Introduction: Advances in medical ultrasound (US) result in an increasing number of valvular diseases. They facilitate diagnosis even in patients with mild or no symptoms. When treating a heart valve disease, surgical approach remains currently the gold standard therapy.

Methods: We present the case of a hypertensive 64 years old man referred to our clinic with dyspnoea on exertion in recent months. Clinical examination at admission revealed systolic murmurs at the Aortic (II/6) and Mitral auscultation areas (IV/6) without any pathological aspects. Laboratory panel was in normal range. Transthoracic US showed a morphological as-pect of rheumatic valve disease affecting the Aortic val-ve (mild stenosis Pmax/Pmed 43/20 mmHg) and the mitral valve (significant regurgitation with an eccentric flow towards the interatrial septum), a normal systolic function of left ventricle and no pulmonary hyperten-sion. Transesophageal showed a mitral valve with cal-cium deposits with severe regurgitation due to flail of the posterior mitral leaflet secondary to chordae ruptu-re. With normal coronary and carotid angiograms the indication was clear and the patient was referred to a surgical unit for the procedure.

Results: T he patient later underwent aortic and mi-tral valve replacement with two mechanical prosthe-ses, the surgeon opting for correction of both heart valves. Post-operatively the patient developed a total atrio-ventricular block and a pacemaker was implan-ted. Three months after the procedure the patient was readmitted for severe dyspnoea. At US a severe pros-thetic aortic paravalvular leak was identified with sub-sequent surgical repair. Following the re-intervention the patient’s evolution was slightly unfavorable, develo-ping a severe anemia requiring multiple blood transfu-sions through repeated hospital admissions. In order to investigate anemia’s etiology, consecutive gastrointesti-nal and hematologic exams were performed, resulting in excluding them as source of the anemic syndrome. At readmission in our clinic, two months after the re-intervention, patient’s clinical status was unchanged. US was repeated revealing a normal functioning mitral prosthesis and mismatch of the aortic one (Pmax/Pmed 76/46 mmHg with an effective orifice area of 0.79 cm2/ m2). It was opted for closely monitor patient’s evoluti-on, correction of the anemia and the clinical-biological status taking into consideration a surgical re-interven-tion.

Conclusions: T he severe anemia, responsive only to transfusion, was interpreted as a secondary to the mismatch of the aortic prosthesis. When it comes to rheumatic valvular disease, with multiple valve invol-vement, the decision to approach even the mild/mo-derate lesions fearing a re-intervention in the future is a difficult one, requiring a multidisciplinary approach.