Silent patent ductus arteriosus incidentally found before balloon mitral valvotomy for severe rheumatic mitral stenosis

Abstract

Rheumatic heart disease (RHD) and congenital heart disease (CHD) rarely co-exist in the same patient. However, such associations are not unknown in areas where RHD is endemic. We report a rare combination of severe rheumatic mitral stenosis, severe pulmonary artery hypertension (PAH), and an incidental clinically silent patent ductus arteriosus (PDA). The patient was initially subjected to a balloon mitral valvotomy to assess if the resultant fall in PA pressure would alter the flow dynamics of the PDA. Since the ductal flow remained small and clinically inaudible, no further intervention was advised. The case highlights the importance of detailed echocardiographic examination in patients with RHD to detect co-existent CHD and logical decision making in their management. <Learning objective: A detailed echocardiographic examination is needed in all cases even when a diagnosis is apparent. Despite obvious rheumatic mitral stenosis, meticulous echocardiography revealed a small PDA, which was clinically silent. Since severe PAH can alter findings of PDA, we first performed balloon mitral valvotomy to see if resultant fall in PA pressure would alter the flow dynamics of PDA. Despite fall in PA pressures, the PDA flow remained trivial and it was clinically inaudible. Hence, no further intervention was advised.>.

Keywords: Balloon mitral valvotomy; Patent ductus arteriosus; Rheumatic mitral stenosis.

Fig. 1

12-Lead electrocardiogram (a) showing sinus tachycardia, right axis deviation, and bi-atrial enlargement; X-ray chest (b) depicting cardiomegaly, enlargement of the left and right atrium, and evidence of severe pulmonary artery hypertension.

Fig. 2

Pre balloon mitral valvotomy (BMV) 2D echocardiography showing severe mitral stenosis (parasternal short-axis view, a) and a small patent ductus arteriosus (PDA) (2D and Doppler, b, c); Post BMV 2D echocardiography showing adequately open mitral valve (parasternal short-axis view), (d) and the tiny PDA (2D and Doppler, e, f). Ao, aorta; MPA, main pulmonary artery; PDA, patent ductus arteriosus; DA, descending aorta.