Massive hemoptysis from severe mitral stenosis
Published in the American Journal of Medicine, the authors present an unusual case that presented a diagnostic and management dilemma.

A 55-year-old man presented to the Emergency Department with dyspnea and hemoptysis. He was hemodynamically unstable, requiring intubation and pressor support.

On examination, he was afebrile and tachycardic in atrial fibrillation. Lung auscultation revealed diffuse, coarse rhonchi. No murmur was heard, although body habitus limited examination. Laboratory data revealed anemia requiring blood transfusions and renal failure requiring dialysis.

Bronchoscopy revealed tortuous mucosal vessels, suggesting that the hemoptysis may be secondary to pulmonary hypertension. Transthoracic echocardiogram was limited by poor windows. Transesophageal echocardiogram (TEE) revealed severe rheumatic mitral stenosis (valve area of 0.9 cm2, mean gradient of 13 mm Hg). Additionally, TEE revealed a thrombus in the left atrial appendage.

The decision was made to pursue PMBV (percutaneous mitral balloon valvuloplasty) using TEE guidance, to visualize the catheter during the procedure and lower the risk of embolization of the left atrial appendage thrombus. After valvuloplasty, the patient's valve area improved from 0.9 cm2 to 1.7 cm2.

High left atrial pressures persisted but with lower gradient. Following PMBV, the patient showed clinical improvement and after 2 weeks, he was weaned from dialysis, extubated, and discharged home. He remained stable and underwent definitive surgical mitral valve replacement.

Case learning:-
- This case is unique in many ways. First, this patient had severe rheumatic disease and secondly was complicated by hemodynamic instability, multi-organ failure, and atrial thrombus, making the choice of intervention complex.

- Severe hemoptysis in a critically ill patient must prompt rapid development of a broad differential.

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