Cardiac Magnetic Resonance in Rheumatic Heart Disease: Insights into Myocardial Dysfunction and Valve-in-Valve Intervention

Presenting Author(s)

• 

  Natassia SSC Gomes, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil

Co-Author(s)

• 

  Natassia SSC Gomes, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil

Primary Author(s)

• GP

  Gabriela Fernandes Pereira, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia, Brazil

Co-Author(s)

• GC

  Giseli Casarini, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia, Brazil
• TD

  Tacianne RB Delamain, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia, Brazil
• 

  Marina R. Cavallari, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• 

  Camilla F. Reimberg, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia
  São Paulo , Sao Paulo, Brazil
• GM

  Gustavo R. Modolo, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia, Brazil
• 

  Amanda Marsiaj Rassi, MD

  Cardiologist
  Instituto Dante Pazzanese de cardiologia
  São Paulo, Sao Paulo, Brazil
• EB

  Everton R. Barbosa, MD

  MD
  Instituto Dante Pazzanese de Cardiologia, Brazil
• 

  Alice Cunha Darzé, MD

  Cardiologist
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• JC

  João Marcelo Caneschi, MD

  Cardiologist
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• 

  Paul Salvador Salvador Morales, MD

  Cardiologist
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• Rd

  Rafael de Castro Hendges, MD, PhD

  Cardiologist
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• LP

  Luciano G. Possa, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia, Brazil
• JJ

  José Tuma Junior, MD

  Cardiologist
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• CP

  Carlos Eduardo E E D Prazeres, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia, Brazil
• 

  Tiago Senra, MD, PhD

  Physician
  Dante Pazzanese Institute of Cardiology
  Sao Paulo, Sao Paulo, Brazil
• 

  Antonio Tito 3. Paladino Filho, MD, PhD

  Cardiologist
  Hospital Vila Nova Star, Rede D’or São Paulo-SP
  Sao Paulo, Sao Paulo, Brazil
• 

  Ibraim Masciarelli Pinto, MD, PhD

  Director, Non Invasive Cardiology
  Instituto Dante Pazzanese de Cardiologia
  Sao Paulo, Sao Paulo, Brazil

Description of Clinical Presentation: We present the case of a 24-year-old female with a history of severe rheumatic mitral valve disease, who underwent mitral valve replacement with a bioprosthesis and tricuspid repair at the age of 13 following an acute rheumatic fever complicated by pericardial effusion and hemodynamic compromise. In evolution, she developed progressive biventricular dysfunction and prosthetic valve complications during long-term follow-up- bioprosthesis thrombosis successfully treated with anticoagulation. Eleven years after surgery, she presented with progressive heart failure (NYHA III) and evidence of prosthetic degeneration with severe stenosis.

Diagnostic Techniques and Their Most Important Findings: Transthoracic echocardiography confirmed prosthetic dysfunction with severe restriction of leaflet mobility, elevated gradients, and biventricular impairment. Cardiac magnetic resonance (CMR) was performed on a 3T scanner with a comprehensive protocol, including cine SSFP imaging, inversion recovery, perfusion, and late gadolinium enhancement (LGE). CMR revealed marked biatrial and biventricular dilatation with severe global systolic dysfunction, intraventricular dyssynchrony, and bioprosthetic leaflet degeneration. Tissue characterization demonstrated non-ischemic mid-wall LGE in the inferoseptal segments, indicative of myocardial fibrosis, while no edema or fat infiltration was detected. These findings provided a comprehensive assessment of structural remodeling, functional deterioration, and myocardial injury, complementing echocardiographic data and guiding the Heart Team’s therapeutic strategy. The patient underwent successful percutaneous mitral valve-in-valve replacement, resulting in symptomatic improvement and hemodynamic stabilization.

Learning Points from this Case: This case illustrates the progressive course of rheumatic heart disease and highlights the value of multimodality imaging in its management. While echocardiography remains the first-line tool, CMR provided high-fidelity quantification of ventricular function, detailed prosthesis evaluation, and tissue characterization that revealed irreversible myocardial fibrosis and dyssynchrony. These findings explained the patient’s advanced symptoms and supported the choice of valve-in-valve therapy in the setting of prohibitive surgical risk. CMR thus proved instrumental in bridging the gap between anatomical and functional assessment, reinforcing its role as a complementary modality in the management of complex valvular heart disease.

Cine SSFP sequences for morphological and functional evaluation
Cine SSFP sequences for morphological and functional evaluation
LGE short-axis images showed a non-ischemic mid-wall pattern in the basal and mid inferoseptal segments.