Severe rheumatic mitral stenosis and ARDS in pregnancy managed with percutaneous mitral commissurotomy and ECMO: A case report and literature review

Severe rheumatic mitral stenosis and ARDS in pregnancy managed with percutaneous mitral commissurotomy and ECMO: A case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Severe rheumatic mitral stenosis and ARDS in pregnancy managed with percutaneous mitral commissurotomy and ECMO: A case report and literature review Carlos Enrique Vesga-Reyes, Paula Andrea Cárdenas-Marín, Maria Juliana Reyes-Cardona, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6681230/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Apr, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Rheumatic mitral stenosis (MS) remains a leading cause of cardiovascular complications in pregnancy, particularly in low-resource settings. Hemodynamic changes during pregnancy can precipitate decompensation in previously asymptomatic patients, increasing the risk of maternal and fetal morbidity. Early recognition and management, including percutaneous mitral commissurotomy (PMC) in selected cases, are crucial to optimizing outcomes. Case Presentation: We present the case of a 32-year-old pregnant woman (G4P3) at 22.6 weeks of gestation who developed severe respiratory distress and cardiogenic shock due to previously undiagnosed severe rheumatic MS. Initial management of respiratory distress at a rural hospital included inhaled beta-agonists; however, her condition rapidly deteriorated, requiring orotracheal intubation and urgent transfer to a tertiary care center. Transthoracic echocardiography confirmed severe MS (mitral valve area: 1.3 cm², mean gradient: 17 mmHg) with a severely dilated left atrium. A respiratory molecular panel was positive for Influenza A. Despite medical therapy, she developed refractory hypoxemia, distributive and cardiogenic shock, necessitating escalating vasopressor support and mechanical ventilation. A multidisciplinary team decision led to urgent PMC, successfully performed with a post-procedure mitral valve area of 2.6 cm². However, due to persistent respiratory failure, veno-venous extracorporeal membrane oxygenation (ECMO) was initiated, with successful decannulation after 33 days. The patient recovered without residual respiratory distress, and subsequent obstetric ultrasounds confirmed fetal viability and normal growth. She later underwent an uneventful delivery at 38 weeks, with favorable maternal and neonatal outcomes. Conclusions: This case underscores the importance of early diagnosis, echocardiographic assessment, and multidisciplinary management in pregnant patients with severe MS. PMC remains the preferred intervention for severe symptomatic MS during pregnancy, significantly improving hemodynamics and reducing maternal risk. In cases of severe decompensation, ECMO serves as a life-saving bridge to recovery, ensuring both maternal stabilization and favorable perinatal outcomes. This case report highlights the need for preconception counseling, early intervention, and individualized care in high-risk pregnancies complicated by valvular heart disease. Mitral Valve Stenosis Heart Valve Diseases Rheumatic Heart Disease Pregnancy Complications Cardiovascular Extracorporeal Membrane Oxygenation Balloon Valvuloplasty Echocardiography Transesophageal Respiratory Distress Syndrome Adult Figures Figure 1 Figure 2 Figure 3 Background Valvular heart disease (VHD) represents a significant global health burden, with its prevalence, etiology, and impact varying considerably based on age, geographic region, and demographic factors. In the United States, moderate to severe VHD affects approximately 2.5% of the population. Mitral valve (MV) stenosis is diagnosed when the mitral valve area (MVA) is ≤1.5 cm² and is more frequently observed in women. Rheumatic fever remains the leading cause of mitral stenosis (MS). While its prevalence has markedly declined in industrialized countries, it continues to be a major health concern in developing nations. In these regions, rheumatic MS is the most common cardiovascular condition complicating pregnancy and remains a significant cause of maternal morbidity and mortality (1–3). Case presentation A 32-year-old pregnant woman (G4P3) at 22.6 weeks of gestation, with no known prior medical history, presented to a rural hospital with flu-like symptoms and dyspnea. She was discharged with inhaled beta-agonist therapy but returned with respiratory distress, a heart rate of 122 beats per minute, an arterial oxygen saturation (SaO₂) of 75% despite fraction of inspired oxygen (FiO₂) 100% and a blood pressure of 142/84 mmHg. Given the severity of her condition, she required orotracheal intubation and was emergently transferred to a higher-complexity center. Upon admission, bedside ultrasonography revealed abundant B-lines and hepatization of the left lung. A respiratory panel tested positive for Influenza A. Obstetric ultrasound confirmed a single live fetus with no evidence of malformations, growing within normal percentiles. Transthoracic echocardiography (TTE) revealed a preserved left ventricular ejection fraction of 60% and a severely dilated left atrium (area of 31 cm²). The MV exhibited diffuse thickening of both leaflets, commissural fusion, and minimal calcification, consistent with rheumatic valve disease leading to severe stenosis and mild regurgitation. MS parameters included a maximum velocity of 2.8 m/s, a peak gradient of 31 mmHg, mean gradient of 17 mmHg and MVA of 1.3 cm² by planimetry. The patient was admitted to the intensive care due to hypoxemic respiratory failure, cardiogenic and distributive shock requiring escalating dual vasopressor support with norepinephrine and vasopressin. She had refractory hypoxemia (PaFi <100) under invasive mechanical ventilation, sedation and neuromuscular blockade. A multidisciplinary team involving clinical cardiology, critical care, cardiovascular surgery and interventional cardiology specialists determined that PMC was the best course of action. A pre-procedural transesophageal echocardiogram (TEE) confirmed severe MS with a mean gradient of 17 mmHg and a MVA of 1.3 cm² by planimetry (Wilkins score: 6 points). Additionally, rheumatic aortic valve involvement was observed, with mild regurgitation (Figure 1) (Supplementary file Video 1). PMC was successfully performed under TEE guidance. An 8 Fr femoral venous introducer was placed, followed by transseptal puncture using a BRK1 guidewire. A Protak guidewire was positioned in the left atrium, and an Inoue No. 28 balloon was advanced into the left ventricle for mitral valvuloplasty, which was completed without complications (Figure 2) (Supplementary file Video 2). Post-procedural echocardiography demonstrated marked improvement in MV opening, with a MVA of 2.6 cm² by 3D planimetry, maximum velocity of 1.5 m/s, peak gradient of 9 mmHg, mean gradient of 3.8 mmHg, and trivial residual regurgitation (Figure 3). Due to acute respiratory distress syndrome with persistent hypoxemia, worsening ventilatory mechanics and a failed prone positioning attempt, veno-venous extracorporeal membrane oxygenation (ECMO) was initiated without complications and maintained for 33 days. Following successful decannulation, the patient transitioned to high-flow nasal cannula support for 20 days. Serial obstetric ultrasounds confirmed a viable fetus with normal growth parameters. She was ultimately discharged in stable condition, without oxygen supplementation, respiratory distress or peripheral edema. She was later readmitted for contractions at 38 weeks and underwent vaginal delivery with favorable maternal-fetal outcomes. The newborn weighed 3160 gr and breathed spontaneously. Postpartum maternal clinical course was satisfactory without bleeding or cardiac symptoms, a subdermal implant was placed for contraception and she was discharged with her newborn two days after delivery. Discussion Rheumatic heart disease (RHD) is the leading pre-existing cardiovascular disease in pregnancy in low-income countries, accounting for 56-89% of cardiac diseases (4). RHD is a chronic condition resulting from damage to the cardiac valves due to acute rheumatic fever, an autoimmune reaction following pharyngitis by Streptococcus pyogenes, resulting from molecular mimicry between bacterial antigens and cardiac “M-protein”. The MV is involved in >95% of cases of RHD, causing mitral regurgitation early in the course of the disease (frequently seen in children and young adults) and MS later on, presenting in older patients with a long asymptomatic period followed by gradual dyspnea on exertion and findings of right heart failure and pulmonary hypertension (PH) (5). Aortic valve involvement is detected in 20-30% of cases, most frequently with concomitant MV disease. Approximately two thirds of patients with RHD are female, many of them first presenting during pregnancy as stenotic left valvular disease is poorly tolerated (6), with a high risk of adverse fetal-maternal outcomes in limited-resources settings. Mitral RHD pathology is characterized by thickening of the leaflets, nodularity and commissural fusion, resulting in systolic and diastolic leaflet motion restriction and MV narrowing, sometimes exacerbated by chordal fusion and retraction. While the normal MVA is 4-6 cm 2 , clinically significant MS is defined by a MVA ≤1.5 cm 2 and most patients are symptomatic when the area is less than 1cm 2 (7). Patients with MS most commonly present with dyspnea on exertion or related to conditions causing tachycardia, increased flow through the valve or lack of atrial contraction (e.g. Atrial fibrillation (AF)), which are associated with a rise of mean left-atrial pressure. Less frequent symptoms include hemoptysis, orthopnea, fatigue, palpitations due to AF and hoarseness due to left atrial enlargement. Complications include PH, right heart failure and thromboembolic events related to atrial dilation and AF (2,7). Pregnancy can precipitate symptoms related to previously asymptomatic MS due to increased intravascular volume and heart rate, especially in second and third trimesters, as the stenotic valve limits the capacity to increase cardiac output leading to retrograde congestion and insufficient uteroplacental blood flow. Our undiagnosed, previously asymptomatic patient presented with respiratory failure in the second trimester of pregnancy due to MS and concomitant Influenza A viral pneumonia. Echocardiography is the imaging modality of choice for the diagnosis, classification and anatomical characterization of MS in pregnant and non-pregnant patients. The valve area measured by 2D planimetry serves as the reference standard for assessing MS severity, while the mean transvalvular gradient and pulmonary pressures indicate its hemodynamic impact and prognostic significance. Three-dimensional (3D) TTE planimetry may provide further diagnostic value. In most cases, TTE provides a satisfactory assessment. However, a TEE may be needed for a detailed anatomical evaluation before procedures or to exclude left atrial thrombus prior to PMC, for which echocardiography plays a relevant periprocedural role (2). In the present case, TTE was used for the diagnosis of severe MS and detection of morphological abnormalities suggestive of a rheumatic etiology. TEE was used for preprocedural planning and intraprocedural guidance of PMC. An increased risk of maternal and fetal complications has been reported in patients with MS. Prematurity occurs in 20–30% of cases, intrauterine growth restriction in 5–20%, and fetal mortality ranges from 1–5% (4). In the study by van-Hagen et al (8), including 273 pregnant women with rheumatic MS, maternal death during pregnancy occurred in 1 patient (1.9% of severe MS) and 2 women died in the first 6 months postpartum. 23.1% required hospital admission for a cardiac cause. The main reason was heart failure, especially in patients with severe MS (49.1%). An intervention during pregnancy was performed in 5.9% of patients, 93% had PMC and the remaining had surgical valve replacement, all of them with favorable outcomes. Women with severe MS had an earlier delivery and newborns with lower birth weight. Considering the high maternal and fetal morbidity related to MS, management of pregnant patient with MS must be guided by a multidisciplinary team involving cardiology and maternal-fetal medicine. Patients with significant MS should receive preconception counseling advising against pregnancy. Whenever possible, intervention —preferably percutaneous— should be considered before conception, even in asymptomatic women, especially if the MVA is <1cm 2 (4,9). However, often the onset of symptoms and diagnosis of MS take place during pregnancy, as occurred in our case. In this scenario, medical management includes selective beta-blockers, activity restriction and diuretics, avoiding volume depletion to preserve uteroplacental perfusion. Anticoagulation is indicated if AF, left atrial thrombosis or prior embolism are present (4). PMC should be considered in women with NYHA class III/IV or systolic pulmonary artery pressure ≥50 mmHg despite medical management (4), in patients with favorable criteria according to the Wilkins, Cormier, and Echo scores, and who have no contraindications for the procedure. It is preferably performed after 20 weeks of gestation to avoid radiation exposure to the fetus in the first trimester of pregnancy. In a systematic review and meta-analysis of observational studies of PMC during pregnancy (10), the procedure was successful in 93.6% of cases with failure more often in patients with subvalvular disease. Maternal mortality was 6.5% in women who had a successful procedure and 31.6% in those whose procedure was unsuccessful. The most frequent complications were mitral regurgitation (12.7%) and restenosis (2.4%). Among neonatal complications the most common was low birthweight (5.4%), which may be attributed to the underlying disease rather than the procedure itself. ECMO is a life-saving intervention used in pregnant patients with severe MS who develop refractory cardiogenic shock, pulmonary edema or severe respiratory failure despite optimal medical therapy and interventions (11). Our patient presented with persistent hypoxemic respiratory failure requiring prolonged ECMO and high-flow nasal cannula support with successful weaning. Vaginal delivery is indicated in patients in NYHA class I/II without PH, while caesarean section is usually recommended in patients in NYHA class III/IV or with PH without possibility of prior intervention (4). Our patient was asymptomatic after discharge and underwent vaginal delivery with favorable maternal and fetal outcomes. Conclusions Rheumatic MS remains a significant contributor to maternal morbidity and mortality, particularly in resource-limited settings where RHD is prevalent. Pregnancy exacerbates the hemodynamic burden of MS, often leading to decompensation, heart failure, and increased fetal risks. Early diagnosis, close clinical and echocardiographic follow-up, and a multidisciplinary approach are essential for optimal maternal-fetal outcomes. PMC remains the preferred intervention for symptomatic severe MS during pregnancy, offering substantial hemodynamic improvement while minimizing procedural risk. However, in cases of refractory respiratory failure or cardiogenic shock, ECMO may be required as a life-saving measure, as demonstrated in this case. This report highlights the importance of preconception counseling, early intervention, and individualized management in pregnant patients with MS, ensuring both maternal stabilization and favorable perinatal outcomes. List of Abbreviations AF – Atrial Fibrillation ECMO – Extracorporeal Membrane Oxygenation FiO₂ – Fraction of Inspired Oxygen G4P3 – Gravida 4, Para 3 MVA – Mitral Valve Area MS – Mitral Stenosis MV – Mitral Valve NYHA – New York Heart Association PaFi – PaO₂/FiO₂ Ratio PH – Pulmonary Hypertension PMC – Percutaneous Mitral Commissurotomy RHD – Rheumatic Heart Disease SaO₂ – Arterial Oxygen Saturation TEE – Transesophageal Echocardiography TTE – Transthoracic Echocardiography VHD – Valvular Heart Disease Declarations Ethics approval and consent to participate This case report was reviewed and approved by the Institutional Review Board (IRB) of Fundación Valle del Lili, Cali, Colombia. The patient provided informed consent for the use and publication of their medical information, and all identifying details have been anonymized to ensure confidentiality. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Competing Interest The authors declare that they have no competing interests. Funding This study was not supported by any external funding. Clinical trial number: not applicable. Authors' contributions C.E.V., P.A.C. and M.J.R conceptualized the case report, reviewed the literature and drafted the manuscript. P.O., J.A.Z. and J.S. selected the diagnostic imaging figures, interpreted the imaging findings and contributed insights with their expertise on the field. C.A.C., M.G. and D.F.B. led the clinical management of the patient, reviewed the manuscript and provided critical input on the clinical aspects of the case. Acknowledgements Not applicable. References Otto CM, Nishimura RA, Bonow RO, Carabello BA, rwin JP, Gentile F, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2021 Feb 2 [cited 2024 Dec 29],143(5):E72–227. Available from: http://ahajournals.org Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022 Feb 14,43(7):561–632. Coisne A, Lancellotti P, Habib G, Garbi M, Dahl JS, Barbanti M, et al. ACC/AHA and ESC/EACTS Guidelines for the Management of Valvular Heart Diseases: JACC Guideline Comparison. J Am Coll Cardiol [Internet]. 2023 Aug 22 [cited 2024 Dec 29],82(8):721–34. Available from: https://pubmed.ncbi.nlm.nih.gov/37587584/ Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018 Sep 7,39(34):3165–241. Aluru JS, Barsouk A, Saginala K, Rawla P, Barsouk A. Valvular Heart Disease Epidemiology. Med Sci (Basel) [Internet]. 2022 Jun 1 [cited 2025 Mar 16],10(2). Available from: https://pubmed.ncbi.nlm.nih.gov/35736352/ Rubino AS, Chan K, Patterson T, Weich H, Herbst P, Smit F, et al. Transcatheter heart valve interventions for patients with rheumatic heart disease. Front Cardiovasc Med [Internet]. 2023 [cited 2025 Mar 16],10:1234165. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10525355/ Chandrashekhar Y, Westaby S, Narula J. Mitral stenosis. The Lancet [Internet]. 2009 Oct 10 [cited 2024 Oct 24],374(9697):1271–83. Available from: http://www.thelancet.com/article/S0140673609609946/fulltext Van Hagen IM, Thorne SA, Taha N, Youssef G, Elnagar A, Gabriel H, et al. Pregnancy outcomes in women with rheumatic mitral valve disease: Results from the registry of pregnancy and cardiac disease. Circulation [Internet]. 2018 [cited 2025 Mar 24],137(8):806–16. Available from: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.032561 Sajjadieh Khajouei A, Tavana A, Bahrami P, Movahedi M, Mirshafiee S, Behjati M. Pregnancy outcomes in women with mitral valve stenosis: 10-year experience of a tertiary care center. Arch Gynecol Obstet [Internet]. 2025 [cited 2025 Mar 12],311(2). Available from: https://pubmed.ncbi.nlm.nih.gov/39960518/ Sreerama D, Surana M, Moolchandani K, Chaturvedula L, Keepanasseril A, Keepanasseril A, et al. Percutaneous balloon mitral valvotomy during pregnancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand [Internet]. 2021 Apr 1 [cited 2025 Mar 12],100(4):666–75. Available from: https://pubmed.ncbi.nlm.nih.gov/33070306/ Jalil S, Ahmed A, Abdalla M, Al-Hijji M. Severe mitral stenosis masquerading as cardiogenic shock successfully managed with extracorporeal membrane oxygenation and percutaneous mitral commissurotomy: a case report. Eur Heart J Case Rep [Internet]. 2023 Nov 2 [cited 2025 Mar 24],7(11). Available from: https://dx.doi.org/10.1093/ehjcr/ytad553 Additional Declarations No competing interests reported. Supplementary Files Video1.mp4 Video 1. Pre-procedural echocardiogram. Rheumatic mitral valve disease, with diffuse thickening of both leaflets, commissural fusion, little calcification, subvalvular thickening of the chordae tendineae. A. Transthoracic echocardiogram. Parasternal long-axis view. B. Transesophageal echocardiogram, 41°. Video2.mp4 Video 2. Percutaneous mitral commissurotomy. Fluoroscopy (A) and transesophageal echocardiography (B) guidance showing inflation of a properly positioned valvuloplasty balloon. Cite Share Download PDF Status: Published Journal Publication published 08 Apr, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 10 Dec, 2025 Reviews received at journal 07 Dec, 2025 Reviewers agreed at journal 28 Nov, 2025 Reviews received at journal 30 May, 2025 Reviewers agreed at journal 30 May, 2025 Reviewers invited by journal 28 May, 2025 Editor invited by journal 21 May, 2025 Editor assigned by journal 20 May, 2025 Submission checks completed at journal 20 May, 2025 First submitted to journal 16 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6681230","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":462837345,"identity":"d9cb001f-d3ab-4a37-b962-24c79938c110","order_by":0,"name":"Carlos Enrique Vesga-Reyes","email":"","orcid":"","institution":"Fundación Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"Enrique","lastName":"Vesga-Reyes","suffix":""},{"id":462837346,"identity":"8d15fbbb-9389-4ca0-862f-e105b8142acd","order_by":1,"name":"Paula Andrea Cárdenas-Marín","email":"","orcid":"","institution":"Fundación Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Paula","middleName":"Andrea","lastName":"Cárdenas-Marín","suffix":""},{"id":462837347,"identity":"301c941c-278c-4e86-89b5-6d3b4e48a86e","order_by":2,"name":"Maria Juliana Reyes-Cardona","email":"","orcid":"","institution":"Fundación Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Juliana","lastName":"Reyes-Cardona","suffix":""},{"id":462837348,"identity":"255d425a-f7b8-4d0c-9568-194c3fd5418f","order_by":3,"name":"Pastor Olaya","email":"","orcid":"","institution":"Fundación Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Pastor","middleName":"","lastName":"Olaya","suffix":""},{"id":462837349,"identity":"c607bee1-6a82-4be0-88bb-3c10140eb479","order_by":4,"name":"Jorge Alexander Zambrano-Franco","email":"","orcid":"","institution":"Fundación Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Jorge","middleName":"Alexander","lastName":"Zambrano-Franco","suffix":""},{"id":462837350,"identity":"d99e599d-89aa-4309-a06e-e5eb9bcb120c","order_by":5,"name":"Jairo Sanchez-Blanco","email":"","orcid":"","institution":"Fundación Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Jairo","middleName":"","lastName":"Sanchez-Blanco","suffix":""},{"id":462837351,"identity":"ee83341d-030b-41ab-b1b6-dfd82afc1257","order_by":6,"name":"Miller Giraldo-Sandoval","email":"","orcid":"","institution":"Fundación Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Miller","middleName":"","lastName":"Giraldo-Sandoval","suffix":""},{"id":462837352,"identity":"105a8b13-90ee-4f4b-810c-2e7bdcc297fb","order_by":7,"name":"Diego Fernando Bautista-Rincon","email":"","orcid":"","institution":"Fundación Valle del Lili","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"Fernando","lastName":"Bautista-Rincon","suffix":""},{"id":462837353,"identity":"c324b15c-4650-4a5c-88df-cb223255be4d","order_by":8,"name":"Camilo Andres Calderon-Miranda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYJCCAw9AJDuDAYiSY29gbiCsJQFEMkO0GPMcYCSshQFZS2IPIS387acTDyRUMMjzNzNvfFxRcSe9RyKxgeHjnlqgFHatEmdyNxxIOMNgOOMwW7HhmTPPckFaGGc8Ow6UOoBViwEDUEtiG9Bth3nMJBvbDufu5znYwMxz4BiDgUQCdi38byFa5A/zmP8EaknnIahFAmqLAdAWRqCWBB72RpCWGpxaJG68BflFwnAj0C+SDWcOG/YAtRycceAADy6/8Pfnbv7wocJGXu5488aPDRWH5XmYmQ8++HCgTg5XiMEsQ+UCjT/Mg089VlBHso5RMApGwSgYtgAAjr9j7B+tajIAAAAASUVORK5CYII=","orcid":"","institution":"Fundación Valle del Lili","correspondingAuthor":true,"prefix":"","firstName":"Camilo","middleName":"Andres","lastName":"Calderon-Miranda","suffix":""}],"badges":[],"createdAt":"2025-05-16 13:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6681230/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6681230/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-026-09013-4","type":"published","date":"2026-04-08T15:58:39+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83675789,"identity":"f7021d19-067a-498e-a8b5-743b38d9067f","added_by":"auto","created_at":"2025-05-30 14:51:28","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":187676,"visible":true,"origin":"","legend":"\u003cp\u003eTransthoracic echocardiogram. A. Parasternal long-axis view. Mitral valve with diffuse thickening of both leaflets, restriction in their marginal opening with bicommissural fusion, minimal calcification. B. Spectral Doppler. Mitral stenosis with a maximum velocity of 2.8 m/s, a peak gradient of 31 mmHg and mean gradient of 17 mmHg. Mild mitral regurgitation.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6681230/v1/21062be2aa8fb84193477beb.jpg"},{"id":83675788,"identity":"ad912b7d-d490-4613-aa08-3d20f3405180","added_by":"auto","created_at":"2025-05-30 14:51:28","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":177270,"visible":true,"origin":"","legend":"\u003cp\u003ePercutaneous mitral commissurotomy. A. Fluoroscopy showing inflation of a properly positioned valvuloplasty balloon. B. Transesophageal echocardiogram (TEE), 77°. Advancement of balloon valvuloplasty catheter. C. TEE, 65°. The balloon is inflated, opening the mitral leaflets.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6681230/v1/b645c9b588b9c930e8ba5741.jpg"},{"id":83675790,"identity":"b5239f56-d4fd-458e-8e62-84af9778b189","added_by":"auto","created_at":"2025-05-30 14:51:28","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":195464,"visible":true,"origin":"","legend":"\u003cp\u003ePost-procedural transesophageal echocardiogram. Significant improvement in mitral valve opening. A. Maximum velocity: 1.5 m/s, peak gradient: 9 mmHg, mean gradient: 3.8 mmHg. B. Mitral valve area by 3D planimetry: 2.6 cm\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6681230/v1/4a5cc5b41c78ea77872b94f0.jpg"},{"id":106808880,"identity":"7cf906c7-6b90-4cee-b000-046c62f3714e","added_by":"auto","created_at":"2026-04-13 16:04:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1028784,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6681230/v1/eabcc352-751e-477f-a841-6fb25c46500b.pdf"},{"id":83675792,"identity":"d470a57d-0ce7-4d17-b89c-96a5fb024ffe","added_by":"auto","created_at":"2025-05-30 14:51:29","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13989882,"visible":true,"origin":"","legend":"\u003cp\u003eVideo 1. Pre-procedural echocardiogram. Rheumatic mitral valve disease, with diffuse thickening of both leaflets, commissural fusion, little calcification, subvalvular thickening of the chordae tendineae. A. Transthoracic echocardiogram. Parasternal long-axis view. B. Transesophageal echocardiogram, 41°.\u003c/p\u003e","description":"","filename":"Video1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6681230/v1/539ae3da739683e7481c2bd8.mp4"},{"id":83675791,"identity":"f930b16f-a77c-4bd1-9e3c-d5772659dd92","added_by":"auto","created_at":"2025-05-30 14:51:28","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":4256901,"visible":true,"origin":"","legend":"\u003cp\u003eVideo 2. Percutaneous mitral commissurotomy. Fluoroscopy (A) and transesophageal echocardiography (B) guidance showing inflation of a properly positioned valvuloplasty balloon.\u003c/p\u003e","description":"","filename":"Video2.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6681230/v1/cb25a04423f921a00052f1fd.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Severe rheumatic mitral stenosis and ARDS in pregnancy managed with percutaneous mitral commissurotomy and ECMO: A case report and literature review","fulltext":[{"header":"Background","content":"\u003cp\u003eValvular heart disease (VHD) represents a significant global health burden, with its prevalence, etiology, and impact varying considerably based on age, geographic region, and demographic factors. In the United States, moderate to severe VHD affects approximately 2.5% of the population. Mitral valve (MV) stenosis is diagnosed when the mitral valve area (MVA) is \u0026le;1.5 cm\u0026sup2; and is more frequently observed in women. Rheumatic fever remains the leading cause of mitral stenosis (MS). While its prevalence has markedly declined in industrialized countries, it continues to be a major health concern in developing nations. In these regions, rheumatic MS is the most common cardiovascular condition complicating pregnancy and remains a significant cause of maternal morbidity and mortality (1\u0026ndash;3).\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 32-year-old pregnant woman (G4P3) at 22.6 weeks of gestation, with no known prior medical history, presented to a rural hospital with flu-like symptoms and dyspnea. She was discharged with inhaled beta-agonist therapy but returned with respiratory distress, a heart rate of 122 beats per minute, an arterial oxygen saturation (SaO₂) of 75% despite fraction of inspired oxygen (FiO₂) 100% and a blood pressure of 142/84 mmHg. Given the severity of her condition, she required orotracheal intubation and was emergently transferred to a higher-complexity center.\u003c/p\u003e\n\u003cp\u003eUpon admission, bedside ultrasonography revealed abundant B-lines and hepatization of the left lung. A respiratory panel tested positive for Influenza A. Obstetric ultrasound confirmed a single live fetus with no evidence of malformations, growing within normal percentiles.\u003c/p\u003e\n\u003cp\u003eTransthoracic echocardiography (TTE) revealed a preserved left ventricular ejection fraction of 60% and a severely dilated left atrium (area of 31 cm²). The MV exhibited diffuse thickening of both leaflets, commissural fusion, and minimal calcification, consistent with rheumatic valve disease leading to severe stenosis and mild regurgitation. MS parameters included a maximum velocity of 2.8 m/s, a peak gradient of 31 mmHg, mean gradient of 17 mmHg and MVA of 1.3 cm² by planimetry.\u003c/p\u003e\n\u003cp\u003eThe patient was admitted to the intensive care due to hypoxemic respiratory failure, cardiogenic and distributive shock requiring escalating dual vasopressor support with norepinephrine and vasopressin. She had refractory hypoxemia (PaFi \u0026lt;100) under invasive mechanical ventilation, sedation and neuromuscular blockade. A multidisciplinary team involving clinical cardiology, critical care, cardiovascular surgery and interventional cardiology specialists determined that PMC was the best course of action.\u003c/p\u003e\n\u003cp\u003eA pre-procedural transesophageal echocardiogram (TEE) confirmed severe MS with a mean gradient of 17 mmHg and a MVA of 1.3 cm² by planimetry (Wilkins score: 6 points). Additionally, rheumatic aortic valve involvement was observed, with mild regurgitation (Figure 1) (Supplementary file Video 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePMC was successfully performed under TEE guidance. An 8 Fr femoral venous introducer was placed, followed by transseptal puncture using a BRK1 guidewire. A Protak guidewire was positioned in the left atrium, and an Inoue No. 28 balloon was advanced into the left ventricle for mitral valvuloplasty, which was completed without complications (Figure 2) (Supplementary file Video 2). Post-procedural echocardiography demonstrated marked improvement in MV opening, with a MVA of 2.6 cm² by 3D planimetry, maximum velocity of 1.5 m/s, peak gradient of 9 mmHg, mean gradient of 3.8 mmHg, and trivial residual regurgitation (Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to acute respiratory distress syndrome with persistent hypoxemia, worsening ventilatory mechanics and a failed prone positioning attempt, veno-venous extracorporeal membrane oxygenation (ECMO) was initiated without complications and maintained for 33 days. Following successful decannulation, the patient transitioned to high-flow nasal cannula support for 20 days. Serial obstetric ultrasounds confirmed a viable fetus with normal growth parameters. She was ultimately discharged in stable condition, without oxygen supplementation, respiratory distress or peripheral edema.\u003c/p\u003e\n\u003cp\u003eShe was later readmitted for contractions at 38 weeks and underwent vaginal delivery with favorable maternal-fetal outcomes. The newborn weighed 3160 gr and breathed spontaneously. Postpartum maternal clinical course was satisfactory without bleeding or cardiac symptoms, a subdermal implant was placed for contraception and she was discharged with her newborn two days after delivery.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRheumatic heart disease (RHD) is the leading pre-existing cardiovascular disease in pregnancy in low-income countries, accounting for 56-89% of cardiac diseases (4). RHD is a chronic condition resulting from damage to the cardiac valves due to acute rheumatic fever, an autoimmune reaction following pharyngitis by Streptococcus pyogenes, resulting from molecular mimicry between bacterial antigens and cardiac \u0026ldquo;M-protein\u0026rdquo;. The MV is involved in \u0026gt;95% of cases of RHD, causing mitral regurgitation early in the course of the disease (frequently seen in children and young adults) and MS later on, presenting in older patients with a long asymptomatic period followed by gradual dyspnea on exertion and findings of right heart failure and pulmonary hypertension (PH) (5). Aortic valve involvement is detected in 20-30% of cases, most frequently with concomitant MV disease. Approximately two thirds of patients with RHD are female, many of them first presenting during pregnancy as stenotic left valvular disease is poorly tolerated (6), with a high risk of adverse fetal-maternal outcomes in limited-resources settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMitral RHD pathology is characterized by thickening of the leaflets, nodularity and commissural fusion, resulting in systolic and diastolic leaflet motion restriction and MV narrowing, sometimes exacerbated by chordal fusion and retraction. While the normal MVA is 4-6 cm\u003csup\u003e2\u003c/sup\u003e, clinically significant MS is defined by a MVA \u0026le;1.5 cm\u003csup\u003e2\u003c/sup\u003e and most patients are symptomatic when the area is less than 1cm\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e(7).\u003c/p\u003e\n\u003cp\u003ePatients with MS most commonly present with dyspnea on exertion or related to conditions causing tachycardia, increased flow through the valve or lack of atrial contraction (e.g. Atrial fibrillation (AF)), which are associated with\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ea rise of\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003emean left-atrial pressure. Less frequent symptoms include hemoptysis, orthopnea, fatigue, palpitations due to AF and hoarseness due to left atrial enlargement. Complications include PH, right heart failure and thromboembolic events related to atrial dilation and AF (2,7).\u003c/p\u003e\n\u003cp\u003ePregnancy can precipitate symptoms related to previously asymptomatic MS due to increased intravascular volume and heart rate, especially in second and third trimesters, as the stenotic valve limits the capacity to increase cardiac output leading to retrograde congestion and insufficient uteroplacental blood flow. Our undiagnosed, previously asymptomatic patient presented with respiratory failure in the second trimester of pregnancy due to MS and concomitant Influenza A viral pneumonia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEchocardiography is the imaging modality of choice for the diagnosis, classification and anatomical characterization of MS in pregnant and non-pregnant patients. \u0026nbsp;The valve area measured by 2D planimetry serves as the reference standard for assessing MS severity, while the mean transvalvular gradient and pulmonary pressures indicate its hemodynamic impact and prognostic significance. Three-dimensional (3D) TTE planimetry may provide further diagnostic value. In most cases, TTE provides a satisfactory assessment. However, a TEE may be needed for a detailed anatomical evaluation before procedures or to exclude left atrial thrombus prior to PMC, for which echocardiography plays a relevant periprocedural role (2). In the present case, TTE was used for the diagnosis of severe MS and detection of morphological abnormalities suggestive of a rheumatic etiology. TEE was used for preprocedural planning and intraprocedural guidance of PMC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn increased risk of maternal and fetal complications has been reported in patients with MS. Prematurity occurs in 20\u0026ndash;30% of cases, intrauterine growth restriction in 5\u0026ndash;20%, and fetal mortality ranges from 1\u0026ndash;5% (4).\u0026nbsp;In the study by van-Hagen et al (8), including 273 pregnant women with rheumatic MS, maternal death during pregnancy occurred in 1 patient (1.9% of severe MS) and 2 women died in the first 6 months postpartum. 23.1% required hospital admission for a cardiac cause. The main reason was heart failure, especially in patients with severe MS (49.1%). An intervention during pregnancy was performed in 5.9% of patients, 93% had PMC and the remaining had surgical valve replacement, all of them with favorable outcomes. Women with severe MS had an earlier delivery and newborns with lower birth weight.\u003c/p\u003e\n\u003cp\u003eConsidering the high maternal and fetal morbidity related to MS, management of pregnant patient with MS must be guided by a multidisciplinary team involving cardiology and maternal-fetal medicine. Patients with significant MS should receive preconception counseling advising against pregnancy. Whenever possible, intervention \u0026mdash;preferably percutaneous\u0026mdash; should be considered before conception, even in asymptomatic women, especially if the MVA is \u0026lt;1cm\u003csup\u003e2\u003c/sup\u003e (4,9).\u003c/p\u003e\n\u003cp\u003eHowever, often the onset of symptoms and diagnosis of MS take place during pregnancy, as occurred in our case. In this scenario, medical management includes selective beta-blockers, activity restriction and diuretics, avoiding volume depletion to preserve uteroplacental perfusion. Anticoagulation is indicated if AF, left atrial thrombosis or prior embolism are present (4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePMC should be considered in women with NYHA class III/IV or systolic pulmonary artery pressure \u0026ge;50 mmHg despite medical management (4), in patients with favorable criteria according to the Wilkins, Cormier, and Echo scores, and who have no contraindications for the procedure. It is preferably performed after 20 weeks of gestation to avoid radiation exposure to the fetus in the first trimester of pregnancy. In a systematic review and meta-analysis of observational studies of PMC during pregnancy (10), the procedure was successful in 93.6% of cases with failure more often in patients with subvalvular disease. Maternal mortality was 6.5% in women who had a successful procedure and 31.6% in those whose procedure was unsuccessful. The most frequent complications were mitral regurgitation (12.7%) and restenosis (2.4%). Among neonatal complications the most common was low birthweight (5.4%), which may be attributed to the underlying disease rather than the procedure itself.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eECMO is a life-saving intervention used in pregnant patients with severe MS who develop refractory cardiogenic shock, pulmonary edema or severe respiratory failure despite optimal medical therapy and interventions (11). Our patient presented with persistent hypoxemic respiratory failure requiring prolonged ECMO and high-flow nasal cannula support with successful weaning.\u003c/p\u003e\n\u003cp\u003eVaginal delivery is indicated in patients in NYHA class I/II without PH, while caesarean section is usually recommended in patients in NYHA class III/IV or with PH without possibility of prior intervention (4). Our patient was asymptomatic after discharge and underwent vaginal delivery with favorable maternal and fetal outcomes. \u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eRheumatic MS remains a significant contributor to maternal morbidity and mortality, particularly in resource-limited settings where RHD is prevalent. Pregnancy exacerbates the hemodynamic burden of MS, often leading to decompensation, heart failure, and increased fetal risks. Early diagnosis, close clinical and echocardiographic follow-up, and a multidisciplinary approach are essential for optimal maternal-fetal outcomes.\u003c/p\u003e\n\u003cp\u003ePMC remains the preferred intervention for symptomatic severe MS during pregnancy, offering substantial hemodynamic improvement while minimizing procedural risk. However, in cases of refractory respiratory failure or cardiogenic shock, ECMO may be required as a life-saving measure, as demonstrated in this case.\u003c/p\u003e\n\u003cp\u003eThis report highlights the importance of preconception counseling, early intervention, and individualized management in pregnant patients with MS, ensuring both maternal stabilization and favorable perinatal outcomes.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eAF \u0026ndash; Atrial Fibrillation\u003c/li\u003e\n \u003cli\u003eECMO \u0026ndash; Extracorporeal Membrane Oxygenation\u003c/li\u003e\n \u003cli\u003eFiO₂ \u0026ndash; Fraction of Inspired Oxygen\u003c/li\u003e\n \u003cli\u003eG4P3 \u0026ndash; Gravida 4, Para 3\u003c/li\u003e\n \u003cli\u003eMVA \u0026ndash; Mitral Valve Area\u003c/li\u003e\n \u003cli\u003eMS \u0026ndash; Mitral Stenosis\u003c/li\u003e\n \u003cli\u003eMV \u0026ndash; Mitral Valve\u003c/li\u003e\n \u003cli\u003eNYHA \u0026ndash; New York Heart Association\u003c/li\u003e\n \u003cli\u003ePaFi \u0026ndash; PaO₂/FiO₂ Ratio\u003c/li\u003e\n \u003cli\u003ePH \u0026ndash; Pulmonary Hypertension\u003c/li\u003e\n \u003cli\u003ePMC \u0026ndash; Percutaneous Mitral Commissurotomy\u003c/li\u003e\n \u003cli\u003eRHD \u0026ndash; Rheumatic Heart Disease\u003c/li\u003e\n \u003cli\u003eSaO₂ \u0026ndash; Arterial Oxygen Saturation\u003c/li\u003e\n \u003cli\u003eTEE \u0026ndash; Transesophageal Echocardiography\u003c/li\u003e\n \u003cli\u003eTTE \u0026ndash; Transthoracic Echocardiography\u003c/li\u003e\n \u003cli\u003eVHD \u0026ndash; Valvular Heart Disease\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis case report was reviewed and approved by the Institutional Review Board (IRB) of Fundaci\u0026oacute;n Valle del Lili, Cali, Colombia. The patient provided informed consent for the use and publication of their medical information, and all identifying details have been anonymized to ensure confidentiality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003eCompeting Interest\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any external funding.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.E.V., P.A.C. and M.J.R conceptualized the case report, reviewed the literature and drafted the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eP.O., J.A.Z. and J.S. selected the diagnostic imaging figures, interpreted the imaging findings and contributed insights with their expertise on the field.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eC.A.C., M.G. and D.F.B. led the clinical management of the patient, reviewed the manuscript and provided critical input on the clinical aspects of the case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOtto CM, Nishimura RA, Bonow RO, Carabello BA, rwin JP, Gentile F, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2021 Feb 2 [cited 2024 Dec 29],143(5):E72\u0026ndash;227. Available from: http://ahajournals.org\u003c/li\u003e\n\u003cli\u003eVahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022 Feb 14,43(7):561\u0026ndash;632. \u003c/li\u003e\n\u003cli\u003eCoisne A, Lancellotti P, Habib G, Garbi M, Dahl JS, Barbanti M, et al. ACC/AHA and ESC/EACTS Guidelines for the Management of Valvular Heart Diseases: JACC Guideline Comparison. J Am Coll Cardiol [Internet]. 2023 Aug 22 [cited 2024 Dec 29],82(8):721\u0026ndash;34. Available from: https://pubmed.ncbi.nlm.nih.gov/37587584/\u003c/li\u003e\n\u003cli\u003eRegitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomstr\u0026ouml;m-Lundqvist C, C\u0026iacute;fkov\u0026aacute; R, De Bonis M, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018 Sep 7,39(34):3165\u0026ndash;241. \u003c/li\u003e\n\u003cli\u003eAluru JS, Barsouk A, Saginala K, Rawla P, Barsouk A. Valvular Heart Disease Epidemiology. Med Sci (Basel) [Internet]. 2022 Jun 1 [cited 2025 Mar 16],10(2). Available from: https://pubmed.ncbi.nlm.nih.gov/35736352/\u003c/li\u003e\n\u003cli\u003eRubino AS, Chan K, Patterson T, Weich H, Herbst P, Smit F, et al. Transcatheter heart valve interventions for patients with rheumatic heart disease. Front Cardiovasc Med [Internet]. 2023 [cited 2025 Mar 16],10:1234165. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10525355/\u003c/li\u003e\n\u003cli\u003eChandrashekhar Y, Westaby S, Narula J. Mitral stenosis. The Lancet [Internet]. 2009 Oct 10 [cited 2024 Oct 24],374(9697):1271\u0026ndash;83. Available from: http://www.thelancet.com/article/S0140673609609946/fulltext\u003c/li\u003e\n\u003cli\u003eVan Hagen IM, Thorne SA, Taha N, Youssef G, Elnagar A, Gabriel H, et al. Pregnancy outcomes in women with rheumatic mitral valve disease: Results from the registry of pregnancy and cardiac disease. Circulation [Internet]. 2018 [cited 2025 Mar 24],137(8):806\u0026ndash;16. Available from: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.032561\u003c/li\u003e\n\u003cli\u003eSajjadieh Khajouei A, Tavana A, Bahrami P, Movahedi M, Mirshafiee S, Behjati M. Pregnancy outcomes in women with mitral valve stenosis: 10-year experience of a tertiary care center. Arch Gynecol Obstet [Internet]. 2025 [cited 2025 Mar 12],311(2). Available from: https://pubmed.ncbi.nlm.nih.gov/39960518/\u003c/li\u003e\n\u003cli\u003eSreerama D, Surana M, Moolchandani K, Chaturvedula L, Keepanasseril A, Keepanasseril A, et al. Percutaneous balloon mitral valvotomy during pregnancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand [Internet]. 2021 Apr 1 [cited 2025 Mar 12],100(4):666\u0026ndash;75. Available from: https://pubmed.ncbi.nlm.nih.gov/33070306/\u003c/li\u003e\n\u003cli\u003eJalil S, Ahmed A, Abdalla M, Al-Hijji M. Severe mitral stenosis masquerading as cardiogenic shock successfully managed with extracorporeal membrane oxygenation and percutaneous mitral commissurotomy: a case report. Eur Heart J Case Rep [Internet]. 2023 Nov 2 [cited 2025 Mar 24],7(11). Available from: https://dx.doi.org/10.1093/ehjcr/ytad553\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mitral Valve Stenosis, Heart Valve Diseases, Rheumatic Heart Disease, Pregnancy Complications, Cardiovascular, Extracorporeal Membrane Oxygenation, Balloon Valvuloplasty, Echocardiography, Transesophageal, Respiratory Distress Syndrome, Adult","lastPublishedDoi":"10.21203/rs.3.rs-6681230/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6681230/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Rheumatic mitral stenosis (MS) remains a leading cause of cardiovascular complications in pregnancy, particularly in low-resource settings. Hemodynamic changes during pregnancy can precipitate decompensation in previously asymptomatic patients, increasing the risk of maternal and fetal morbidity. Early recognition and management, including percutaneous mitral commissurotomy (PMC) in selected cases, are crucial to optimizing outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e We present the case of a 32-year-old pregnant woman (G4P3) at 22.6 weeks of gestation who developed severe respiratory distress and cardiogenic shock due to previously undiagnosed severe rheumatic MS. Initial management of respiratory distress at a rural hospital included inhaled beta-agonists; however, her condition rapidly deteriorated, requiring orotracheal intubation and urgent transfer to a tertiary care center. Transthoracic echocardiography confirmed severe MS (mitral valve area: 1.3 cm², mean gradient: 17 mmHg) with a severely dilated left atrium. A respiratory molecular panel was positive for Influenza A. Despite medical therapy, she developed refractory hypoxemia, distributive and cardiogenic shock, necessitating escalating vasopressor support and mechanical ventilation. A multidisciplinary team decision led to urgent PMC, successfully performed with a post-procedure mitral valve area of 2.6 cm². However, due to persistent respiratory failure, veno-venous extracorporeal membrane oxygenation (ECMO) was initiated, with successful decannulation after 33 days. The patient recovered without residual respiratory distress, and subsequent obstetric ultrasounds confirmed fetal viability and normal growth. She later underwent an uneventful delivery at 38 weeks, with favorable maternal and neonatal outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis case underscores the importance of early diagnosis, echocardiographic assessment, and multidisciplinary management in pregnant patients with severe MS. PMC remains the preferred intervention for severe symptomatic MS during pregnancy, significantly improving hemodynamics and reducing maternal risk. In cases of severe decompensation, ECMO serves as a life-saving bridge to recovery, ensuring both maternal stabilization and favorable perinatal outcomes. This case report highlights the need for preconception counseling, early intervention, and individualized care in high-risk pregnancies complicated by valvular heart disease.\u003c/p\u003e","manuscriptTitle":"Severe rheumatic mitral stenosis and ARDS in pregnancy managed with percutaneous mitral commissurotomy and ECMO: A case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-30 14:51:24","doi":"10.21203/rs.3.rs-6681230/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-10T11:37:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-07T05:31:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21133591070011289569876396987286840490","date":"2025-11-28T05:24:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-30T07:14:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325781522782530526755913222658266671548","date":"2025-05-30T05:12:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-28T04:50:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-21T12:30:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-20T11:37:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-20T11:34:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-05-16T13:29:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8ade5a7e-41f7-407a-abb6-56bbdf749a7b","owner":[],"postedDate":"May 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:01:33+00:00","versionOfRecord":{"articleIdentity":"rs-6681230","link":"https://doi.org/10.1186/s12884-026-09013-4","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2026-04-08 15:58:39","publishedOnDateReadable":"April 8th, 2026"},"versionCreatedAt":"2025-05-30 14:51:24","video":"","vorDoi":"10.1186/s12884-026-09013-4","vorDoiUrl":"https://doi.org/10.1186/s12884-026-09013-4","workflowStages":[]},"version":"v1","identity":"rs-6681230","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6681230","identity":"rs-6681230","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}