Rheumatic Mitral and Tricuspid Valvular Disease with Cerebral Embolism

Clinical History

This 40 year old female had a past history of rheumatic fever 27 years previously. She presented with sudden loss of consciousness 4 hours earlier. Examination revealed a comatose, afebrile female, pulse 64 and fibrillating, BP 180/120 mm Hg. The eyes deviated to the left and the pupils were dilated - the left being greater than the right. There was 2.5 cm jugular venous congestion and the apex beat was in the 6th left intercostal space 12.5 cm from the mid- sternal line. A systolic and mid-diastolic murmur was heard at the apex. Bilateral crepitations were present. The patient showed left upper motor neurone signs. The patient was thought to have suffered a cerebral embolus. She developed a swinging temperature with bronchopneumonia and died 10 days following admission.

Pathology

The specimen is of heart sliced open to display the right atrium, ventricle and tricuspid valve. The tricuspid valve cusps are thickened and partially fused and the chordae shortened and thickened. This is an example of tricuspid stenosis, most likely of rheumatic origin. The posterior aspect of the specimen shows a markedly dilated left atrium and a "button-hole" mitral orifice 1.5 x 1 cm, with thickening and fusion of the valve leaflets. At necropsy antemortem thrombi were found in the left atrial appendage and a splenic infarct was present. The aortic valve was normal.