Severe Rheumatic Mitral Stenosis Complicated by Recent Ischemic Stroke and Severe Pulmonary Hypertension: A Case Report and Review of Current Guidelines

Background: Percutaneous mitral commissurotomy (PMC) is the treatment of choice for symptomatic severe rheumatic mitral stenosis with favorable valve anatomy. The management of patients presenting with recent ischemic stroke and severe pulmonary hypertension remains challenging, particularly when surgical intervention is considered high risk. Case Presentation: A 53-year-old man with no significant past medical history presented with exertional dyspnea associated with acute left hemiparesis. Electrocardiography revealed atrial fibrillation. Transthoracic echocardiography demonstrated severe rheumatic mitral stenosis with a mitral valve area of 0.75 cm², mild mitral regurgitation, severe left atrial enlargement, grade II tricuspid regurgitation, and severe pulmonary hypertension with an estimated systolic pulmonary artery pressure of 90 mm Hg. Pulmonary vascular resistance was 3 Wood units. Transesophageal echocardiography excluded left atrial thrombus and demonstrated favorable valve morphology with a Wilkins score of 5. Cerebral computed tomography confirmed an acute ischemic thalamic stroke. The patient was considered unsuitable for surgery because of the recent stroke and severe pulmonary hypertension. Following multidisciplinary Heart Team discussion, PMC was proposed. Conclusion: This case illustrates that recent ischemic stroke and severe pulmonary hypertension should not be considered absolute contraindications to PMC when valve anatomy is favorable and left atrial thrombus is excluded. Current ESC/EACTS and ACC/AHA guidelines strongly support PMC in such patients.