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Cardiovascular Images
June 24, 2020

A Woman in Her 90s With Dyspnea on Exertion and a Systolic and Diastolic Murmur

Author Affiliations
  • 1Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Department of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Cardiol. Published online June 24, 2020. doi:10.1001/jamacardio.2020.1453

A woman in her 90s with a history of rheumatic heart disease, severe mitral stenosis, and 2 prior balloon valvuloplasty procedures (most recently 3 years prior) presented to the emergency department with 1 week of increased dyspnea on exertion. Her physical examination results were notable for a holosystolic murmur and faint low-pitched diastolic rumble at the apex and jugular venous pressure of 12 cm of water. A transthoracic echocardiogram showed a preserved left ventricular ejection fraction (60%), severe mitral stenosis with a mitral valve area of 0.75 cm2, and a mean transmitral valve gradient of 15 mm Hg with severe mitral regurgitation. A chest radiograph showed a right-sided pleural effusion and splaying of the carina consistent with left atrial enlargement (Figure, A). The left atrium was severely dilated with a volume of 440 mL (Figure, B). These imaging findings are classic for chronic severe mitral valve stenosis with associated left atrial dilation.1,2