Letter to the Editor Quadrivalvular rheumatic heart disease Sachin Talwar, Honnakere Venkataiya Jayanthkumar, Gautam Sharma, Arkalgud Sampath Kumar T Department of Cardiothoracic & Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India Received 27 September 2004; accepted 22 October 2004 Available online 5 March 2005 Keywords: Rheumatic heart disease; Quadrivalvular; Sinus rhythm 1. Introduction Although involvement of all four heart valves has been known to occur in patients with acute rheumatic carditis, quadrivalvular involvement is extremely rare in patients with chronic rheumatic heart disease [1]. Less than 20 cases have been reported in the English medical literature [2–7]; only five of these patients have been successfully operated upon [2–4]. In an earlier communication, we had reported the autopsy findings in a 20-year-old woman with rheumatic quadrivalvular heart disease [5]. We report another patient who successfully underwent surgery for this condition and is doing well 8 years after operation. A 20-year-old woman presented with exertional dysp- noea and palpitations of 2-year duration. Her symptoms were of NYHA Class II severity. She had suffered from recurrent attacks of rheumatic fever in her childhood. On clinical examination, she was in sinus rhythm. The jugular venous pressure was elevated with a prominent baQ wave. The first heart sound was loud and the second heart sound was normally split. There was a mid-diastolic murmur associated with a palpable thrill at the apex and another mid- diastolic murmur accentuated during inspiration at the lower left sternal border. There was a grade-III systolic ejection murmur at the upper left sternal border conducted to both the carotid arteries. The liver was enlarged and tender and bilateral pitting oedema feet were present. Chest radiograph (Fig. 1) showed cardiomegaly and was consistent with severe pulmonary arterial and pulmonary venous hypertension. Electrocardiogram showed normal sinus rhythm with evidence of left atrial enlargement and left and right ventricular hypertrophy. Transthoracic echo- cardiography showed leaflet thickening and stenosis of all four valves and aortic regurgitation. The mitral valve area was 0.8 cm 2 and the tricuspid valve area was 1.5 cm 2 . The 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.10.062 T Corresponding author. Tel./fax: +91 11 26588889. E-mail address: asampath _ kumar@hotmail.com (A.S. Kumar). Fig. 1. Chest radiograph showing cardiomegaly and with severe pulmonary arterial and pulmonary venous hypertension. International Journal of Cardiology 106 (2006) 117– 118 www.elsevier.com/locate/ijcard