Balloon pulmonary valvuloplasty for severe rheumatic pulmonary stenosis in quadrivalvular heart disease after prior multivalve surgery: a case report

Abstract

Background: Rheumatic heart disease predominantly affects left-sided cardiac valves. Quadrivalvular involvement with clinically significant pulmonary valve stenosis is exceedingly rare, and evidence regarding minimally invasive management strategies in such complex cases is limited. Case summary: A 30 year-old woman with chronic rheumatic heart disease and prior mitral and aortic bioprosthetic valve replacement with tricuspid valve repair presented with a four-month history of progressive exertional dyspnea and palpitations (New York Heart Association functional class lll). Transthoracic echocardiography revealed severe pulmonary valve stenosis with a peak gradient of 97 mmHg, moderate pulmonary regurgitation, mild tricuspid regurgitation, right ventricular hypertrophy with preserved systolic function, and normally functioning prosthetic mitral and aortic valves. Given the presence of predominant commissural fusion, minimal valve calcification, preserved right ventricular function, and elevated surgical risk due to prior cardiac surgery, percutaneous balloon pulmonary valvuloplasty was performed. An 18 x 40 x 110 mm Nucleus balloon was deployed under fluoroscopic guidance, resulting in immediate symptomatic improvement. Post-procedural echocardiography demonstrated a reduction in the pulmonary valve gradient to 35 mmHg. At follow-up visit at 1 week, 1 month, and 3 months, the patient remained asymptomatic, with sustained gradient reduction (35-38 mmHg), preserved right ventricular function, moderate but clinically well-tolerated pulmonary regurgitation, and continued normal prosthetic valve function. Discussion: Pulmonary valve involvement in rheumatic heart disease is rare and typically occurs as part of multivalvular disease. In carefully selected patients, balloon pulmonary valvuloplasty can provide a safe and effective minimally invasive alternative to reoperation, achieving durable hemodynamic and clinical improvement.