Managing Rheumatic Mitral Stenosis Complicated by Shock and Cardiac Cirrhosis Beyond Guidelines.

backgroundRheumatic mitral stenosis (MS) is the most common form of valvular heart disease worldwide, which could lead to cardiac cirrhosis when associated with severe tricuspid regurgitation. This report presents how we manage patients with cardiogenic obstructive shock due to severe MS complicated by edema but with intravascular volume depletion due to hypoalbuminemia secondary to cardiac cirrhosis. CASE SUMMARY: A 66-year-old woman who was previously diagnosed with rheumatic MS was evaluated for refractory dyspnea, shock, and peripheral edema. The examination revealed cardiac cirrhosis and hypoalbuminemia as complications of severe MS. DISCUSSION: This case highlights the presence of cardiac cirrhosis and hypoalbuminemia, which further exacerbates hemodynamic compromise and complicates the management of congestion in a patient with uncorrected rheumatic MS. TAKE-HOME MESSAGES: In rheumatic MS complicated by severe tricuspid regurgitation, cardiac cirrhosis, and hypoalbuminemia, congestion and shock create a delicate therapeutic balance. Effective management requires careful titration of diuretics and inotropes, close monitoring of end-organ function, and proactive planning for surgical or percutaneous correction of the underlying valvular pathology.