Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging

: 2022  |  Volume : 6  |  Issue : 1  |  Page : 56--58

Quadrivalvular Involvement in Rheumatic Heart Disease: A Rare Case Report

CM Satvic, Arnab Ghosh Chaudhury, Lachikarathman Devegowda, Prabhavathi Bhat, CN Manjunath 
 Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Arnab Ghosh Chaudhury
Sambhram Apartment II, Gokulam Main Road, V V Mohalla, Mysore - 570 002, Karnataka


Four-valve involvement (mitral, aortic, tricuspid, and pulmonary) in rheumatic heart disease (RHD) is an exceedingly rare entity. We report the case of a 24-year-old male, a known case of RHD, who presented with dyspnea and presyncope for 2 months. On examination, the patient had severe mitral stenosis, moderate mitral regurgitation, severe aortic stenosis, severe aortic regurgitation, and severe tricuspid regurgitation. Echocardiography revealed severe tricuspid stenosis with moderate pulmonary stenosis in addition to other clinically detectable valve lesions. The patient underwent aortic and mitral valve replacement, tricuspid valve repair with pulmonary valvotomy successfully.

How to cite this article:
Satvic C M, Chaudhury AG, Devegowda L, Bhat P, Manjunath C N. Quadrivalvular Involvement in Rheumatic Heart Disease: A Rare Case Report.J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:56-58

How to cite this URL:
Satvic C M, Chaudhury AG, Devegowda L, Bhat P, Manjunath C N. Quadrivalvular Involvement in Rheumatic Heart Disease: A Rare Case Report. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2022 Jul 6 ];6:56-58
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Full Text


All four-valve involvement in rheumatic heart disease (RHD) is an exceedingly rare entity. Four-valve involvement is also possible in patients with congenital pulmonary stenosis who develops rheumatic valvular heart disease later involving mitral, aortic, and tricuspid valves. Very rarely valve prolapses involving all four valves can present with regurgitant lesions in mitral, aortic, tricuspid, and pulmonary valves. However, stenotic lesions will not be associated in that case. We report the case of a 24-year-old man who presented with RHD with the involvement of mitral, aortic, tricuspid, and PVs.

 Case Report

A 13-year-old male presented with New York Heart Association (NYHA) class III dyspnea in 2006. He was diagnosed to have RHD, severe mitral stenosis (MS), and mild aortic stenosis (AS). He underwent percutaneous transvenous mitral commissurotomy (PTMC) elsewhere. In 2009, the patient came to our hospital with similar symptoms. Review echo revealed severe MS with moderate AS. Repeat PTMC was done successfully. In June 2017, the patient presented again with NYHA class III dyspnea and multiple episodes of presyncope of 2-month duration. On clinical examination, the patient had a low volume regular pulse with carotid shudder suggestive of severe AS. Blood pressure was 110/70 mmHg. Jugular venous pulse was elevated with prominent C-V waves suggestive of severe tricuspid regurgitation (TR). The patient did not have any dysmorphic features including marfanoid habitus. Cardiovascular examination revealed left ventricular type of apex which was forceful and well sustained suggestive of predominant AS (pressure overload). On auscultation, S1 was loud, A2 and P2 were soft. The patient had mid-diastolic murmur at the mitral area, pansystolic murmur at the tricuspid area, ejection systolic murmur at the aortic area, early diastolic murmur at the neo aortic area suggestive of severe MS, severe AS, severe aortic regurgitation (AR), and severe TR.

Electrocardiogram revealed sinus rhythm, biatrial enlargement, left ventricular hypertrophy, and left axis deviation. Chest X-ray showed cardiomegaly and pulmonary venous hypertension. There was no evidence of active rheumatic activity as evidenced by normal antistreptolysin-O titer and c-reactive protein levels. Transthoracic echocardiography revealed severe MS with mitral valve orifice area of 0.48 cm2 and gradient of 20/13 mmHg [Figure 1]a and [Figure 2]a, [Figure 2]b. There was moderate mitral regurgitation (MR) with eccentric jet [Figure 1]a, [Figure 1]b and [Video 1]. Severe AS was noted (aortic valve gradient was 154/91 mmHg) with severe AR [Figure 3]a, [Figure 3]b and [Video 2]. There was severe tricuspid stenosis (TS) with tricuspid valve gradient of 26/21 mmHg [Figure 4]a, [Figure 4]b and [Video 3] with severe TR [Figure 5]a, [Figure 5]b and [Video 4]. Pulmonary valve showed thickening with turbulence across the valve [Figure 6]a and [Video 5]. The pulmonary valve gradient was 40/18 mmHg suggestive of moderate pulmonary stenosis (PS) [Figure 6]b. Grade I pulmonary regurgitation (PR) was also noted. The final diagnosis was RHD, severe MS, moderate MR, severe AS, severe AR, severe TS, severe TR, moderate PS, and mild PR. The patient was treated with replacement of mitral and aortic valves with mechanical prosthetic valves, tricuspid valve repair, and surgical pulmonary valvotomy [Figure 7]. The patient is doing well after 6 months following surgery.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}

Video 1: Transthoracic echocardiography parasternal short axis view: colour flow Doppler showing mitral stenosis, moderate mitral regurgitation with eccentric jet.


Video 2: Transthoracic echocardiography apical five chamber view: colour flow Doppler showing severe aortic stenosis with severe aortic regurgitation


Video 3: Transthoracic echocardiography apical four chamber view: colour flow Doppler showing severe tricuspid stenosis.


Video 4: Transthoracic echocardiography apical four chamber view: colour flow Doppler showing severe tricuspid regurgitation.


Video 5: Transthoracic echocardiography parasternal short axis view: colour flow Doppler showing severe pulmonary stenosis with doming of the pulmonary valve.



Involvement of all the four cardiac valves due to a rheumatic process is rare.[1] Rheumatic quadrivalvar damage has been found on necropsy (one in 586 patients with valve deformities) and by cardiac catheterization.[2] There is a high incidence of multivalvular damage when Aschoff bodies are identified at necropsy. Earlier, pulmonary valve involvement was diagnosed only at the surgery. Organic tricuspid valve involvement is reported to occur in more than one-third of the patients with RHD studied at necropsy in the Indian subcontinent.[3] Four-valve involvement is also possible in the case of a congenital pulmonary stenosis patient who develops rheumatic mitral, aortic, and tricuspid involvement later. In our case, old echocardiography findings of the same patient in 2006 and 2009 demonstrated normal pulmonary valve, ruling out the possibility of congenital pulmonary stenosis. The pulmonary valve was thickened suggestive of rheumatic pathology contrary to typical thin doming valves seen in congenital pulmonary stenosis. There are a few reports of echocardiographic diagnosis of rheumatic cardiopathy affecting all four cardiac valves.[4] Preoperative echocardiographic diagnosis of rheumatic involvement of all four cardiac valves and successful surgical treatment has also been reported.[5] A study done in our institute included 13,289 patients of valvular heart disease (2010–2012).[6] Only one patient among the cases had combined mitral, tricuspid, and pulmonary valve involvement of rheumatic origin. Four-valve involvement was not reported in that study.[6]


Quadrivalvular involvement in RHD can occur though it is extremely rare. Operator awareness regarding possible quadrivalvular damage is essential for appropriate diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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