How to manage a patient with rheumatic heart disease (RHD) and severe mitral stenosis (MS) presenting with severe respiratory distress, hypotension, tachycardia, and diffuse bilateral chest crepitations?

Emergency Management of Rheumatic Heart Disease with Severe Mitral Stenosis in Respiratory Distress

The patient requires immediate management with oxygen supplementation, intravenous diuretics, and consideration for mechanical ventilation due to cardiogenic pulmonary edema from decompensated severe mitral stenosis.

Initial Stabilization

• Immediately place patient in upright position to reduce pulmonary congestion 1
• Administer high-flow oxygen via non-rebreather mask to improve oxygenation 1
• Establish two large-bore intravenous access lines for medication administration 1
• Start continuous cardiac monitoring, pulse oximetry, and frequent blood pressure measurements 1
• If available, initiate non-invasive ventilation (CPAP/BiPAP) to improve oxygenation and reduce work of breathing 2
• For patients with severe respiratory distress and impending respiratory failure, prepare for endotracheal intubation and mechanical ventilation 2

Pharmacological Management

• Administer intravenous loop diuretics (furosemide 40-80 mg IV) as first-line therapy to reduce pulmonary congestion 1
• Consider intravenous morphine in small doses (2-4 mg) to reduce anxiety, preload, and afterload if blood pressure allows 1
• Initiate inotropic support with dobutamine or dopamine if hypotension persists despite initial measures 1
• For patients with rapid heart rate, consider cautious use of beta-blockers or rate-controlling calcium channel blockers to prolong diastolic filling time across the stenotic mitral valve 1
• If atrial fibrillation is present, control ventricular rate to improve hemodynamics 1

Hemodynamic Monitoring and Support

• Insert an arterial line for continuous blood pressure monitoring 1
• Consider right heart catheterization (Swan-Ganz) for direct measurement of pulmonary artery pressures and optimization of preload 1
• Maintain adequate preload while avoiding pulmonary congestion - this requires careful fluid balance monitoring 1
• Target heart rate control (60-80 bpm) to maximize diastolic filling time across the stenotic valve 1
• For refractory hypotension, consider vasopressors (norepinephrine preferred) to maintain coronary perfusion 1

Advanced Management Considerations

• If the patient stabilizes, perform comprehensive echocardiography to assess mitral valve area, gradient, and suitability for intervention 1
• For patients with favorable valve morphology (pliable, non-calcified valves with minimal subvalvular fusion), consider urgent percutaneous mitral balloon commissurotomy once stabilized 1
• For patients with unfavorable valve morphology or those who fail to stabilize with medical therapy, consider urgent surgical intervention (mitral valve repair or replacement) 1
• If mechanical ventilation is required, use lung-protective strategies with tidal volumes of 6 ml/kg predicted body weight and PEEP titration based on oxygenation status 2

Common Pitfalls and Caveats

• Avoid excessive fluid administration, which can worsen pulmonary edema in mitral stenosis 1
• Avoid tachycardia at all costs, as it shortens diastolic filling time and worsens mitral valve obstruction 1
• Be cautious with sedatives and vasodilators as they may worsen hypotension in an already compromised hemodynamic state 1
• Recognize that rheumatic mitral stenosis patients may develop acute pulmonary edema suddenly, even when previously stable 1
• Consider comorbid conditions such as atrial fibrillation, pulmonary hypertension, or right ventricular dysfunction that may complicate management 1, 3
• Be aware that patients with rheumatic heart disease may have mixed valve disease (both stenosis and regurgitation), which requires special consideration in management 1, 4

Transfer Considerations

• If the patient fails to stabilize or if advanced interventions (percutaneous mitral valvuloplasty or surgery) are indicated but not available at your facility, arrange for urgent transfer to a Comprehensive Valve Center 1
• During transfer, maintain all supportive measures and ensure continuous monitoring of vital signs 1