Massive hemoptysis in mitral stenosis

Abstract

Introduction: Massive hemoptysis is an uncommon but life-threatening emergency. The loss of at least 600 ml of blood within a 48-hour period has been associated with a high mortality rate. Although most commonly hemoptysis caused by valvulopathies is not massive enough to be life threatening, have been reported cases of asphyxia after pulmonary hemorrhage in patients with mitral stenosis. Hemoptysis and occurrence of pulmonary edema associated with end stage and severe mitral stenosis would be an indication for early surgery. Aim of the study: To assess the clinical, laboratory aspects and the presentation of a clinical case with massive hemoptysis and mitral stenosis occurred at mature age. Material and methods: The patient was hospitalized, examined, evaluated in Hospital "Saint Trinity", Chisinau. Results: Patient aged 45 years was hospitalized in Emergency Department due to pulmonary hemorrhage (>21/24 hours) and hemorrhagic shock. From anamnesis, the patient is known with rheumatic heart defect - mitral stenosis at the age of 25 years. It is of interest that massive hemoptysis in this patient occurred as a first manifestation of mitral stenosis. He administered anticoagulation therapy - Warfarin. Physical examination on admission revealed a normal weight patient in critical condition. Relative limits were deflected: left heart border - by 4 cm and right - by 2 cm, arrhythmic heart sounds, atrial fibrillation, diastolic murmur, distended jugular, peripheral edema at the calves, lower liver edge - 4 cm below the right costal border. Echocardiographic examination revealed the patient's hardened, calcified aorta walls, indurated annulus and aortic valves, calcified, with formation of the moderate regurgitation (II degree), mitral annulus calcification, mitral valves endured pronounced calcified stenosis formation, transmitral pressure gradient - 36 mmHg., mitral orifice area - 1,5 cm2, considerable dilatation of the left atrium, right atrium, moderate dilatation of the right ventricle, asymmetrical hypertrophy of the left ventricular myocardium, ejection fraction - 60%. Tricuspid valve insufficiency - IIIrd gr. Pulmonary artery valve insufficiency - IInd gr. Severe pulmonary hypertension, pulmonary artery pressure - 68 mmHg. Initial treatment consisted from antishock therapy (ice bag. airway maintenance, oxygen 2-4 1/min, permanent venous access, fluid resuscitation, hemostasis and hemodynamic correction), (3-blockers and digitalis administration. Patient's general condition improved by stopping hemoptysis and reducing dyspnea, but pulmonary bleeding complications required a special intervention-the reference to cardiac surgeon. Conclusion: Our patient's history and clinical course illustrate that severe hemoptysis may complicate moderate degrees of mitral stenosis. The patient had the high thromboembolic risk necessitated anticoagulation therapy. Mitral valve operation would appear to be beneficial in cessation of hemoptysis.