What is the management for Rheumatic Heart Disease with severe Mitral Stenosis, Atrial Fibrillation, and history of Cerebrovascular Accident without Congestive Cardiac Failure?

Management of Rheumatic Heart Disease with Severe Mitral Stenosis, Atrial Fibrillation, and Prior Stroke

This patient requires lifelong anticoagulation with warfarin (target INR 2.5-3.5) and urgent cardiology referral for percutaneous mitral commissurotomy (PMC) or surgical intervention, as the combination of severe mitral stenosis with atrial fibrillation and prior cerebrovascular accident represents extremely high thromboembolic risk that mandates both aggressive anticoagulation and definitive valve intervention. 1, 2, 3

Immediate Anticoagulation Management

Anticoagulation with vitamin K antagonists (warfarin) is absolutely mandatory in this clinical scenario due to multiple high-risk features:

• Target INR should be 2.5-3.5 (some guidelines suggest 2.5-3.0, but the higher range of 2.5-3.5 is appropriate given the history of prior stroke) 1
• The combination of atrial fibrillation, severe mitral stenosis, and prior cerebrovascular accident creates an extremely high thromboembolic risk 1, 2
• NOACs (direct oral anticoagulants) are contraindicated in moderate-to-severe mitral stenosis due to lack of efficacy data and should not be used 1, 4, 5
• Anticoagulation is indicated regardless of CHA2DS2-VASc score when mitral stenosis is present with atrial fibrillation 5

Heart Rate Control

Rate control is critical because tachycardia shortens diastolic filling time and worsens hemodynamic status in mitral stenosis:

• Beta-blockers are first-line for rate control 1, 2, 4
• Alternative options include diltiazem, verapamil, or digoxin (particularly useful in atrial fibrillation with mitral stenosis) 1, 2, 4
• Do not attempt cardioversion before valve intervention in severe mitral stenosis, as sinus rhythm will not be maintained until the mechanical obstruction is relieved 1

Definitive Valve Intervention - Urgent Cardiology Referral Required

This patient needs urgent cardiology evaluation for intervention because symptomatic severe mitral stenosis (or even asymptomatic with high-risk features like prior embolism) is a Class I indication for intervention 1, 2, 3:

Percutaneous Mitral Commissurotomy (PMC)

• PMC is the first-line intervention if valve anatomy is favorable (pliable leaflets, minimal calcification, minimal subvalvular disease) 1, 2, 3
• PMC is indicated for symptomatic patients (NYHA Class II-IV) with favorable anatomy 1, 2
• PMC should be considered even in asymptomatic patients with high thromboembolic risk (which this patient has due to prior stroke) 1, 2

Surgical Intervention

• Surgery (valve replacement or open commissurotomy) is indicated if PMC is contraindicated or valve anatomy is unfavorable 1, 2, 3
• Contraindications to PMC include: left atrial thrombus (must be excluded by TEE), more than mild mitral regurgitation, severe/bicommissural calcification, or absence of commissural fusion 2, 3

Symptom Management

Diuretics should be used judiciously for symptom relief if pulmonary congestion is present:

• Loop diuretics (furosemide) for pulmonary edema or peripheral edema 1, 2, 4
• Avoid excessive diuresis which can reduce cardiac output in fixed stenotic lesions 2

Critical Monitoring and Follow-up

Before intervention, this patient requires:

• Transesophageal echocardiography (TEE) to exclude left atrial thrombus before any intervention 1
• If thrombus is present, continue anticoagulation for 1-3 months and repeat TEE 1
• Assessment of valve anatomy (echocardiographic score) to determine suitability for PMC vs surgery 1, 2

After intervention:

• Early cardioversion can be attempted if atrial fibrillation is of recent onset and left atrium is only moderately enlarged 1
• Continue lifelong anticoagulation given history of prior stroke even if sinus rhythm is restored 1
• Yearly clinical and echocardiographic follow-up 2, 3

Common Pitfalls to Avoid

• Never use NOACs in mitral stenosis - they are ineffective and dangerous in this population 1, 4, 5
• Never attempt cardioversion before valve intervention in severe mitral stenosis - it will fail or be short-lived 1
• Never delay intervention in symptomatic severe mitral stenosis - medical therapy is purely palliative and does not prevent progression to irreversible pulmonary hypertension and right heart failure 4, 3
• Never underestimate thromboembolic risk - this patient has already had one stroke and is at extremely high risk for recurrence without adequate anticoagulation and valve intervention 1, 5, 6