Decades of silence: Massive left atrial remodeling in elderly rheumatic mitral stenosis A case report an literature review

Rheumatic mitral stenosis (MS) has markedly declined in high-income regions but remains a major cause of valvular disease in low- and middle-income countries. Although MS classically presents in young to middle-aged adults, late presentation in the elderly is uncommon and may be obscured by long-standing compensatory mechanisms, particularly progressive left atrial enlargement. In this paper, we describe the case of a 75-year-old woman without cardiovascular risk factors who presented with progressive exertional dyspnea after years of subtle, overlooked symptoms. Her evaluation revealed severe rheumatic mitral stenosis with profound left atrial enlargement, a compensatory adaptation that likely contributed to the delayed onset and under recognition of symptoms. A multidisciplinary Heart Team recommended mitral valve replacement. Postoperative recovery was uneventful, with complete symptomatic improvement This case illustrates how left atrial remodeling can mask the clinical onset of severe rheumatic mitral stenosis, leading to delayed diagnosis in elderly patients. Heart Team guided therapeutic decision making whether to repair or to replace the valve can achieve excellent outcomes even in advanced disease, underscoring the importance of early recognition and adherence to guideline-directed management.