Case Report: Shared decision-making in severe rheumatic mitral stenosis complicating pregnancy

Luis Armando Velásquez Trujillo, Manuel Alejandro Hurtado Rivera, V. Enriquez, Sebastián Ayala Zapata, Stephany Barbosa Balaguera, Álvaro Andrés Herrera Escandón

Severe rheumatic mitral stenosis (MS) is one of the highest-risk valvular lesions in pregnancy, and it becomes particularly hard to manage when the valve is unsuitable for percutaneous balloon mitral valvuloplasty (PBMV) and the patient declines termination. We describe a 20-year-old primigravida who presented at 23.5 weeks of gestation with progressive dyspnea, having deteriorated from New York Heart Association (NYHA) class I to class III. Multimodality echocardiography confirmed severe rheumatic MS, with a valve area of 0.5 cm 2 by two-dimensional planimetry and 0.572 cm 2 by three-dimensional transesophageal planimetry, a mean transmitral gradient of 15 mmHg, and a Wilkins score of 13, together with severe left atrial dilatation and pulmonary hypertension. PBMV was not feasible. After a shared decision-making process that respected the patient's refusal of termination, a multidisciplinary cardio-obstetric team provided a medical bridge aimed at fetal viability. Acute pulmonary edema at 28.1 weeks led to cesarean delivery of a 940 g neonate, and the patient underwent uncomplicated mechanical mitral valve replacement two weeks postpartum. The case shows how shared decision-making, multidisciplinary care, and the timing of surgery after delivery can be combined to protect both mother and child.