Severe rheumatic mitral stenosis and ARDS in pregnancy managed with percutaneous mitral commissurotomy and ECMO: A case report and literature review

Background: Rheumatic mitral stenosis (MS) remains a leading cause of cardiovascular complications in pregnancy, particularly in low-resource settings. Hemodynamic changes during pregnancy can precipitate decompensation in previously asymptomatic patients, increasing the risk of maternal and fetal morbidity. Early recognition and management, including percutaneous mitral commissurotomy (PMC) in selected cases, are crucial to optimizing outcomes. Case Presentation: We present the case of a 32-year-old pregnant woman (G4P3) at 22.6 weeks of gestation who developed severe respiratory distress and cardiogenic shock due to previously undiagnosed severe rheumatic MS. Initial management of respiratory distress at a rural hospital included inhaled beta-agonists; however, her condition rapidly deteriorated, requiring orotracheal intubation and urgent transfer to a tertiary care center. Transthoracic echocardiography confirmed severe MS (mitral valve area: 1.3 cm², mean gradient: 17 mmHg) with a severely dilated left atrium. A respiratory molecular panel was positive for Influenza A. Despite medical therapy, she developed refractory hypoxemia, distributive and cardiogenic shock, necessitating escalating vasopressor support and mechanical ventilation. A multidisciplinary team decision led to urgent PMC, successfully performed with a post-procedure mitral valve area of 2.6 cm². However, due to persistent respiratory failure, veno-venous extracorporeal membrane oxygenation (ECMO) was initiated, with successful decannulation after 33 days. The patient recovered without residual respiratory distress, and subsequent obstetric ultrasounds confirmed fetal viability and normal growth. She later underwent an uneventful delivery at 38 weeks, with favorable maternal and neonatal outcomes. Conclusions: This case underscores the importance of early diagnosis, echocardiographic assessment, and multidisciplinary management in pregnant patients with severe MS. PMC remains the preferred intervention for severe symptomatic MS during pregnancy, significantly improving hemodynamics and reducing maternal risk. In cases of severe decompensation, ECMO serves as a life-saving bridge to recovery, ensuring both maternal stabilization and favorable perinatal outcomes. This case report highlights the need for preconception counseling, early intervention, and individualized care in high-risk pregnancies complicated by valvular heart disease.