A 63-year-old man with heart failure 3 years after bioprosthetic replacement of mitral and aortic heart valves

Abstract

A 63-year-old man sought medical treatment due to dyspnea during slight exertion, increased abdominal volume and edema, which had started two weeks prior to presentation at the clinic. He also complained of a cough and fever that he experienced in the week prior to presentation.He reported his dyspnea had started 9 years before, progressing to dyspnea during slight exertion and edema of the lower limbs. He also complained of chest pain, triggered by exertion and relieved by rest. The patient was referred to INCOR for therapy (9/6/93).The patient was diagnosed with rheumatoid arthritis in 1998 and had been previously treated for syphilis. Serological test results for Chagas' disease were negative.On physical examination (9/6/93), the patient showed a regular pulse rate (80 bpm), his blood pressure (BP) was 130/80 mmHg and he had an increased venous jugular pressure. Lung examination failed to show any abnormality. His heart examination revealed a first sound with diminished intensity, a systolic murmur +++/4+ in the mitral area, radiating to the axilla, and a rumbling diastolic murmur ++/ 4+ in the left sternal border. The patient had ascites and his liver was felt 5cm below the right costal margin.The electrocardiogram (ECG) performed in August 94 showed atrial fibrillation (AF), heart rate (HR) of 80bpm, QRS -20º backwards, left ventricular hypertrophy and secondary ventricular repolarization abnormalities ( fig. 1). Chest X-ray showed an enlarged cardiac silhouette (+++/ 4+), a bulging medium arch, and enlargement of the hilar vessels and of the pulmonary vasculature.The echocardiogram (1/10/94) showed marked dilation and hypokinesia of the left ventricle (LV), pulmonary hypertension, marked aortic regurgitation and slight mitral and tricuspid regurgitation (tab. I).The hemodynamic (tab. II) and cineangiographic studies (2/94) showed normal coronary arteries, a dilated LV, with diffuse hypokinesia (+++), moderate mitral regurgitation and marked aortic regurgitation.The patient received the diagnoses of aortic regurgitation and mitral regurgitation secondary to ventricular dilation, both of unknown origin.