CASE PRESENTATION
A thirty-year-old female with no significant medical history presented
with dyspnea on exertion (NYHA class I). The physical examination
revealed a blood pressure of 110/70 mm Hg with an irregular pulse rate
of 76 beats/minute and had an oxygen saturation of 98% on room air. The
neck veins were not distended. The lungs were clear to percussion and
auscultation. The examination of the heart revealed a mid-diastolic as
well as grade III pansystolic murmur at the apex. The abdominal
examination yielded normal findings, and there was no peripheral edema.
The electrocardiogram on admission showed atrial flutter with a variable
block (Figure 1). The chest radiography revealed massive cardiomegaly
with the left heart border showing a prominent main pulmonary artery and
left atrial appendage. The right heart border showed a double contour of
atrial shadow (Figure 2). An echocardiogram showed a giant left atrium
measuring 14.4 cm x 16.7 cm that encroached on the other cardiac
chambers with a left ventricular ejection fraction of 48% (Figure 3).
Thickened mitral valves along with doming and restricted motion of
anterior and posterior mitral leaflets were diagnostic of rheumatic
heart disease (RHD). There was severe mitral stenosis with a mitral
valve area of 0.9 cm2 on mitral valve planimetry and
moderate MR with vena contracta of 4 mm and an effective regurgitant
orifice area of 0.3 cm2. The patient was administered
furosemide 20 mg PO daily with improvement and was discharged from the
hospital. She reported continued improvement in her dyspnea on her
follow-up visit in the outpatient clinic two weeks later.