Conundrum of aortic stenosis in a case of multivalvular rheumatic heart disease: perspicuity is in the details

A 36-year-old woman presented with dyspnoea on exertion for 5 years. She was evaluated elsewhere and diagnosed to have severe mitral stenosis. She was referred for mitral valve replacement to our centre. Echocardiography revealed a thickened aortic valve with mild aortic regurgitation, with transaortic gradient suggestive of mild aortic stenosis, in addition to severe rheumatic mitral stenosis. Detailed echocardiographic analysis and cardiac catheterisation revealed features suggestive of moderate to severe aortic stenosis. Detailed assessment of aortic valve needs to be done in patients with coexistent mitral stenosis. Each modality for assessment of aortic stenosis has its own limitations and a decision regarding treatment needs to be taken based on combined analysis of all the parameters. Dimensionless velocity index is a relatively less time-consuming, flow independent measure of aortic stenosis. Prompt recognition of this concealed aortic stenosis helps to avoid repeat valve surgery. Subsequently, patient was sent for dual valve replacement.