Diagnostic and Management Dilemma: Massive Hemoptysis from Severe Mitral Stenosis

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

The differential diagnosis for hemoptysis is broad. In developed countries, bronchitis, bronchogenic carcinoma, and bronchiectasis are the most common causes.^1, 2 Other etiologies include infection, trauma, pulmonary embolism, and pulmonary-renal syndromes. A computed tomography (CT) scan ruled out pulmonary embolism, and noted no evidence of malignancy or infection. Pulmonary-renal pathology (such as Goodpasture syndrome and granulomatosis with polyangiitis) was ruled out with lab work. 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) as displayed in the Figure. Additionally, TEE revealed a thrombus in the left atrial appendage.

The patient’s rapid atrial fibrillation led to increased mitral valve gradient and high pulmonary pressures. His heart rate was difficult to control with medications given hypotension, and there was hesitancy to cardiovert with left atrial appendage thrombus. Structural cardiology and cardiovascular surgery evaluated the patient for management options, specifically percutaneous mitral balloon valvuloplasty (PMBV) vs surgical intervention. The patient’s Wilkins score was 7, which is associated with favorable outcomes with PMBV.³ However, the patient had left atrial appendage thrombus, increasing the risk of stroke with PMBV.⁴ Ongoing hemoptysis precluded the imitation of anticoagulation. Also, he remained hemodynamically unstable, preventing surgical intervention from being a feasible option.