APCU25CR5 Supraannular mitral valve replacement in a 45 year old female with severe degenerative mitral stenosis from end stage renal disease

Introduction Degenerative mitral stenosis (DMS) is the most common non-rheumatic cause of mitral stenosis and is more common in developed countries. It is difficult to diagnose and treat adequately as there is no clear consensus for treatment. This disease is associated with high mortality rates when managed conservatively. Here we present a successful mitral valve replacement in the supraannular position in a patient with severe DMS.Case Presentation A 45-year-old female with end stage renal disease secondary to chronic glomerulonephritis presented with 1 year history of intermittent angina. 3 weeks prior to admission the patient severe chest pain; ECG showed anterior wall myocardial infarction. Angiography revealed a totally occluded LAD, with heavily calcified mitral valve. She was transferred to our institution. The vital signs were stable and cardiac examination showed normal heart sounds, regular rate and rhythm, and no murmurs. 2D echo showed moderate to severe degenerative mitral stenosis with mitral valve annulus of 1.59cm2 by continuity, mean gradient of 12.6 mmHg and DVI of 0.46. Cardiac CT was done to characterize the extent of annular calcification, showing marked calcification of the mitral valves with near circumferential involvement of the annulus and subannular areas.Results She underwent supraannular mitral valve replacement with coronary artery bypass grafting of the LIMA to LAD. No perioperative complications were noted and she was discharged improved. On follow-up, there was improvement in angina and exertional dyspnea.Discussion Evidence for valve intervention among patients with DMS is scarce. Because our patient presented with degenerative disease early in her lifetime due to her kidney disease, accelerated degeneration of her mitral valve was expected. The team decided to perform mitral valve intervention and coronary revascularization. There was an anticipated difficulty in in achieving adequate surgical debulking and placement of a prosthetic valve in the native position thus supraannular mitral valve replacement was chosen as the most appropriate intervention.Conclusion DMS is an emerging cause of mitral stenosis. Management and intervention is not yet well-defined and requires a multidisciplinary and patient-centered approach, coupled with judicious use of noninvasive imaging modalities, especially in resource-limited areas.