COMPLEX MULTIVALVULAR HEART DISEASE ASSOCIATED WITH TRIPLE-VESSEL CORONARY ARTERY DISEASE AND LOW-FLOW LOW-GRADIENT AORTIC STENOSIS: A CHALLENGING THERAPEUTIC DECISION

Rheumatic heart disease remains a major cause of complex multivalvular pathology, particularly in developing countries. The coexistence of severe mitral restenosis, low flow low gradient aortic stenosis, ventricular dysfunction, pulmonary hypertension, and multivessel coronary artery disease represents a highly challenging clinical scenario. We report the case of a 67-year-old woman with prior mitro-aortic surgery presenting with progressive dyspnea and advanced heart failure. Echocardiography revealed severe mitral restenosis and classical low-flow low-gradient aortic stenosis with reduced ejection fraction, while coronary angiography demonstrated diffuse triple-vessel disease. The interaction between valvular obstruction, ventricular dysfunction, and coronary ischemia complicated clinical assessment and therapeutic decision making. Following multimodality imaging and multidisciplinary Heart Team evaluation, redo surgery with coronary bypass was considered but deemed prohibitive, and the patient declined intervention. An individualized strategy based on optimized medical therapy was adopted.This case highlights the importance of multimodality imaging, Heart Team-based decision-making, and patient-centered care in complex high-risk multivalvular–coronary disease.