What is the acute management for a patient with rheumatic heart disease, severe mitral stenosis status post mitral‑valve replacement who now presents in atrial fibrillation with rapid ventricular response and acute pulmonary edema?

Acute Management of Pulmonary Edema in Post-MVR Patient with AF and Rapid Ventricular Response

Immediate rate control with intravenous beta-blockers or diltiazem is the cornerstone of acute management, targeting a heart rate <100 bpm to allow adequate diastolic filling time and reduce pulmonary congestion. 1, 2

Immediate Stabilization (First 30 Minutes)

Airway and Oxygenation

• Provide high-flow oxygen or non-invasive positive pressure ventilation (BiPAP/CPAP) to maintain SpO2 >90%, as hypoxemia from pulmonary edema requires urgent correction 2
• Prepare for intubation if respiratory failure is imminent despite non-invasive support 2

Rate Control for Atrial Fibrillation with RVR

• Administer intravenous metoprolol 2.5-5 mg over 2 minutes, repeat every 5 minutes up to 15 mg total, OR diltiazem 0.25 mg/kg IV over 2 minutes 1, 3
• Target heart rate <100 bpm initially, then <80 bpm once stabilized 1, 3
• Avoid digoxin as monotherapy in acute settings—it has slower onset and insufficient rate control during acute decompensation 1

Volume Management

• Administer intravenous furosemide 40-80 mg IV bolus (or double the patient's home oral dose if already on diuretics) 1, 2
• Monitor urine output closely; repeat or increase dose if inadequate diuresis within 2 hours 1
• Avoid aggressive diuresis if hypotensive, as this may worsen cardiac output in the setting of fixed prosthetic valve function 2

Critical Assessment Within First Hour

Identify Precipitating Factors

• Check for prosthetic valve dysfunction (thrombosis, dehiscence, pannus formation) with urgent transthoracic echocardiography 4, 2
• Assess for infection (endocarditis, pneumonia, sepsis triggering AF with RVR) with blood cultures and chest imaging 2
• Evaluate medication non-compliance, particularly anticoagulation in mechanical valve patients 1
• Rule out acute coronary syndrome with troponin and ECG 2

Hemodynamic Monitoring

• Obtain systolic pulmonary artery pressure via echocardiography—values >50 mmHg indicate severe pulmonary hypertension and high risk for further decompensation 4, 2
• Assess right ventricular function and tricuspid regurgitation severity, as RV dysfunction portends worse outcomes 4, 2
• Measure left atrial size and evaluate for thrombus with transesophageal echocardiography if cardioversion is considered 1

Anticoagulation Management

For Mechanical Mitral Valve

• Continue warfarin with target INR 2.5-3.5 (or 3.0-4.0 for older generation mechanical valves in mitral position) 1
• Never use NOACs in patients with mechanical prosthetic valves—this is contraindicated and associated with increased thrombotic and bleeding complications 1

For Bioprosthetic Mitral Valve

• Warfarin remains preferred over NOACs in bioprosthetic mitral valves placed for rheumatic mitral stenosis, as the atria remain large and severely diseased despite valve replacement 1
• Target INR 2.0-3.0 for atrial fibrillation with bioprosthetic valve 1

Cardioversion Considerations

Do not attempt cardioversion in this acute setting—it will not durably restore sinus rhythm in severe mitral stenosis (even post-MVR) and delays definitive management. 1

• Cardioversion may be considered only after successful intervention if AF is of recent onset and left atrium is only moderately enlarged 1
• The priority is rate control, not rhythm control, in the acute phase 1, 3

Avoid Common Pitfalls

Do Not Use Vasopressors

• Midodrine and other vasopressors are contraindicated—increased afterload worsens cardiac output through the prosthetic valve and can exacerbate pulmonary congestion 3
• If hypotension persists despite rate control and diuresis, consider cardiogenic shock and need for mechanical circulatory support 2

Do Not Delay Intervention Assessment

• Urgent cardiology consultation is mandatory to evaluate for prosthetic valve dysfunction requiring reoperation 4, 2
• Patients with prosthetic valve thrombosis require urgent intervention (thrombolysis vs. surgery) within hours 4

Do Not Underestimate Tricuspid Regurgitation

• Functional tricuspid regurgitation is common post-MVR and contributes to right heart failure—assess severity and consider need for tricuspid intervention if severe 4, 2

Disposition After Stabilization

• Admit to cardiac intensive care unit for continuous telemetry and hemodynamic monitoring 2
• Transition to oral rate control agents (metoprolol, diltiazem, or combination) once stable 1, 3
• Optimize diuretic regimen to maintain euvolemia without hypotension 1
• Arrange follow-up echocardiography within 30 days to reassess prosthetic valve function and pulmonary pressures 4