What is the management of recurrent rheumatic valve replacement (RVR)?

From the Guidelines

The optimal management of again rheumatic mitral stenosis (RVR) is either percutaneous mitral balloon commissurotomy (PMBC) or surgery, with PMBC being the preferred treatment for patients with favorable valve morphology and less than 2+ mitral regurgitation (MR) in the absence of left atrial (LA) thrombus. When considering the management of RVR, several factors should be taken into account, including:

• Valve morphology, with favorable morphology consisting of mobile and relatively thin valve leaflets, free of calcium, and without significant subvalvular fusion 1
• Clinical factors, such as age, New York Heart Association (NYHA) functional class, and presence or absence of atrial fibrillation (AF), which are predictive of outcome 1
• The presence of severe limiting symptoms, such as those classified as NYHA functional class III or IV, which may indicate the need for surgical intervention 1 PMBC is a safe and effective treatment option for patients with RVR, with randomized trials establishing its efficacy compared to surgical closed or open commissurotomy in patients with favorable valve morphology 1. However, mitral valve surgery, including commissurotomy or replacement, may be necessary for patients with severe valvular thickening, subvalvular fibrosis, or moderate to severe tricuspid regurgitation (TR) 1. It is essential to note that PMBC should only be performed by experienced operators with immediate availability of surgical backup for potential complications 1. Long-term follow-up has shown that 70% to 80% of patients with an initial good result after PMBC are free of recurrent symptoms at 10 years, and 30% to 40% are free of recurrent symptoms at 20 years 1.

From the Research

Management of Rheumatic Valve Disease

• The management of rheumatic valve disease involves a combination of medical and surgical interventions, with the goal of preventing further valve damage and reducing the risk of complications 2, 3, 4, 5.
• Secondary prophylaxis with antibiotics is a crucial aspect of management, aiming to prevent recurrent rheumatic fever and further valve damage 2, 3, 6.
• The choice of antibiotic prophylaxis, either oral or intramuscular, depends on various factors, including the patient's age, compliance, and the presence of valve disease 2, 3, 6.

Surgical Interventions

• Surgical interventions, such as valve replacement or repair, may be necessary for patients with severe valve disease 4, 5.
• The decision to replace or repair the valve depends on various factors, including the extent of valve damage, the patient's overall health, and the presence of other cardiac conditions 4, 5.
• Percutaneous balloon valvuloplasty/commissurotomy is a minimally invasive procedure that may be suitable for selected patients with rheumatic mitral and/or aortic stenosis 4.

Adherence to Secondary Prophylaxis

• Adherence to secondary prophylaxis is crucial to prevent recurrent rheumatic fever and further valve damage 6.
• Strategies to improve adherence include register/recall systems, dedicated health teams, education, and strong staff-patient relationships 6.
• International bilateral partnership models, visiting surgeons from endemic regions, simulation training, and courses by professional societies may help increase exposure and training in rheumatic valve surgery 5.

Future Directions

• Further research is needed to understand the optimal management of rheumatic valve disease, including the role of antibiotic prophylaxis and surgical interventions 3, 5.
• The development of novel educational paradigms and increased consideration for valve repair in low- and middle-income countries may help improve outcomes for patients with rheumatic heart disease 5.