Original case provided by Lauren Brown, MD.
Edits and graphics by Yilin Zhang, MD.
30yo woman with progressive dyspnea on exertion x 3 years. She is originally from Nepal and moved to the US 2 years ago. She reports associated orthopnea, palpitations and chest pain. She denies fevers, chills, weight changes. She reports joint pains x several years. She denies any significant family history and denies tobacco, EtOH or other substance use.
On exam, she is afebrile, HR 80, BP 90/60, SpO2 99% on RA. Her JVP is 10 cm with a laterally displaced PMI. She has an irregularly irregular heart rhythm and a 3/6 holosystolic and diastolic murmur.
CXR is shown below:
Cardiomegaly is suggested by when the cardiac silhouette is >1/2 the width of the thoracic cavity on a PA film.
What is the most likely diagnosis?
She has a holosystolic murmur which is most likely mitral regurgitation and diastolic murmur that could be mitral stenosis (especially in the presence of a large LA, or could be tricuspid stenosis in the setting of a large RA).
She underwent a TTE which showed severe mitral stenosis with rheumatic appearing valve leaflets with massive LA enlargement, enlarged RA, moderate MR and TR. Overall, her clinical picture is consistent with rheumatic heart disease.
She underwent a successful mitral valve replacement and tricuspid valve repair. She continued to have permanent atrial fibrillation on lifelong anticoagulation but was no longer symptomatic and returned her previous level of activity.
TAKE HOME POINTS
- Cardiomegaly is suggested by when the cardiac silhouette is > 1/2 width of the total thoracic cavity.
- Heart chamber enlargement can be seen on a CXR.