Managing Rheumatic Mitral Stenosis Complicated by Shock and Cardiac Cirrhosis Beyond Guidelines

Figures

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  Figure 1. Abdominal Ultrasonography Findings Abdominal ultrasound demonstrates hepatomegaly with dilatation of hepatic veins and IVC, consistent with hepatic congestion. The gallbladder, pancreas, and spleen appear normal, with no stones identified. IVC = inferior vena cava.

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  Figure 2. Electrocardiogram on Admission Electrocardiogram showed atrial fibrillation with rapid ventricular response. Features suggestive of right ventricular strain are observed, consistent with severe pulmonary hypertension and advanced rheumatic mitral stenosis.

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  Figure 3. Clinical and Echocardiographic Findings (A) Icteric sclera on physical examination. (B) Transthoracic echocardiography demonstrates severe rheumatic MS with an MVA of 1.0 cm2 by planimetry. (C and D) Color Doppler imaging shows severe TR with systolic flow reversal in the hepatic veins. (E and F) Continuous-wave Doppler reveals elevated TR peak velocity with shortened pulmonary acceleration time, consistent with severe pulmonary hypertension (PASP 63 mm Hg; mPAP 56 mm Hg). (G) Doppler assessment demonstrates respiratory stroke volume variation of approximately 50%, suggesting preload responsiveness. MS = mitral stenosis; MVA = mitral valve area; mPAP = mean pulmonary artery pressure; PASP = pulmonary artery systolic pressure; TR = tricuspid regurgitation.

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  Figure 4. Echocardiographic Assessment of Ventricular Function (A) Echocardiography showed preserved LVEF systolic function of 92%. (B) TAPSE measurement showed reduced RV systolic function (TAPSE 14 mm). (C) RV FAC demonstrated severely impaired RV systolic function. (D) Speckle-tracking echocardiography showed RV global longitudinal strain −12.1% and free wall strain −10.8%, confirming advanced RV dysfunction. FAC = fractional area change; LVEF = left ventricular ejection fraction; RV = right ventricular; TAPSE = tricuspid annular plane systolic excursion.