What is the treatment for a patient with rheumatic heart disease, severe mitral (mitral valve) stenosis, and moderate mitral (mitral valve) regurgitation?

Treatment of Rheumatic Heart Disease with Severe Mitral Stenosis and Moderate Mitral Regurgitation

For rheumatic heart disease with severe mitral stenosis and moderate mitral regurgitation, mitral valve replacement is the definitive treatment, as the combination of significant regurgitation and stenosis makes percutaneous balloon commissurotomy unsuitable and repair unlikely to be durable. 1, 2

Initial Assessment and Risk Stratification

Evaluate for high-risk features requiring urgent intervention:

• Systolic pulmonary artery pressure >50 mmHg at rest indicates high risk for hemodynamic decompensation and mandates urgent intervention even if asymptomatic 2
• History of systemic embolism, stroke, or atrial fibrillation 2
• Dense spontaneous contrast in the left atrium or left atrial thrombus 2
• Right ventricular dysfunction or dilation from chronic pressure overload 2
• Severe (functional) tricuspid regurgitation secondary to RV dilation 2

Perform comprehensive imaging:

• Transthoracic echocardiography to assess valve morphology, severity of stenosis and regurgitation, left ventricular function, pulmonary pressures, and tricuspid valve function 1
• Transesophageal echocardiography to evaluate for left atrial thrombus, assess valve anatomy in detail, and guide surgical planning 3
• Cardiac catheterization if non-invasive imaging is inconclusive or to assess for coronary artery disease in patients >40 years or with risk factors 4, 3

Treatment Algorithm

Why Percutaneous Balloon Commissurotomy is NOT Appropriate

Percutaneous mitral balloon commissurotomy (PMBC) is contraindicated in your patient because:

• Moderate or greater mitral regurgitation is an absolute contraindication to PMBC 4, 3, 5
• PMBC is only suitable for patients with predominant mitral stenosis without significant regurgitation 4, 3
• The presence of both severe stenosis and moderate regurgitation indicates advanced rheumatic valve disease with structural deformity 3, 5

Why Mitral Valve Repair is NOT Recommended

Mitral valve repair has limited durability in rheumatic disease:

• Rheumatic mitral valve disease is less suitable for repair than degenerative disease due to thickened/calcified leaflets, extensive subvalvular disease with chordal fusion and shortening, and progression of rheumatic disease 1
• Freedom from reoperation at 20 years is only 50-60% even in experienced hands 1
• Repair should be limited to patients with less advanced disease where durable repair is achievable, or when mechanical prosthesis cannot be used due to anticoagulation concerns 1
• The combination of severe stenosis and moderate regurgitation indicates advanced disease unlikely to be amenable to durable repair 1

Definitive Treatment: Mitral Valve Replacement

Surgical mitral valve replacement is indicated:

• For symptomatic patients with severe mitral stenosis (valve area <1.5 cm²) and moderate or greater mitral regurgitation 4, 5
• When valve morphology is unfavorable for PMBC or repair 2, 3
• When concomitant severe tricuspid regurgitation or other valve disease requires surgical correction 2

Prosthesis selection considerations:

• Mechanical valve requires lifelong anticoagulation with warfarin (target INR 2.5-3.5) but offers superior durability 2, 4
• Bioprosthetic valve avoids long-term anticoagulation but has limited durability, particularly in younger patients 4
• Patient age, anticoagulation reliability, and patient preference should guide prosthesis choice 1

Concomitant Tricuspid Valve Management

Address tricuspid regurgitation at the time of mitral surgery:

• Perform concomitant tricuspid annuloplasty if tricuspid annular diameter is ≥40 mm or >21 mm/m², even with mild tricuspid regurgitation 2, 6
• Tricuspid valve repair with ring annuloplasty is preferred when possible 6
• Do not underestimate tricuspid regurgitation severity, as altered hemodynamics from severe mitral stenosis mask true severity 2

Medical Management Prior to Surgery

Initiate anticoagulation if indicated:

• Warfarin with target INR 2.5-3.5 is mandatory for patients with atrial fibrillation, prior embolism, left atrial thrombus, or dense spontaneous contrast 2
• Do NOT use DOACs for anticoagulation in rheumatic mitral stenosis—only warfarin is appropriate 2

Optimize heart failure management:

• Diuretics for pulmonary congestion 4, 5
• Rate control for atrial fibrillation (beta-blockers or calcium channel blockers) to prevent tachycardia-induced pulmonary edema 2, 4

Alternative for Prohibitive Surgical Risk

Transcatheter mitral valve replacement may be considered:

• For patients with prohibitive surgical risk due to severe comorbidities 7
• This is an emerging option with limited data in rheumatic disease, requiring experienced operators at specialized centers 7
• Outcomes data are limited compared to surgical valve replacement 7

Critical Pitfalls to Avoid

• Do not delay intervention in symptomatic patients or those with high-risk features (pulmonary hypertension >50 mmHg, RV dysfunction), as irreversible pulmonary hypertension and RV dysfunction develop rapidly 2
• Do not attempt PMBC in patients with moderate or greater mitral regurgitation, as this will worsen regurgitation and lead to acute decompensation 4, 3, 5
• Do not underestimate the need for tricuspid intervention at the time of mitral surgery, as isolated tricuspid surgery later carries higher mortality 2, 6
• Do not use DOACs for anticoagulation in rheumatic mitral stenosis—warfarin is the only appropriate agent 2

Post-Operative Management

Long-term surveillance:

• Baseline echocardiography within 30 days post-procedure, then at 1 year and annually thereafter to monitor prosthetic function 8
• Lifelong anticoagulation management if mechanical valve implanted 4
• Ongoing heart failure management with appropriate medications 6
• Monitor for prosthetic dysfunction, valve deterioration, and hemodynamic changes 8