What is the management plan for a 51-year-old patient with a history of scarlet fever as a child, now presenting with moderate to severe mitral stenosis?

Management of Moderate to Severe Mitral Stenosis in a 51-Year-Old Patient with History of Scarlet Fever

For a 51-year-old patient with moderate to severe mitral stenosis secondary to childhood scarlet fever, percutaneous mitral commissurotomy (PMC) is the recommended first-line intervention if the valve anatomy is favorable. 1, 2

Initial Assessment

• Confirm rheumatic etiology through:

  • History of scarlet fever (already established)
  • Echocardiographic findings of commissural fusion
  • Valve morphology assessment using Wilkins score

• Complete evaluation should include:

  • Transthoracic echocardiography to assess:
    • Mitral valve area (MVA)
    • Mean transmitral gradient
    • Pulmonary artery pressure
    • Left atrial size
    • Presence of other valve disease
  • Transesophageal echocardiography to exclude left atrial thrombus before intervention

Treatment Algorithm

Step 1: Determine Intervention Candidacy

• If favorable valve anatomy (low Wilkins score, no severe calcification, minimal mitral regurgitation):

  • PMC is first-line therapy 1, 2

• If unfavorable valve anatomy (heavy calcification, significant mitral regurgitation, absence of commissural fusion):

  • Mitral valve surgery (repair or replacement) is indicated 1

Step 2: Medical Management

• Anticoagulation:

  • If in atrial fibrillation: Vitamin K antagonist (warfarin) with target INR 2-3 1, 3
  • If in sinus rhythm with history of embolism or dense spontaneous echo contrast: Consider anticoagulation 1

• Symptom management:

  • Diuretics for volume overload
  • Beta-blockers or calcium channel blockers for rate control
  • Careful management of fluid status

Special Considerations

For PMC Candidates:

• Contraindications to PMC include:
  • Left atrial thrombus
  • More than mild mitral regurgitation
  • Severe bicommissural calcification
  • Absence of commissural fusion (degenerative MS)

For Surgical Candidates:

• Valve repair is preferred when feasible
• For valve replacement:
  • Mechanical valve: Consider in younger patients, requires lifelong anticoagulation
  • Bioprosthetic valve: Consider in older patients or those with contraindications to anticoagulation

Follow-up Protocol

• After successful PMC:

  • Similar to asymptomatic patients
  • Annual clinical and echocardiographic examinations

• If PMC unsuccessful:

  • Consider early surgical intervention 1

• For moderate stenosis without intervention:

  • Follow-up every 2-3 years with echocardiography 2

Pitfalls to Avoid

• Don't delay intervention in symptomatic patients, as this leads to worse outcomes
• Don't assume all mitral stenosis in this age group is rheumatic; confirm commissural fusion
• Don't use NOACs instead of warfarin in patients with mitral stenosis and atrial fibrillation 1
• Don't attempt cardioversion before intervention in patients with severe mitral stenosis and atrial fibrillation, as sinus rhythm is unlikely to be maintained 1

This patient's history of scarlet fever strongly suggests rheumatic mitral stenosis, which typically responds well to PMC if valve anatomy is favorable. The decision between PMC and surgical intervention should be based on careful assessment of valve morphology and clinical status.