Tetralogy of Fallot with rheumatic mitral stenosis: A case report

An unusual association of rheumatic mitral stenosis in an adult Indian male patient aged 35 years with Tetralogy of Fallot and subacute bacterial endocarditis of the aortic valve is presented.In this case report the diagnostic implications, hemodynamic and therapeutic consequences of mitral stenosis in Tetralogy of Fallot are discussed. In addition, the morbidity and mortality of infective endocarditis in adult patients with congenital heart disease are summarized. The risk of a coincident rheumatic process in patients with congenital heart disease is highlighted and the need for careful attention to this possibility during primary and follow-up evaluation of such patients emphasized.Rheumatic and congenital heart diseases account for about 65% of total cardiac admissions in India and the prevalence rate of rheumatic heart disease is reported as 0.5 to 0.67 per 1000 [1]. Coexistent rheumatic disease in patients with congenital heart defects is known to occur [2,3]. We discuss an interesting association of rheumatic mitral stenosis in an adult with tetralogy of Fallot (TF) complicated by infective endocarditis of the aortic valve.TF remains the most common type of congenital heart lesion seen beyond infancy and childhood with about 5% of patients surviving to the age of 40 years. Aortic regurgitation may occur in affected patients in or beyond the second decade of life, and this may predispose to infective endocarditis [4]. Mitral inflow obstruction in congenital heart disease may be due to a supramitral ring, congenital or acquired valvular stenosis and parachute mitral valve, all of which result in an elevated transmitral gradient – the hemodynamic hallmark of mitral stenosis [5]. In TF, an increasing severity of mitral stenosis potentiates the passive pulmonary venous congestion which may aggravate the hypoxemia.Atrial fibrillation is an uncommon rhythm disturbance in TF. However, mitral stenosis may predispose the patient to atrial fibrillation, with disastrous h