Complex perioperative course in a patient with severe rheumatic mitral stenosis: left ventricular rupture, severe...

Mitral valve surgery in patients with chronic severe heart failure carries a high perioperative risk. Life-threatening complications such as intraoperative left ventricular rupture, severe postoperative ventricular dysfunction, and subsequent mechanical valve thrombosis remain challenging and require urgent multidisciplinary management.

A 57-year-old woman with severe rheumatic mitral stenosis, atrial fibrillation, and New York Heart Association class III heart failure underwent mitral valve replacement, tricuspid annuloplasty, left atrial thrombectomy, and left atrial appendage closure. Intraoperative acute left ventricular rupture was successfully repaired urgently. Postoperatively, she developed severe left ventricular dysfunction (left ventricular ejection fraction [LVEF], 22%) requiring intra-aortic balloon pump support on postoperative day 1 (POD 1), followed by successful extubation (POD 11), stress-induced gastrointestinal bleeding (POD 13), device removal (POD 14), and prosthetic valve thrombosis (POD 20) managed by intensified anticoagulation. Ventricular and valve function improved markedly by POD 29 (LVEF 43%; effective orifice area, 1.7 cm²). At 3- and 5-month follow-ups, optimized medical therapy maintained stable cardiac function, and the patient remained asymptomatic.

This case highlights critical surgical and postoperative challenges associated with long-standing rheumatic mitral stenosis. Despite preserved preoperative LVEF, the patient developed profound haemodynamic instability requiring mechanical circulatory support. Additionally, the coexistence of gastrointestinal bleeding and prosthetic valve thrombosis required a carefully balanced and individualized anticoagulation strategy. This study emphasizes the importance of early recognition of risk factors for ventricular rupture, prompt surgical intervention, and multidisciplinary collaboration in managing complex cardiac cases. Furthermore, it underscores the role of conservative management with intensified anticoagulation when reoperation or thrombolysis is not feasible.