Management of atrial fibrillation in patients with rheumatic mitral stenosis

Abstract

Atrial fibrillation (AF) is frequent in patients with rheumatic mitral stenosis (MS). Pressure overload leads to marked structural and electrical remodelling of left atrium. The frequency of persistent AF increases with age and paroxysmal, asymptomatic, AF seems even more frequent. The occurrence of AF worsens the haemodynamic tolerance of MS and markedly increases the risk of thromboembolic events. AF has a negative impact on the natural history of MS and on its outcome after commissurotomy. The respective indications of rhythm and rate control should be adapted to patient characteristics, particularly the consequences of MS, and take into account the high risk of recurrence of AF. Oral anticoagulant therapy is mandatory when AF complicates MS, regardless of its severity and CHA2DS2-VASc score. Non-vitamin K antagonists oral anticoagulants are not recommended in moderate-to-severe MS due to the lack of data. Percutaneous mitral commissurotomy does not appear to prevent the occurrence of AF in MS but should be considered as the first-line therapy when AF is associated with severe symptomatic MS, followed by the discussion of cardioversion or ablation. AF ablation should be considered in patients with mitral disease requiring intervention, but the ideal timing and techniques are difficult to determine due to the lack of appropriate specific randomised trials in patients with MS.

Risk Factors for Mitral Valve Surgery: Atrial Fibrillation and Pulmonary Hypertension

“…Factors that predict successful cardioversion and maintenance of SR include duration of AF, LA size, and age. 38 Anticoagulation. In contrast to other causes of ischemic stroke, where antiplatelet therapy is used to prevent stroke, patients in AF must be anticoagulated.…”

“…In this setting, amiodarone is commonly used for either rate or rhythm control. 38,39 Prior to surgical correction, the few patients who do revert are unlikely to remain in SR though. Factors that predict successful cardioversion and maintenance of SR include duration of AF, LA size, and age.…”

“…Factors that predict successful cardioversion and maintenance of SR include duration of AF, LA size, and age. 38…”

Mitral stenosis and atrial fibrillation

“…Over the past decades, the incidence of mitral stenosis (MS) due to rheumatic fever has markedly decreased. Regardless, rheumatic fever remains associated with about 80% of all cases of MS, and so relatively the most relevant contributor to MS 1. Aside from rare causes such as congenital MS, MS due to myxoma or MS following infiltrating diseases, another important cause of MS is indeed severe calcification of the mitral annulus and its leaflets.…”

“…While this may become more frequent in the ageing population, it only rarely causes severe MS 2. Due to the pathomechanism of MS, which includes left atrial enlargement due to constant pressure and volume overload, the prevalence of atrial fibrillation is high 1. Oral anticoagulation is recommended not only in patients with atrial fibrillation, but also in those with sinus rhythm and dense spontaneous echocardiographic contrast and/or large left atrium 3.…”