 25 mm, left atrium 52 mm, right ventricle 44 mm, left ventricle 34/21 mm, ejection fraction 70%, septum thickness and posterior wall 11 mm; there was no alteration in segment contraction of the left ventricle; right ventricle’s systolic function was normal; mitral valve presented thickened cusps with commissural fusion and reduced opening, compatible with a severely compromised rheumatic condition, and there was significant valve insufficiency. The maximum diastolic gradient between the left atrium and the ventricle was estimated at 30 mm Hg, and the medium, at 18 mm Hg; the aortic valve showed discrete signs of fibrocalcification without functional alterations; the tricuspid valve had severe insufficiency. Pulmonary artery systolic pressure was estimated at 140 mmHg. Losartan 100 mg, furosemide 40 mg, digoxin 0,25 mg and acetylsalicylic acid 100 mg daily were prescribed. Surgical treatment of the mitral valve was indicated. In December 2010 the patient sought emergency medical attention due to tachycardia and dyspnea. The ECG (16/Dec/2010) revealednodal reentrant tachycardia, with 178 bpm frequency (Figure 2). The patient underwent chemical cardioversion with intravenous amiodarone. At the outpatient ward (5/Apr/2011) the patient was asymptomatic, with controlled blood pressure (120/80 mmHg) and heart rate of 84 bpm, and the physical exam resulted normal, except for preexisting alterations in the cardiac auscultation. The patient used 200 mg of amiodarone, 40 mg of furosemide, 100 mg of losartan and 60 mg of diltiazem. The patient continued waiting to be operated and on 16/Sep/2011 she sought emergency medical care, with dyspnea in small exertions and productive cough with purulent sputum, and no fever was reported. The physical exam showed a sleepy patient, with cold extremities and a heart rate of 98 bpm, blood pressure 93 x 58 mmHg. Pulmonary auscultation revealed crackling rales in the lower third of both hemithorax; cardiac auscultation revealed rhythmic heart sounds, mitral regurgitation systolic murmur +++/6+ and diastolic arrhythmia ++/6+; the abdomen had no abnormalities and there was edema ++/4+ in the lower limbs. The ECG (16/Sep/2011) showed sinus rhythmwith 97 bpm frequency, PR 168 ms, dQRS 89 ms, SÂQRS + 150º reverse, QTc 513 ms, biatrial overload, giant P wave positive at V1 and right ventricular overload (Figure 3). The echocardiogram (17/Sep/2011) revealed hypokinesia of the right and left ventricles, the latter with 55% ejection fraction, frommoderate to strong mitral insufficiency, maximal mitral transvalve gradient at 22 mm Hg and medium, at 13 mmHg. Pulmonary artery pressure was estimated at 81 mmHg; however, the patient had systemic arterial hypotension, 53 mmHg medium pressure. 215