A 71-year-old woman came to the emergency department with a sensation of continuous precordial palpitation accompanied by dyspnoea at rest.

History, current illness and physical examination
71-year-old woman with slowly progressive dyspnoea of 2 years' evolution, reaching functional class II/IV. Arterial hypertension, type 2 diabetes mellitus. She denies toxic habits. Multiple visits to the Emergency Department for non-condensing respiratory infection and bronchial hyperreactivity for approximately 10 years. Habitual orthopnoea for which he uses two pillows.
Usual treatment: Metformin, enalapril, hydrochlorothiazide, inhaled bronchodilators irregularly.
He presents progressive clinical worsening in the last 2 months, reports occasional chest palpitations, dyspnoea on minimal exertion, worsening of his orthopnoea requiring greater inclination to sleep, oedematisation of the lower limbs, asthenia and adynamia. She denies infectious symptoms and has never presented episodes of chest pain. In the last 3 days she presented with a sensation of continuous precordial palpitation accompanied by dyspnoea at rest, which prompted her to go to the emergency department.

Examination on admission: Conscious, oriented, reactive, perceptive. Heart rate 120 bpm, respiratory rate 30 rpm, BP 117/70 mmHg. Jugular ingurgitation at 45 degrees. Tachycardic and arrhythmic heart tones, fixed split second tone. Opening snap. Diffusely diminished vescicular murmur with expiratory wheezing and crepitant rales up to midfields. Oedema of lower limbs up to middle third of both legs.

Complementary tests
- Haemogram: Hb 13 g/dL, HTC 39%, leucocytes 8,760 /mm3, platelets 201,000/mm3.
- Biochemistry: glucose 108 mg/dL, creatinine 0.79 mg/dL, sodium 138 mEq/L, potassium 4 mEq/L, chlorine 101 mEq/L.
- Electrocardiogram: Atrial fibrillation with RVR at 120 bpm, normal axis, without repolarisation alterations.
- Chest X-ray: Cardio-thoracic index increased with dilatation of RA and pulmonary arteries, small aortic button. Increased pulmonary capillary pressure. Pulmonary parenchyma without significant pathological findings.
- Transthoracic echocardiogram/transesophageal echocardiogram: Dilated right chambers, LA 46 mm. Thickened rheumatic mitral valve with calcified annulus and reduced opening. Mitral planimetry of 1.15. Aortic valve with normal opening. Left ventricle of normal geometry and volume with homogeneous contraction and preserved contractility. Aneurysm of the fossa ovalis with CIA ostium secundum of 12 mm. Cavae and suprahepatic normal.
- Doppler: Stenotic mitral filling in AF with Hattle area of 1.2 cm2. Mild TR. PSP 50 mmHg. Flow at the level of the fossa ovalis I > D of moderate amount.
- Wilkins score: 11 points.

Clinical evolution
He was hospitalised in the Cardiology ward where he evolved satisfactorily, responding favourably to the depletive management. She spontaneously reverted to sinus rhythm and showed marked symptomatic improvement, mainly by reducing her dyspnoea. Cardiac catheterisation showed diffuse coronary atherosclerosis without significant coronary lesions. Calcified mitral valve with moderate-severe stenosis. Gorlin area of 1 cm2 with mean gradient of 8 mmHg without end-diastolic gradient due to restrictive ASD. Mean RA pressure of 14 mmHg through which I-D shunt of 2.55 occurs. Moderate mixed passive hyperdynamic passive pulmonary hypertension. Reduced IC. Preserved LVEF. Occlusion test: A significant increase in mean LA pressure was observed with increased transmitral gradients and increased interlocking pressure, demonstrating the presence of severe mitral stenosis. The case was presented at SMQ and it was decided to perform mitral valve replacement and closure of the ASD.

Diagnosis
- Severe rheumatic aortic stenosis
- Atrial septal defect, ostium secundum type
- Lutembacher's syndrome
