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Abstract Aims Mitral stenosis (MS) occasionally coexists with aortic stenosis (AS). Limited data are available regarding the functional class and clinical outcomes of patients who undergo transcatheter aortic valve implantation (TAVI) for combined AS and MS. This study compared the clinical outcomes in patients with and without MS who underwent TAVI for severe AS and assessed the impact of mitral annulus calcification (MAC) severity, transmitral gradient (TMG) and mitral valve area (MVA) on outcomes in patients with combined AS and MS. Methods We investigated patients in the OCEAN‐TAVI registry who underwent TAVI. MS was defined as an MVA ≤ 1.5 cm2 or TMG ≥ 5 mmHg. The composite of all‐cause death and admission for heart failure was compared between patients with and without MS. The impact of MAC, TMG and MVA on outcomes was assessed in patients with combined AS and MS. Results We identified 106 patients with MS (MAC 84%; TMG 6.4 ± 2.6 mmHg; MVA 1.10 ± 0.31 cm2) and 6570 without MS as controls. The MS group was older (85 ± 5 vs. 84 ± 5 years, P = 0.033), more of women (85 vs. 67%, P

Abstract Yeo’s index, the product of the mitral leaflet separation index and dimensionless index of mitral valve (MV), was recently described to accurately identify severe rheumatic mitral stenosis (MS). We assess the association between Yeo’s index and clinical outcomes in patients with rheumatic MS. We studied 297 patients with rheumatic MS. Clinical and echocardiographic data were obtained from the electronic medical record and Yeo’s index was measured in all cases. The outcome studied was a composite of all cause death, heart failure (HF) hospitalisation, MV intervention and stroke or transient ischaemic attack. We also performed subgroup analysis of patients without pre-existing atrial fibrillation (AF) to assess for association with new onset AF. The median follow up was 6.3 years; 145 patients (48.8%) developed the composite outcome. Yeo’s index (p

Introduction: High pulmonary artery pressure (PAP) is a critical survival parameter in patients with severe mitral stenosis. We investigated changes in PAP and their impact on survival in patients undergoing mitral valve replacement for severe mitral stenosis. Methods: We retrospectively analyzed 42 patients who underwent mitral valve replacement for severe mitral stenosis between January 2020 and January 2022. Changes in systolic pulmonary artery pressure (sPAP) assessed by echocardiography and survival outcomes were analyzed. Results: The mean age of the patients was 56.05±14.21 years. Among the patients, 71.4% were female and 28.6% were male. The median postoperative sPAP was 29 mmHg, which was significantly lower than the preoperative value (p

Abstract Background Ball thrombus is rare and life-threatening. The correct diagnosis and timely management are key to improving patient prognosis. Here, we present a case report and literature review of ball thrombus. Case presentation A 75-year-old woman presented to our outpatient clinic because of palpitations and chest distress for 8 months. She was diagnosed mitral stenosis, and transthoracic echocardiography (TTE) showed a round mass attached to the left atrial (LA) wall. Before anesthesia induction, TTE found that the mass has dropped from the LA wall, and was spinning in the LA causing intermittent obstruction of the valve. Anesthesia induction was then carried out under TTE monitoring, and transesophageal echocardiograph found another mass in the LA appendage after intubation. She underwent LA mass removal and mitral valve replacement, and was discharged uneventfully. Histopathology confirmed the diagnosis of thrombus. Our literature review identified 19 cases of ball thrombus between 2015 and 2024. The average age was 54.8 (range 3–88) years. Heart failure was present as the initial symptom in 11 cases, and most patients had mitral valve disease or concomitant with atrial fibrillation. 12 cases received surgery, and 7 received medical treatment only. 2 deaths occurred, one due to the obstruction of left ventricular inflow tract and the other due to the worsening of heart failure. Conclusion Ball thrombus is rare in clinical settings. Urgent thrombectomy should be performed as soon as possible, and echocardiography can be used for real-time monitoring during surgery.

Abstract Background Rheumatic mitral stenosis (MS) remains a common and concerning health problem in Asia. Percutaneous balloon mitral valvuloplasty (PBMV) is the standard treatment for patients with symptomatic severe MS and favorable valve morphology. However, studies on the incidence and predictors of adverse cardiac outcomes following PBMV in Asia have been limited. This study aims to evaluate the incidence and predictors of adverse outcomes in patients with rheumatic MS following PBMV. Methods A retrospective cohort study was conducted on patients with symptomatic severe MS who underwent successful PBMV between 2002 and 2020 at a tertiary academic institute in Thailand. Patients were followed up to assess adverse outcomes, defined as a composite of cardiac death, heart failure hospitalization, repeat PBMV, or mitral valve surgery. Univariable and multivariable analyses were performed to identify predictors of adverse outcomes. A p-value of

Abstract Mitral stenosis (MS) is a complex valvular pathology with significant clinical burden even today. Its effect on the right heart is often overlooked, despite it playing a considerable part in the symptomatic status. We enrolled 39 mitral valve stenosis patients and 39 age- and gender-matched healthy controls. They underwent conventional, speckle-tracking and 3D echocardiographic examinations. The 3D data was analyzed using the ReVISION software to calculate RV functional parameters. In the MS group, 3D RV ejection fraction (EF) (49 ± 7% vs. 61 ± 4%; p

Kefelegn Dejene Tadesse,1 Yidnekachew Asrat Birhan2 1Cardiology Department, Cardiac Center of Ethiopia, Addis Ababa, Ethiopia; 2Internal Medicine Department, Addis Ababa University, Addis Ababa, EthiopiaCorrespondence: Kefelegn Dejene Tadesse, Email kefruit@gmail.comAbstract: Percutaneous transvenous mitral commissurotomy is an established treatment for rheumatic mitral stenosis. Dextrocardic heart can be affected by rheumatic pathology just like the normal heart. However, it is technically demanding to percutaneous interventions especially the septal puncture which should be done in a mirror image of the normal. Here we are reporting a 45 year old woman with severe rheumatic mitral stenosis with dextrocardia with situs inversus totalis. She has undergone a successful percutaneous transvenous mitral commissurotomy.Keywords: dextrocardia, mitral stenosis

BackgroundRheumatic mitral stenosis (RMS) is a common valvular heart disease in developing countries. We sought to evaluate the early experience of patients with RMS undergoing transcatheter mitral valve replacement (TMVR).MethodsIn this retrospective study, a total of 5 RMS patients accepted TMVR. All patients underwent computed tomography and echocardiography before having the procedure. After the preprocedural comprehensive evaluations, the surgeons planned to use the Prizvalve (a novel balloon-expandable transcatheter aortic valve system which is now under the clinical registration study) for TMVR. Clinical data were collected at baseline, before discharge, and at the 30-day follow-up.ResultsThe median age of the 5 RMS patients was 61 years (range 60–77 years); 60% were male, and the median Society of Thoracic Surgeons score was 13.3% (range 6.2–17.1%). TMVR was successful in all patients. Postoperative transesophageal echocardiography showed that 60.0% (n = 3) of the patients had no paravalvular leakage and 40.0% (n = 2) had trace paravalvular leakage. The median postoperative peak velocity decreased to 1.4 m/s (range 1.1–1.7 m/s), and the median pressure gradient decreased to 3 mmHg (range 2–3 mmHg). No deaths occurred at the 30-day follow-up, and all patients had an improvement of ≥1 on the New York Heart Association functional rating.ConclusionsOur early experience with TMVR in RMS patients suggests that it is a safe and feasible procedure. The early results of the procedure are acceptable and provide bright prospects and directions for the precision treatment of RMS. Clinical Trial RegistrationClinicalTrials.gov, identifier (NCT02917980).

Segmentation of mitral valve is not only important for clinical diagnosis, but also has far-reaching impact on prevention and prognosis of the disease by experts and doctors. In this paper, the multi-channel cross fusion transformer based U-Net network model (MCCT-UNet) is proposed according to the classical U-Net architecture. First, the jump connection part of MCCT-UNet is designed by using a multi-channel cross-fusion based attention mechanism module (MCCT) instead of the original jump connection, and this module fuses the feature maps from different scales in different stages of the encoder. Second, the optimization of the feature fusion method is proposed in the decoding stage by designing the cross-compression excitation sub-module (C-SENet) to replace the simple feature splicing, and the C-SENet is used to bridge the inconsistency of the semantic hierarchy by effectively combining the deeper information in the encoding stage with the shallower information. This two modules can establish a close connection between the encoder and decoder by exploring multi-scale global contextual information to solve the semantic divide problem, thus it significantly improves the segmentation performance of the network. The experimental results show that the improvement is effective, and the MCCT-UNet model outperforms the other 9 network models. Specifically, the MCCT-UNet achieved a Dice coefficient of 0.8734, an IoU of 0.7854, and an accuracy of 0.9977, demonstrating significant improvements over the compared models.

Background: Patients with symptomatic moderate-to-severe mitral stenosis (MS) with pliable valves are indicated for percutaneous transvenous mitral commissurotomy (PTMC) typically over a valve replacement based on favorable anatomic characteristics. Currently, this decision is arrived based on Wilkins’ echocardiographic score which is considered to be a simplistic estimate often. In the current work, the authors present a novel machine learning (ML) framework that considers a comprehensive set of clinical and echocardiographic variables to indicate the possible outcome for choosing the transvenous procedure over an invasive surgery. Methods: Data considered for this retrospective study included demographic, clinical, and preprocedural echocardiographic variables pertaining to patients with moderate-to-severe MS without significant mitral regurgitation (MR). The success of the procedure was defined by four different postprocedural variables such as the final mitral valve area (MVA), MR, left atrial pressure, and right ventricular systolic pressure (RVSP). Three data mining tasks highlighting the importance of ML techniques to predict the outcome of the PTMC procedure in patients with MS have been demonstrated. The potential predictive value of the outcome of a PTMC procedure considering a comprehensive set of variables using ML techniques has not been investigated till date according to the authors’ knowledge. Cover coefficient-based clustering power as weights (C3PW), a novel problem transformation technique which deals with the multilabel classes, is proposed to correctly classify the patients having successful PTMC procedure. Results: Extreme gradient boosting (XGB), an ML technique, gave the best performance (accuracy: 0.79; F-score: 0.87) on the transformed single-label problem. Application of association rule mining revealed that a combination of the following parameters such as “initial MVA”

Abstract Background Percutaneous balloon mitral valvuloplasty (PBMV) is the ACC/AHA class I recommendation for treating symptomatic rheumatic mitral stenosis with suitable valve morphology, less than moderate MR and absence of left atrium clot. The mitral valve restenosis and significant mitral regurgitation (MR) are known adverse outcomes of PBMV. This study aimed to evaluate the outcomes of PBMV in patients with severe mitral stenosis and the effect of Commissural Calcification (CC) on the outcomes. Methods In this single-center retrospective cohort study, 876 patients who underwent PBMV were categorized into three groups based on their Wilkins score (Group I: score ≤ 8, Group II: score 9–10, and Group III: score 11–12). Patients were evaluated before, early after PBMV and at 6- and 24-month follow-ups. Main clinical outcomes were defined as significant restenosis and or symptomatic significant MR (moderate to severe and severe MR) or candidate for mitral valve replacement (MVR). The outcomes were compared between patients with and without CC. Results A total of 876 patients with mean age 46.4 ± 12.3 years (81.0% females) were categorized based on Wilkins score. 333 (38.0%) were in Group I, 501 (57.2%) were in Group II, and 42 (4.8%) were in Group III. CC was present in 175 (20.0%) of the patients, among whom 95 (54.3%) had calcification of the anterolateral commissure, 64 (36.6%) had calcification of the posteromedial commissure, and in 16 (9.1%) patients both commissures were calcified. There was a significant difference in Wilkins score between patients with and without CC (P

Introduction: Yeo’s Index, product of the mitral leaflet separation index and dimensionless index, is a novel measure of the severity of rheumatic mitral stenosis (MS). We assess Yeo’s index in patients with rheumatic MS with or without mixed valve disease. Methods: In a retrospective cohort study, Yeo’s index was measured in 237 cases of rheumatic MS − 124 in a transthoracic echocardiography validation cohort using mitral valve area (MVA) by pressure half-time and planimetry as comparator and 113 in a transesophageal echocardiography (TEE) validation cohort using TEE three-dimensional MVA as comparator. Patients were considered to have mixed valve disease if they had MS and concomitant mitral regurgitation or aortic valve disease. Results: There were 113 patients with isolated MS and 124 patients with mixed valve disease. Overall, Yeo’s index ≤ 0.26 cm showed 93.0 % sensitivity and 87.5 % specificity for identifying severe MS (MVA ≤ 1.5 cm2). In isolated MS, Yeo’s index ≤ 0.26 cm showed sensitivity of 94.6 % and specificity of 90.0 % for identifying severe MS, while in mixed valve disease sensitivity was 90.6 % and specificity 86.7 %. Overall, Yeo’s index ≤ 0.15 cm showed 83.6 % sensitivity and 94.3 % specificity for very severe MS (MVA ≤ 1.0 cm2). In isolated MS, the threshold of ≤0.15 cm showed sensitivity of 84.4 % and specificity of 92.6 % for very severe MS, while in mixed valve disease sensitivity was 81.3 % and specificity 95.3 %. The presence of atrial fibrillation did not influence the performance of Yeo’s index. Conclusion: Yeo’s Index accurately differentiates severity of rheumatic MS with or without mixed valve disease.

Balloon mitral valvotomy is an effective procedure for the management of mitral stenosis. Procedural failures were reported due to difficulty in the left ventricle (LV) entry, which were addressed by veno-arterial or reverse looping of the balloon catheter. We are reporting three cases in whom LV entry was succeeded with an Agilis NxT catheter.

Atrial fibrillation (AF) is a common arrhythmia in clinical practice, and oral anticoagulation is the cornerstone of stroke prevention in AF. Direct oral anticoagulants (DOAC) significantly reduce the incidence of intracerebral hemorrhage with preserved efficacy for preventing stroke compared to vitamin K antagonists (VKA). However, the pivotal randomized controlled trials (RCTs) of DOAC excluded patients with valvular heart disease, especially mitral stenosis, which remains an exclusion criterion for DOAC use. The INVICTUS study was a large multicenter global RCT aimed at evaluating the role of DOAC compared to VKA in stroke prevention among patients with rheumatic valvular AF. In this study, rivaroxaban failed to prove superiority over VKA in preventing the composite primary efficacy endpoints of stroke, systemic embolism, myocardial infarction, and death. Unfortunately, the bleeding rates were not lower with rivaroxaban either. The death and drug discontinuation rates were higher in the DOAC arm. Close to the heels of the dismal results of INVICTUS, an apixaban trial in prosthetic heart valves, PROACT-Xa, was also prematurely terminated due to futility. Hence, for AF complicating moderate-to-severe mitral stenosis or prosthetic valve VKA remains the standard of care. However, DOAC can be used in patients with surgical bioprosthetic valve implantation, TAVR, and other native valve diseases with AF, except for moderate-to-severe mitral stenosis. Factor XI inhibitors represent a breakthrough in anticoagulation as they aim to dissociate thrombosis from hemostasis, thereby indicating a potential to cut down bleeding further. Multiple agents (monoclonal antibodies—e.g., osocimab, anti-sense oligonucleotides—e.g., fesomersen, and small molecule inhibitors—e.g., milvexian) have garnered positive data from phase II studies, and many have entered the phase III studies in AF/Venous thromboembolism. Future studies on conventional DOAC and new-generation DOAC will shed further light on whether DOAC can dethrone VKA in valvular heart disease.

Lutembacher’s syndrome, a rare cardiac condition characterised by the combination of congenital Atrial Septal Defect (ASD) and acquired mitral stenosis, presents significant clinical challenges. Hereby, the authors present a case report of a 28-year-old female exhibiting mild symptoms, including dysapnoea, intermittent palpitations, and lower limb swelling. Examination revealed characteristic findings, including elevated jugular venous pressure, cardiomegaly, and murmurs indicative of mitral stenosis and tricuspid regurgitation. Transthoracic echocardiography confirmed the presence of ASD and moderate mitral stenosis. The patient was ultimately diagnosed with Lutembacher’s syndrome. Prompt initiation of rheumatic heart disease prophylaxis and diuretics led to symptomatic improvement. The present case underscores the need for early recognition and intervention in Lutembacher’s syndrome, particularly in regions with high rates of rheumatic heart disease. Future research should focus on optimising treatment strategies to enhance patient outcomes. Sharing such cases contributes to a deeper understanding of this complex condition and advocates for improved management approaches.

Introduction: Myxoma of the left atrium is a less typical cause of mitral obstruction. If this develops, a flash pulmonary oedema can be the first manifestation. Case description: We present a case report of a 50-year-old woman who was admitted to our internal department because of dyspnoea. The patient overcame a stroke three years before the index hospitalisation with a negative transthoracic echocardiography. By anamnesis and physical examination, an exacerbation of COPD was assumed, and the patient was treated accordingly. As the patient showed numerous risk factors for heart failure with preserved ejection fraction, transthoracic echocardiography was performed. A large polypoid mass was found in the left atrium, which caused severe mitral obstruction. Subsequent transoesophageal echocardiography confirmed this finding. The patient underwent urgent cardiac surgery, and the tumour was successfully resected. A histological examination revealed a cardiac myxoma. After the cardiac surgery the patient felt well, and no recurrence of the tumour occurred. Conclusions: We provide a case report of a fast-growing myxoma that was incidentally found in a patient with dyspnoea. We highlight the fast growth rate of the tumour and the potential for misdiagnosed signs of pulmonary oedema caused by mitral obstruction.

Abstract Background The present study aimed to detect subtle left ventricular (LV) dysfunction in patients with severe rheumatic mitral stenosis (MS) by measuring global and segmental longitudinal strain with a two-dimensional speckle tracking echocardiography (2D-STE) method. Methods In this case-control study, 65 patients with severe rheumatic MS and preserved ejection fraction (EF ≥ 50% measured by conventional echocardiographic methods) were compared with 31 otherwise healthy control subjects. All patients underwent LV strain measurement by the 2D-STE method in addition to conventional echocardiography using a VIVID S60 echocardiography device. Results Absolute strain values in myocardial segments 1–8, 10, and 12 (all basal, mid anterior, mid anteroseptal, mid inferior, and mid anterolateral segments) were significantly lower in patients with severe MS compared with the control group (P

Background: Pulmonary hypertension (PH) often complicates mitral stenosis (MS). The prognostic impact of pulmonary vascular resistance (PVR) in MS patients remains unclear. Previous study has demonstrated the prognostic impact of right atrial pressure (RAP) in patients with primary PH. We aim to determine the prognostic impact of PVR and RAP in patients with rheumatic MS undergoing percutaneous mitral balloon valvuloplasty (PMBV). Methods: A total of 58 patients with symptomatic severe rheumatic MS who underwent PMBV between 2016 and 2020 were included. Patients were divided into two groups: PVR ≤ 2WU (N = 26) and PVR > 2WU (N = 32). The composite endpoint included death, reintervention or persistent NYHA functional class III-IV during follow-up. Results: The median age was 50 (42–60) years, with 82.8% being female. Median pulmonary artery systolic pressure (PASP) was 42 (35–50.5) mmHg. Patients with PVR ≤ 2WU had lower PASP on both echocardiogram and catheterization. The PMBV success rate was 75.9%. Multivariate analysis, adjusted for PVR, showed RAP as the only independent predictor of the composite endpoint (HR:1.507, 95% CI:1.015–2.237, p = 0.042). The optimal RAP cutoff was 9.5 mmHg (HR:3.481, 95% CI:1.041–11.641; p = 0.043). Conclusions: RAP was an independent predictor of adverse outcomes in patients with rheumatic MS undergoing PMBV, while PVR did not show prognostic significance. These findings suggest that the prognostic value of PVR may be lower than expected.

Background: Net atrioventricular compliance (Cn) can affect the accuracy of mitral valve area (MVA) assessment. We assessed how different methods of MVA assessment are affected by Cn, and if patients with abnormal Cn may be identified by clinical and/or echocardiographic parameters. Methods: We studied 244 patients with rheumatic MS. The concordance between mitral valve area (MVA) by 2D planimetry, pressure half-time (PHT), continuity equation (CE), Yeo’s index, and 3-dimensional mitral valve area assessed by transesophageal echocardiography (TEE 3DMVA) in patients with normal and abnormal Cn (Cn ≤ 4 mL/mmHg) were evaluated in the 110 patients with both transesophageal echocardiogram (TEE) and transthoracic echocardiogram (TTE). Variables that were associated with abnormal Cn were validated in the remaining 134 patients with only TTE. Results: Except for MVA by CE, concordance with TEE 3DMVA was poorer for all other methods of MVA assessment in patients with abnormal Cn. But, the difference in concordance was only statistically significant for MVA by PHT. Patients with MVA ≤ 1.5 cm2 by 2D planimetry and PHT ≤ 130 ms were likely to have an abnormal Cn. (specificity 98.5%). This finding was validated in the remaining 134 patients (specificity 93%). Conclusions: MVA assessment by PHT is significantly affected by Cn. Abnormal Cn should be suspected when 2D planimetry MVA is ≤1.5 cm2 together with an inappropriately short PHT that is ≤130 ms. In this scenario, MVA by PHT is inaccurate.

Background: Yeo’s index is a novel measure of the severity of rheumatic mitral valve stenosis (MS). It is derived from the product of the mitral leaflet separation index and dimensionless index. This study aims to validate Yeo’s index using a transesophageal echocardiogram (TEE) three-dimensional (3D) mitral valve area (MVA) as a comparator and to compare the concordance of existing echocardiographic measures of the MVA with TEE 3DMVA. Methods and Results: We studied 111 patients with rheumatic MS who underwent both transthoracic echocardiography (TTE) and a TEE assessment of MS severity. Yeo’s index, the MVA determined by 2D planimetry, pressure half-time (PHT) and continuity equation (CE) measured on TTE were compared with the TEE 3DMVA. With a linear correlation, Yeo’s index showed the best correlation with TEE 3DMVA (r2 = 0.775), followed by 2D planimetry (r2 = 0.687), CE (r2 = 0.598) and PHT (r2 = 0.363). Using TEE 3DMVA as comparator, Yeo’s index (ρc = 0.739) demonstrated the best concordance, followed by 2D planimetry (ρc = 0.632), CE (ρc = 0.464) and PHT (ρc = 0.366). When both Yeo’s index and 2D planimetry suggested significant MS, the positive predictive value was high (an AUC of 0.966 and a PPV of 100.00% for severe MS, and an AUC of 0.864 and a PPV of 85.71% for very severe MS). When both measures suggested the absence of significant MS, the negative predictive value was also high (an AUC of 0.940 and an NPV of 88.90% for severe MS, and an AUC of 0.831 and an NPV of 88.71% for very severe MS). Conclusions: Yeo’s index performed well in identifying severe MS when compared with TEE 3DMVA and may be a useful adjunct to existing methods of measuring MS severity. Combining it with 2D planimetry could further enhance its accuracy.

Abstract Background Arrhythmia is a known complication of rheumatic heart disease (RHD). It is critical to recognize arrhythmias early on so that prompt preventative actions and vigilant monitoring may be considered while treating these patients. Aim This study aimed at determining the prevalence, clinical characteristics and echocardiographic parameters of arrhythmias among RHD patients attending Jakaya Kikwete Cardiac Institute (JKCI). Methodology Hospital-based cross-sectional study was conducted among 390 patients with an echocardiographic diagnosis of RHD aged 18years and above attending JKCI. Demographic and clinical information was documented. Echocardiography, a resting electrocardiography and 24 h ambulatory Holter monitoring electrocardiography were done. Chi square test was used to determine association between variables and those with a p value ≤ 0.2 were entered in a multivariate logistic regression analysis to determine the independent factors associated with arrhythmias. P value of 48 mm. Conclusion We found a high prevalence of arrhythmias among patients with RHD. The independent predictors of arrhythmias were left atrium dilatation and NYHA functional class III-IV. We recommend close monitoring for arrhythmias among RHD patients in sinus rhythm with higher NYHA functional class and dilated left atrium.

Key Clinical Message Before valvular interventions, echocardiography, especially the TEE or the ventilation/perfusion scan, should be performed to detect silent PTE and set a more accurate treatment and surgical plan. Abstract Pulmonary hypertension (PH) is a progressive and critical disease that can be caused by mitral stenosis (MS). Some of these patients present with disproportionate PH, which is an uncommon phenomenon and is considered a challenging diagnostic and treatment process. In these patients, other causes may also play a role in developing PH. This report presented two cases with disproportionate PH and severe MS who were scheduled for percutaneous mitral valvuloplasty (PMV). The pre‐procedural echocardiography revealed systolic pulmonary artery pressure (sPAP) of 90 and 120 mmHg, mitral valve area of 0.80 and 0.55 cm2 by three‐dimensional (3D) planimetry, and diastolic pressure gradient (DPG) of 13 and 18.8 mmHg, respectively. Furthermore, in the first patient, 3D transesophageal echocardiography (TEE) revealed multiple saddle‐type organized thrombi in the proximal parts of the right and left pulmonary arteries, extending to the distal branches. In the second patient, 3D TEE revealed a large, relatively fresh, flow‐limiting thrombosis in the proximal part of the right pulmonary artery. The diagnosis of pulmonary thromboembolism (PTE) in both patients was confirmed by CT angiography. In both patients, the valves were surgically repaired, while all thrombi were removed from the cardiac chambers and pulmonary vessels during surgery. In addition, patients underwent warfarin therapy orally. They were followed up 6 months after the intervention, and their clinical symptoms had improved significantly.

Objective: To evaluate accuracy of mitral leaflet separation index for the determination of mitral stenosis severity in patients with rheumatic mitral stenosis. Method: The prospective, cross-sectional study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from March 2021 to February 2022, and comprised patients with rheumatic mitral stenosis detected on echocardiography. The best end-diastole parasternal long axis and apical four-chamber views were acquired and Mitral leaflet separation was measured as the distance between the inner edges of the tip of mitral leaflets. Pearson correlation coefficient was computed for mitral leaflet separation index and mitral valve area. Receiver operating characteristic curve was used to determine the cut-off value of the mitral leaflet separation indexto categorise mitral stenosis. Data was analysed using SPSS 19. Results: Of the 277 patients, 205(74%) were females and 72(26%) were males. The overall mean age was 39.93±11.22 years. The mean mitral leaflet separation index value was 7.65±2.23. The correlation was significant and strong between mitral leaflet separation index and mitral valve area on planimetry (p

Hemoptysis is a common clinical symptom in emergency patients. It is characterized by the discharge of bloody sputum, which originates from the lower respiratory tract. In the majority of cases, this event is self-limiting, and only in less than 5% of cases, it is massive. Mitral valve stenosis is an uncommon cause of hemoptysis, with a prevalence of 4.2%. In rare cases of this condition, massive and sudden hemoptysis occurs, which is called pulmonary apoplexy. Here, a 35-year-old woman with a history of mitral valve stenosis is introduced who was referred to the hospital with a complaint of massive hemoptysis and sudden shortness of breath. According to the history of mitral valve stenosis, the patient was diagnosed with pulmonary apoplexy. After treatment, both the imaging findings and the patient's symptoms resolved within a short period of time. Even though pulmonary apoplexy is often severe, it can still respond well to conservative treatments and may indicate a need for immediate attention to the stenosis of the mitral valve.

Percutaneous balloon mitral valvotomy (PBMV) is a good and preferred therapy choice over surgical commissurotomy for patients with rheumatic mitral stenosis (MS). However, interventional cardiologists must recognize that treating patients with rheumatic MS poses unique challenges for each patient, especially in special populations such as pregnant patients or patients with arrhythmias like atrial fibrillation (AF), which can complicate procedures. Based on information from observational studies, PBMV may be a safe and efficient treatment for improving outcomes in MS women who do not have substantial subvalve illness in a specific demographic. A successful PBMV helps to tolerate hemodynamic changes during pregnancy and dramatically reduces mortality. However, there is a paucity of studies on women with poor valve morphology who are not contraindicated, and it has to be seen if PBMV is used in these situations during pregnancy. Conversely, AF leads to a lower PBMV success rate as well as worse long-term and in-hospital outcomes.

Objective: To evaluate accuracy of mitral leaflet separation index for the determination of mitral stenosis severity in patients with rheumatic mitral stenosis. Method: The prospective, cross-sectional study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from March 2021 to February 2022, and comprised patients with rheumatic mitral stenosis detected on echocardiography. The best end-diastole parasternal long axis and apical four-chamber views were acquired and Mitral leaflet separation was measured as the distance between the inner edges of the tip of mitral leaflets. Pearson correlation coefficient was computed for mitral leaflet separation index and mitral valve area. Receiver operating characteristic curve was used to determine the cut-off value of the mitral leaflet separation indexto categorise mitral stenosis. Data was analysed using SPSS 19. Results: Of the 277 patients, 205(74%) were females and 72(26%) were males. The overall mean age was 39.93±11.22 years. The mean mitral leaflet separation index value was 7.65±2.23. The correlation was significant and strong between mitral leaflet separation index and mitral valve area on planimetry (p

"Ball valve thrombus" which is a spherical free-floating clot in left atrium is an often quoted, but uncommonly encountered complication in patients with severe mitral stenosis of rheumatic origin, who are in atrial fibrillation. We describe the case of a 48-year-old man with rheumatic heart disease, severe mitral stenosis, and severe aortic regurgitation. The patient presented with an episode of non-exertional syncope resulting in CVA 1 month back and breathlessness on exertion of 6 months duration and was in normal sinus rhythm. Echocardiography facilitated ante-mortem diagnosis and prompt institution of surgery was lifesaving.

The occurrence of pulmonary artery thrombus in association with rheumatic mitral stenosis is a rare complication. Pulmonary artery thrombus formation may worsen pulmonary artery pressures, and this may precipitate acute right heart failure. The possible mechanisms behind pulmonary artery thrombus formation during mitral valve replacement surgery could be acute coagulopathy following surgery, the presence of chronic pulmonary thromboembolism, or chronic atrial fibrillation. We report an unusual case of pulmonary artery thrombus in a patient with rheumatic MS which was diagnosed with transoesophageal echocardiography after MVR.

Lutembacher’s syndrome is a rare disease defined as the combination of atrial septal defect and mitral stenosis, which relieves the progression of symptoms resulting from mitral stenosis. We present a case of a previously asymptomatic 70-year-old man having Lutembacher’s syndrome with sinus venosus type of interatrial defect associated with partial anomalous pulmonary venous drainage. Our patient’s only complaint was of mild exertional dyspnea, which started six months prior to referral. Clinical suspicion of the combination of defects arose during transthoracic echocardiography. The patient underwent transesophageal echocardiography and multi-slice computed tomography for defect confirmation. The combination of Lutembacher’s syndrome with this complex deformity of pulmonary venous drainage has rarely been described. Such complex congenital defects with multifaceted physiological repercussions can go largely undiagnosed for the patients affected for most of their lifetimes.

Background: In rheumatic severe mitral stenosis, right ventricular mechanics deteriorate with the increasing severity of mitral stenosis. Therefore, we aimed to investigate right ventricular mechanics in patients with mild mitral stenosis using 3-dimensional speckle tracking echocardiography. Methods: In total, 40 patients with mild mitral stenosis and 36 age- and gender-matched healthy controls were included. Conventional echocardiographic examination was performed and 3-dimensional data sets were acquired for strain analysis. Besides conventional echocardiographic parameters, right ventricular volume and function and 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain were compared between patients with mild mitral stenosis and healthy controls. Results: Although 3-dimensional right ventricular volumes and ejection fraction were similar between the groups, 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain was significantly lower in patients with mild mitral stenosis than in controls (25.57 +- 4.39% vs. 27.90 +- 4.71%, P =.028). Significant correlations were observed between right ventricular free wall longitudinal strain and mitral valve area and estimated systolic pulmonary artery pressure (r = 0.597, P

Percutaneous mitral balloon valvuloplasty (PMBV) has been frequently used as an alternative to open or closed surgical mitral commissurotomy for the treatment of selected patients with symptomatic rheumatic mitral stenosis. PMBV has been proven a safe and effective method, often performed under fluoroscopic guidance. With the advent of three-dimensional echocardiography (3DE), interventional cardiologists have been able to successfully perform complex procedures such as paravalvular leak closure, transcatheter edge-to-edge repair of the mitral valve (MV) using MitraClip, etc. With the expertise derived from these procedures, 3DE has received considerable interests in many other procedures, including PMBV. Pre-, intra-, and postprocedural assessments of the mitral valve (MV) area; commissural splitting; the presence, degree, and location of mitral regurgitation; and other procedure-related complications can be more accurately and readily made using 3DE. In addition, real-time 3D transesophageal echocardiography has been proven to be more accurate than two-dimensional (2D) techniques in identifying specific MV abnormalities associated with complex diseases. Moreover, real-time 3DE offers the advantage of shorter fluoroscopy and radiation times throughout PMBV. This article reviews the use of 3DE during PMBV in light of the most recent literature and based on expertise and discusses the pros and cons of 3DE, with emphasis on its superiority to conventional 2D echocardiography.

Abstract Background Shrinking Man syndrome (SMS) is a rare but often serious complication of dialysis-dependent end-stage renal disease, characterized by significant loss of height, bone pain, bone deformity, and skin itching. Patients with SMS always have abnormal facial changes and cardiovascular system damage (manifested by hypertension, hypotension, cardiovascular calcification, and valvular heart disease), which pose a great challenge to anaesthesiologists. The purpose of this report is to describe our anaesthetic experience regarding two patients with SMS combined with alterations of the airway and cardiovascular system. Case presentation We describe two cases of SMS treated at West China Hospital, a tertiary care centre in Chengdu, China. All cases met the diagnostic criteria, which comprised 1) dialysis-dependent end-stage renal disease, 2) loss of height, and 3) bone pain and bone deformity. One patient had an anticipated difficult airway and moderate-to-severe mitral stenosis. The other patient presented with significant hypotension. Anaesthetic considerations included awake fibreoptic bronchoscopy-assisted tracheal intubation, real-time transoesophageal echocardiogram monitoring and individualized blood pressure management strategies. Conclusion This case series highlights the importance of adequate preoperative assessment and preparation, as well as individualized anaesthetic management, in patients with SMS.

Ahmed Hussein,1 Mohamed Eid,1 Sharaf E D Mahmoud,1 Mohamed Sabry,2 Ali Altaher1 1Cardiology Unit, Department of Internal Medicine, Faculty of Medicine, Sohag University Egypt, Sohag, Egypt; 2Department of OB/GYN, Faculty of Medicine, Sohag University Egypt, Sohag, EgyptCorrespondence: Ahmed Hussein, Cardiology Unit, Department of Internal Medicine, Faculty of Medicine, Sohag University, Nasser City, Sohag, 82524, Egypt, Tel +2 01011145537, Fax +2 0934600349, Email ahmed_hussien@med.sohag.edu.egBackground: Percutaneous balloon mitral valvuloplasty (PBMV) is considered the most suitable option for managing symptomatic severe mitral valve stenosis (MS) during pregnancy with favorable anatomy. We do not know the best time to perform PBMV during pregnancy to achieve the best maternal and fetal outcomes. Therefore, we conducted this study to clarify the best procedure timing.Methods: This prospective, observational, single-center study involved 44 pregnant patients suffering from symptomatic MS who underwent PBMV from May 2017 to May 2020. A detailed history is taken, full clinical examination, laboratory assessment, 2 D echocardiography, and follow-up during the hospital stay and monthly until labor.Results: We found that the mean mitral valve area (MVA) had significantly increased from 1.12 ± 0.24 to 2.09 ± 0.46 cm2 (P < 0.001). The mean pressure gradient across the mitral valve reduced from 17.22 ± 5.55 to 8.94 ± 3.75 mmHg (P < 0.001). The procedures were successful in 91% of the patients. Regarding obstetric outcomes, the incidence of preterm labor, fetal death, and composite adverse outcomes was significantly lower in patients who had the procedure during the second trimester than those who had the procedure during the third trimester. All preterm deliveries and intrauterine fetal deaths occurred at least 21 days after PBMV. The patients showed a statistically significant improvement in NYHA functional classification.Conclusion: We can conclude that PBMV performed in pregnant patients is an effective and safe treatment modality, and we observed better obstetric outcomes achieved with early intervention during the second trimester.Keywords: rheumatic heart disease, mitral stenosis, PBMV, pregnancy, obstetric outcomes

Severe mitral stenosis for non-cardiac surgery is a challenge to anesthesiologists. General anesthesia as well as regional anesthesia have their own limitations. We present here a case of abdominal hysterectomy with ovarian cyst in a patient of severe mitral stenosis managed with graded epidural anesthesia who had heart failure in the post-operative period but was successfully managed by continuous positive airway pressure.

Objective. Elaboration of the correction methodology of mitral stenosis, complicated by massive thrombosis of left atrium, for improvement of immediate and late results of surgical treatment of this pathology. Materials and methods. Into the group analyzed 344 patients with mitral stenosis, complicated by massive thrombosis of left atrium, operated in Amosov National Institute of Cardiovascular Surgery in a period from 1 January 1984 yr to 1 January 2019 yr, were incorporated. In all the patients surgical correction of mitral stenosis and thrombectomy from left atrium was performed. In 161 (46.8%) patients a radical removal of thrombotic mass together with their base–lining was performed, while in 183 (53.2%) – without it. In 256 (74.4%) patients the left atrium auricle was ligated or resected, while in 88 (25.6%) – left intact. Results. The hospital lethality index have had directly proportionally raised with enhancement of degree of the left ventricle auricle: I – 0%, II – 3.9%, III – 5.1% (p

A 65-year-old obese woman with rheumatic heart disease and restrictive lung disease presented with decompensated heart failure. Evaluation demonstrated severely thickened mitral valve leaflets, severe mitral stenosis, and moderate mitral regurgitation. She underwent successful transfemoral transseptal transcatheter mitral valve replacement with a dedicated valve resulting in improved functional status. (Level of Difficulty: Advanced.)

Objective: Mitral stenosis (MS) is rarely seen in children and adolescents but is not uncommon in developing countries where rheumatic fever is still endemic. Rheumatic MS in India commonly affects children and young adults less than 20 years old (juvenile mitral stenosis). Although percutaneous transvenous mitral commissurotomy (PTMC) using the ACCURA balloon catheter has been shown to be safe and effective technique in large series of adult patients, reports of this technique in children are scarce. In our study, we aim to evaluate the immediate and early follow-up results of PTMC in 50 patients of rheumatic MS age ≤ 20 years and compare the same with those of the patients aged > 20 years. Methods: Fifty consecutive patients aged ≤ 20 years with symptomatic rheumatic MS who met the inclusion criteria and whose valves are suitable for PTMC formed the cases, another 50 consecutive patients aged > 20 years with similar characteristics formed the control group. PTMC was done for both the groups as per the standard protocol and hemodynamic and echocardiography parameters were noted. Appropriate statistical tests were used to compare these data. Results: The juvenile group had more often severe MS than adult patients at baseline [mitral valve area (MVA) 0.77(0.16) cm2 vs. 0.86(0.15) cm2, p

Treatment decisions in the context of severe aortic stenosis (AS) associated with other valvular heart diseases (VHDs) have become a major challenge in recent years. Transcatheter aortic valve replacement (TAVR) in AS has increased significantly in younger patients with lower surgical risk, which has complicated the choice of the best treatment in cases of other associated valvulopathies. The most frequently associated lesions in this clinical scenario are mitral regurgitation (MR), mitral stenosis, and tricuspid regurgitation (TR). Furthermore, it should be noted that different percutaneous techniques are now available to accommodate any associated valvulopathies, which has considerably broadened the range of therapeutic options. The management of AS treated in isolation, especially by TAVR, has also shown that many cases of significant MR or TR are substantially reduced without any intervention. However, although some parameters have been described as potential risk factors in predicting the poor outcome of untreated VHDs, which cases will progress in a clinically more aggressive way remains uncertain. This review aimed to evaluate the most recent publications to provide the pathophysiology and prognosis of severe AS associated with other significant VHDs and to evaluate the best invasive therapeutic approach depending on the associated valvular disease.

It is extremely rare to encounter primary malignant tumors of the heart. Rhabdomyoma constitutes approximately 20% of all primary malignant tumors of the heart. Rhabdomyoma commonly arises from the ventricular wall, and rarely, they arise from the atrial wall and mimic symptomatic atrioventricular valve stenosis. We describe an extremely rare case of left atrial (LA) rhabdomyosarcoma detected during the transesophageal echocardiography arising from the posterior wall of the left atrium protruding into the left ventricle causing obstruction of the mitral valve. Our case is a rare case of LA rhabdomyosarcoma presenting with mitral inflow obstruction and symptomatically mimicking severe rheumatic mitral stenosis with atrial fibrillation and fast ventricular rate with orthopnea secondary to LA failure and passive pulmonary venous congestion.

Introduction: The female gender is a risk factor for idiopathic pulmonary arterial hypertension. However, it is unknown whether females with rheumatic mitral valve disease are more predisposed to develop pulmonary hypertension compared to males. Aim: We aimed to investigate whether there was a difference in genotypic distribution of endothelin-1 (ET-1) and endothelin receptor A (ETA) genes between female and male patients of pulmonary hypertension associated with rheumatic mitral valve disease (PH-MVD). Methods: We compared prevalence of ET-1 gene (Lys198Asn) and ETA gene (His323His) polymorphisms according to gender in 123 PH-MVD subjects and 123 healthy controls. Results: The presence of mutant Asn/Asn and either mutant Asn/Asn or heterozygous Lys/Asn genotypes of Lys198Asn polymorphism when compared to Lys/Lys in females showed significant association with higher risk (odds ratio [OR] 4.5; p =0.007 and OR 2.39; p =0.02, respectively). The presence of heterozygous C/T and either mutant T/T or heterozygous C/T genotypes of His323His polymorphism when compared to wild C/C genotype in females showed a significant association with higher risk (OR 1.96; p =0.047 and OR 2.26; p =0.01, respectively). No significant difference was seen in genotypic frequencies in males between PH-MVD subjects and controls. Logistic regression analysis showed that mutant genotype Asn/Asn (p =0.007) and heterozygous genotype Lys/Asn of Lys198Asn polymorphism (p =0.018) were independent predictors of development of PH in females. Conclusions: ET-1 and ETA gene polymorphisms were more prevalent in females than males in PH-MVD signifying that females with rheumatic heart disease may be more susceptible to develop PH.

Ebstein anomaly is a challenge to the anaesthetist in terms of large right atrium, atrialised right ventricle and various valve abnormalities associated with it like Tricuspid Regurgitation(TR), Mitral Stenosis(MS), Mitral Regurgitation(MR). In this case study, we report a 14-year-old female child presented with ebstein anomaly and cleft palate in our institution, SMS medical college & hospitals, Jaipur, Rajasthan. Cone’s operation was planned but due to multiple fenestrations in tricuspid leaflet only tricuspid and mitral valves were replaced. Patient was extubated next day with uneventful recovery.

Resumen: La enfermedad valvular reumática continúa siendo la causa más frecuente de afección valvular en los países en desarrollo. A pesar de las dificultades técnicas en este tipo de enfermedad en niños, la reparación valvular presenta mejores resultados a medio y largo plazo frente a la sustitución valvular en niños y adultos jóvenes.Presentamos 2 casos clínicos que ilustran la discusión acerca de las diferentes técnicas utilizadas en la reparación valvular mitral en este grupo de edades. Abstract: Rheumatic valve disease remains the most common cause of valve disease in developing countries. Despite the technical difficulties in this pathology in children, valve repair has shown better medium and long-term outcomes than valve replacement in children and young adults.We present two clinical cases that illustrate the discussion of the different techniques used in mitral valve repair in this age group.

Abstract Background Transcatheter mitral valve-in-valve (TMVIV) or valve-in-ring (TMVIR) replacement offer an alternative therapy for high risk patients. We aimed to highlight the operative and postoperative results of TMVIV and TMVIR procedures. Results We included all patients underwent TMVIV and TMVIR procedures between 2017 and 2020 at two heart centers in Germany. We included a total of 36 high risk patients in our study where 12 received TMVIV and 24 received TMVIR. All patients underwent TMVIV or TMVIR with Edwards Sapien XT or S3 transcatheter valves (Edwards Lifesciences). The mean age was 79 (75–83 years old). The median (IQR) preoperative STS score was 9 (7–13)% and EuroSCORE II was 14.5% (12–16). The majority of our patients were operated via transapical approach (n = 26) and the minority via transseptal approach (n = 10). Out of our records, none of our patients required reopening for bleeding or any other surgical complications. None of our patients required reintervention during the 6 months follow-up period. One mortality was recorded on fifth postoperative day due to low cardiac output syndrome (obviously because of LVOT obstruction by the anterior mitral leaflet). The average blood loss was 200 ml in the first 24 h in patients underwent transapical approach. Average operative time was 93 min and all patients were immediately extubated after the procedure in the operating room (even the patient with echocardiographically documented LVOT obstruction who died on the fifth postoperative day). Length of Intensive Care Unit stay was 2 ± 1.2 days and length of hospital stay was 4.1 ± 1.2 days. In the follow up period, echocardiograms showed normal prosthetic valve function with low transvalvular gradients, no LVOT obstruction in TMVIR cases and no evidence of valve migration or thrombosis (except in one patient). Concerning 6 months readmission, it was recorded in 2 patients due to right sided heart failure symptoms due to preexisting high degree of tricuspid valve regurge which did not disappear or even decrease after the operation and the other patient due to gastrointestinal bleeding. Conclusions TMVIV and TMVIR offer an efficient, safe and less invasive alternative in high surgical risk patients.

Calcium deposition in the heart can present in various ways. Mitral annular calcification (MAC) can cause mitral regurgitation but severe mitral stenosis has been reported very rarely. Mitral stenosis in the Indian subcontinent is mostly caused by rheumatic heart disease; however, here, we present a case of severe mitral stenosis due to MAC in a hypertensive and diabetic female that also had severe calcific aortic stenosis and conduction defect. Clinicians need to be aware of other causes of acquired mitral stenosis that include systemic lupus erythematosus, antiphospholipid antibody syndrome, carcinoid syndrome, mucopolysaccharidosis, Whipple disease, radiation, and MAC. Although MAC usually causes mitral regurgitation, severe mitral stenosis has been reported very rarely. However, when MAC is the cause of severe mitral stenosis, those patients are poor candidates for mitral valve replacement. Differentiating the etiology of mitral stenosis is of therapeutic and prognostic significance.

Background: Rheumatic heart disease and its impact on cardiac health is still a concern in developing countries. Percutaneous trans-mitral commissurotomy (PTMC) is the standard of care in managing severe rheumatic mitral stenosis (MS). This article reports a single-center, 10-year real-world experience in Qatar. Methods: In this retrospective study, we reviewed all the patients who underwent PTMC in Qatar between January 1, 2012, and January 1, 2022. Periprocedural data were collected at baseline, postprocedural, 1 year, and during the last follow-up. The primary outcome was procedural success (improvement in valve area by 50%, final valve area >1.5 cm2, and freedom from > moderate mitral regurgitation, stroke, or pericardial effusion). Safety endpoints were freedom from death, periprocedural cardiogenic shock and cardiac arrest, stroke urgent mitral valve replacement (MVR), or pericardiocentesis. Long-term outcomes included the requirement of redo PTMC or MVR, in addition to rehospitalization due to arrhythmias, heart failure, or stroke. Results: Sixty-five patients were included in the review (age 42 ± 10, female 38 [58.5%]). Sixty-two patients (95.4%) had a successful procedure. One patient developed a hemorrhagic pericardial tamponade and cardiogenic shock, for which he underwent pericardiocentesis and emergency aortic root repair. One patient developed acute stroke 8 h after the procedure, and one patient had tamponade resolved with emergency pericardiocentesis. Two patients required MVR after 1 and 4 years, respectively. Conclusion: PTMC is the mainstay of rheumatic MS management in patients with suitable anatomy as most patients have excellent outcomes with long-term freedom from surgery, which has been the case in our single-center experience.

Introduction Endothelin-1 (ET-1) gene polymorphisms are implicated in pathogenesis of idiopathic pulmonary arterial hypertension Material and methods We studied ET-1 (Lys198Asn and 3A/4A) and endothelin receptor A (ETA) gene (His323His) polymorphisms in 123 subjects with pulmonary hypertension associated with rheumatic mitral valve disease (PH-MVD) and 123 healthy controls. Results The mutant homozygous Asn/Asn genotype in Lys198Asn and T/T genotype in His323His polymorphism was more prevalent in PH-MVD group. Presence of Asn/Asn genotype was significantly associated with increased risk (odds ratio 3.9). Conclusions ET-1 and ET A gene polymorphisms are prevalent in PH-MVD group suggesting that they may predispose to the development of PH.

Abstract Lutembacher syndrome (LS) is a rare heart disorder characterized by a congenital or acquired combination of the atrial septal defect (ASD) and mitral stenosis. In LS, patients may be asymptomatic for years, but early detection and treatment result in a better prognosis. In contrast, the prognosis is usually poor, with conservative treatment if the diagnosis is late and the patient develops heart failure and pulmonary hypertension. Although rheumatic heart disease (RHD) and congenital heart disease are prevalent in Ghana, cases of LS are not reported. Here, we report the case of a 45‐year‐old woman with rheumatic mitral valve stenosis and an exceptionally large ASD with bidirectional flow who was diagnosed with LS and treated conservatively for heart failure at a cardiology clinic in Ghana.