Journal international de recherche cardiovasculaire

Multiple Rheumatic Valvular Heart Disease Involving all Four Valves in a Young Patient: Case Report and Literature Review

Zeine El Abasse*, Rime Benmalek, Ali Rida Bah and Rachida Habbal

Multivalvular Heart Disease (MVD) is still a highly prevalent condition in developing countries such as Morocco causing significant morbidity and mortality. The complex hemodynamic interactions between coexisting valve lesions may alter the clinical expression of each singular lesion, and the clinician should be aware of these interactions that make the diagnosis challenging and the management of these patients often empirical given the absence of current guidelines to guide the strategy. In the available literature, quadrivalvular stenosis is exceptional, mostly diagnosed at autopsy. We here described a very rare case of rheumatic involvement of all four cardiac valves discovered in a 38-year-old female with a history of recurrent attacks of rheumatic fever in her childhood, who presented with gradually progressive exertional dyspnea, palpitations and fatigue of 14-years duration. TTE revealed severe left valves’ disease in addition to a severe Tricuspid disease and moderate Pulmonary Stenosis (PS), with signs of right heart congestion. The case was discussed by the heart-team who decided to try a transcatheter approach given the patient’s high surgical risk, by dilating the aortic valve first, then the mitral and finally the tricuspid valves, in order to avoid sudden increase in cardiac output that may worsen the transaortic valve gradient. Our case highlights the diagnosis and management challenges encountered in the context of a developing country where treatment options are limited. Therefore, the expertise of a multidisciplinary Heart Valve Team is of crucial to properly discuss treatment indications based on several factors such as symptoms, severity and hemodynamic significance of valvular lesions, the risk of morbidity and mortality associated with multiple valve prostheses and the risk of reintervention. The introduction of transcatheter therapy into clinical practice has provided new treatment options for patients with MVD, and new decision-making algorithms are evolving quickly.