From the Guidelines
A 28-year-old man with a history of rheumatic fever at age 12 is at greatest risk for developing mitral valve stenosis. Rheumatic fever, an inflammatory reaction to group A streptococcal infection, typically affects the mitral valve first and most severely, as noted in the 2024 ACC/AHA clinical performance and quality measures for adults with valvular and structural heart disease 1. The disease causes inflammation that leads to scarring and fusion of the valve leaflets, resulting in narrowing (stenosis) of the valve opening. This process develops gradually over 10-20 years following the initial rheumatic fever episode, which aligns with this patient's timeline. While rheumatic fever can affect multiple heart valves, including the aortic valve, the mitral valve is involved in approximately 85% of cases, making it the most commonly affected valve, as supported by the indications for cardiac catheterization and intervention in pediatric cardiac disease 1. The patient should be monitored with regular echocardiograms to assess for valve damage, and antibiotic prophylaxis may be recommended before certain procedures to prevent recurrent rheumatic fever, though guidelines for prophylaxis have become more selective in recent years. Key factors to consider in the management of rheumatic mitral stenosis include the severity of symptoms, valve morphology, and the presence of comorbidities such as atrial fibrillation or pulmonary hypertension, as outlined in the 2024 ACC/AHA guidelines 1. In terms of treatment, percutaneous balloon valvuloplasty is a recommended option for symptomatic patients with moderate to severe mitral stenosis and favorable valve morphology, as well as for asymptomatic patients with moderate to severe mitral stenosis and pulmonary hypertension 1. Surgical intervention, including commissurotomy or mitral valve replacement, may also be considered in certain cases, particularly for patients with severe valvular thickening, subvalvular fibrosis, or significant tricuspid regurgitation 1. Overall, the management of rheumatic mitral stenosis requires a comprehensive approach that takes into account the individual patient's clinical presentation, valve morphology, and comorbidities, with the goal of improving symptoms, preventing complications, and reducing morbidity and mortality. Some key points to consider in the management of this patient include:
- Regular echocardiographic monitoring to assess for valve damage and disease progression
- Antibiotic prophylaxis to prevent recurrent rheumatic fever, as recommended by current guidelines
- Consideration of percutaneous balloon valvuloplasty or surgical intervention, depending on the severity of symptoms and valve morphology
- Management of comorbidities such as atrial fibrillation or pulmonary hypertension to reduce the risk of complications and improve outcomes.
From the Research
Valve Stenosis Risk
The 28-year-old man who had rheumatic fever at age 12 is at greatest risk for developing stenosis of the mitral valve.
- Rheumatic fever is a major cause of acquired heart disease in children and young adults, leading to mitral stenosis 2, 3.
- Mitral stenosis is a common problem in patients with a history of rheumatic fever, with a high incidence of 54 percent among rheumatic heart disease patients 4.
- The mitral valve is most commonly affected by rheumatic heart disease, resulting in stenosis or narrowing of the valve 5, 6.
- Percutaneous mitral balloon commissurotomy (PMBC) and surgical commissurotomy are effective treatments for mitral stenosis, with PMBC being a preferred option for patients with suitable valve morphology 2, 3.
Relevant Studies
Studies have shown that patients with a history of rheumatic fever are at high risk of developing mitral stenosis, and that PMBC is an effective treatment option for these patients 4, 5.
- A study of 463 patients with severe rheumatic mitral valve stenosis found that PMBC was technically successful in 98% of cases, with significant improvements in mitral valve area and cardiac index 5.
- Another study found that patients with atrial fibrillation had worse immediate clinical and echocardiographic outcomes after PMBC, highlighting the importance of careful patient selection and management 4.