Navigating Surgical Risk: A Sequential Percutaneous Strategy for Complex Coronary Disease and Severe Rheumatic Mitral Stenosis

Background

Concomitant severe rheumatic mitral stenosis (MS) and complex coronary artery disease (CAD) can presents as a major therapeutic challenge in an elderly patient with high prohibitive surgical risk. Case Summary: A 78-year-old man with chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, and dyslipidaemia presented with NYHA III–IV dyspnoea, effort angina, and reduced exercise tolerance. Echocardiography demonstrated severe rheumatic MS with a mitral valve area (MVA) of 1.4 cm², a mean transmitral gradient of 18 mmHg, pulmonary artery pressure of 55 mmHg, and preserved left ventricular ejection fraction. Coronary angiography showed total occlusion of the dominant left circumflex artery and a Medina 1,1,1 LAD/D1 bifurcation lesion. Because surgical risk was considered very high and the patient declined open-heart surgery, the Heart Team selected a sequential percutaneous strategy. The LCX was revascularised first, followed by IVUS-guided provisional LAD stenting; D1 compromise was treated with bailout drug-eluting balloon angioplasty and final kissing-balloon inflation without a second stent. Staged balloon mitral valvotomy was then performed during the same hospitalisation. MVA increased to 2.24 cm², the mean transmitral gradient decreased to 3 mmHg, and pulmonary artery pressure decreased to 38 mmHg without significant worsening of mitral regurgitation or a major immediate complication. At six-month follow-up, the patient remained asymptomatic with improved exercise capacity and no recurrent heart-failure hospitalisation or angina.