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Case 373


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A 61-year-old male patient, diagnosed as having acute rheumatic heart disease during childhood, initiated progressive exertional dyspnea, requiring hospitalization due to decompensated heart failure. Undergoing treatment with oral anticoagulants. Transthoracic echocardiogram demonstrated severe mitral stenosis, mitral valve area of 0,5cm², mean gradient of 12mmHg and pulmonary hypertension. Block score of 13 points.

What is the most appropriate therapeutic approach?

a) Clinical management


b) Percutaneous balloon mitral valvuloplasty


c) Open surgical commissurotomy


d) Valve replacement


Image analysis

Image 1: Doppler echocardiogram, parasternal long axis view, demonstrates image suggestive of thrombi in the left atrium (highlighted in red) 


Image 2: Doppler echocardiogram, parasternal short axis views, demonstrates reduced mitral valve area (0,5cm²), highlighted in red.


Image 3: A. Doppler echocardiogram, apical four-chamber view, demonstrates turbulent flow from the left atrium to the left ventricle; B. Spectral Doppler continuous wave registration demonstrates increased pressure gradients between the left atrium and ventricle.  



- In mitral stenosis, there is restriction to the valvar leaflets opening, which results in mitral valve area shorter than 2,5cm². 

- The main cause of mitral stenosis is rheumatic heart disease.

- The increased pressure gradient between the left atrium and ventricle results in pulmonary congestion, which manifests clinically as dyspnea.

- Cardiac auscultation may demonstrate accentuation of first heart sound and diastolic murmur at the mitral focus, which irradiates to the left axillary region.

- Intervention includes percutaneous balloon valvuloplasty, surgical open commissurotomy and valvar replacement; the decision is guided by the Block score.



- Douglas L. Mann, Douglas P. Zipes, Peter Libby, Robert O. Bonow-Braunwald. Tratado de doenças cardiovasculares. 10 ed. Elsevier 2018.

- Fauci, Anthony S., Kasper Dennis L., Hauser, Stephen L., Longo, Dan L., Jameson, J. Larry. Harisson Medicina Interna- 19ª ed. 2016.

- Diretriz Brasileira de Valvopatias - SBC. 2011

- Atualização das diretrizes brasileiras de valvulopatias: abordagem das lesões anatomicamente importantes- SBC. 2017

- ESC EACTS Guidelines for the management of valvular heart disease. 2017



Maria Cecília Landim Nassif, 5th year medical student at Universidade Federal de Minas Gerais.

Email: cecilialn2(arroba)



Maria do Carmo Pereira Nunes, cardiologist and echocardiographist, adjunct professor of the Department of Internal Medicine at the Medical School of Universidade Federal de Minas Gerais. 

Email: mcarmo[arroba] 


Gustavo Brandão de Oliveira, cardiologist and echocardiographist at Hospital das Clínicas da UFMG.

Email: brandaomed[arroba]



Felipe Eduardo Fagundes Lopes, Lara Hemerly De Mori, Mirella Diniz, Gabriella Shiomatsu, Rafael Antonio Teixeira Malta, Prof. Júlio Domingues.


Translated by

Ana Luísa Melgaço Almeida, 6th year medical student at Universidade Federal de Minas Gerais.

E-mail: analuisamelgaco[at]

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