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

Abstract

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. Conclusion: It describes how a carefully planned, staged percutaneous strategy can provide an alternative to conventional surgical management. It also emphasizes the importance of multidisciplinary assessment, procedural sequencing, hemodynamic considerations, and individualized patient selection when multiple cardiovascular pathologies coexist.