Case 04/12 - A 44-year-old male with rheumatic valvular heart disease with multiple previous surgeries of aortic valve replacement admitted for treatment of congestive heart failure

Abstract

Male, 44 years old, with a history of rheumatic attacks in childhood and adolescence and multiple aortic valve replacement surgeries, was admitted with decompensated heart failure. The present illness began with rheumatic attacks characterized by fever, arthritis of the right knee, when he was 7-11 old. At age 15, paroxysmal palpitations appeared. At age 16, the patient initiated follow-up at the outpatient services at InCor. Double aortic lesion and rheumatic disease activity were diagnosed. At the time, the electrocardiogram (ECG) revealed severe left ventricular hypertrophy; a chest radiograph revealed cardiomegaly +++/ 4+. At age 17, the palpitations became more frequent, dyspnea on moderate exertion appeared. Physical examination in primary care (May 1977) revealed pulse rate of 80 bpm, blood pressure 100/0 mmHg; auscultation was normal, cardiac auscultation revealed systolic murmur +++/ 4+ in the aortic area and diastolic murmur in the left sternal border. There was also the presence of a third heart sound; the abdomen showed no changes, no edema, and the pulse was of rapid ascent and descent. The patient was under use of digoxin (0.25 mg daily) and prophylaxis of rheumatic fever with benzathine penicillin 1.2 million units intramuscularly (IM) every two weeks. Surgical treatment of the aortic valve was prescribed. After the indication for surgical treatment, there were several attempts of hospitalization. However, these were frustrated by frequent episodes of fever and arthralgia of the knees treated as rheumatic disease activity and, due to the persistence of this condition, an investigation was conducted.