A 40-year old female presented with dyspnoea on exertion grade III and palpitations. ECG showed atrial fibrillation with fast ventricular rate. Echocardiography shows severe mitral stenosis with left atrial appendage clot. Which of the following is not advised?
Ans. c. EC followed by percutaneous balloon mitral valvuloplasty (Ref: Harrison 19/e p1539, 18/e p1932)"Percutaneous mitral balloon valvotomy has subsequently become a mainstay of the management of rheumatic mitral stenosis. In the past, closed or open commisurotomy (after the advent of cardiopulmonary bypass) was the mainstay of therapy for rheumatic mitral stenosis. Currently, this procedure is most often performed using trans-septal access to the left atrium and a balloon catheter developed by a Japanese surgeon, Kanji Inoue. The dumbbell-shaped Inoue balloon catheter allows stable and sequential dilation of the stenotic mitral valve. A favourable response to mitral dilation is predicated on the presence of fused mitral commissures, as seen in rheumatic disease. Dilation is relatively ineffective in the absence of commissural fusion."Management Strategy for Patients with Mitral Stenosis (MS) and Mild Symptoms. There is controversy as to whether patients with severe MS (MVA <1 cm2) and severe pulmonary hypertension (PH) (PASP >60 mmHg) should undergo percutaneous mitral balloon valvotomy (PMBV) or mitral valve replacement (MVR) to prevent right ventricular failure. CXR, chest x-ray; ECG, electrocardiogram; echo, echocardiography; LA, left atrial; MR, mitral regurgitation; MVA, mitral valve area; MVG, mean mitral valve pressure gradient; NYHA, New York Heart Association; PASP, pulmonary artery systolic pressure; PAWP, pulmonary artery wedge pressure; 2D, 2-dimensional.Indications for Percutaneous Mitral Balloon Valvotomy (PMBV)Class IClass llaClass lIbClass IIIPMBV is effective for symptomatic patients (NYHA functional Class II III, or IV), with moderate or severe mitral stenosis (MS) and valve morphology favorable for PMBV in the absence of left atrial thrombus or moderate to severe MR (Level of evidence: A).PMBV is effective for asymptomatic patients with moderate or severe MS and valve morphology that is favorable for PMBV who have pulmonary hypertension (pulmonary artery systolic pressure > 50 mm Hg at rest or > 60 mm Hg with exercise) in the absence of left atrial thrombus or moderate to severe mitral regurgitation (MR) (level of evidence: C).PMBV isreasonable for patients with moderate or severe MS who have a non- pliable calcified valve, are in NYHA functional Class III or EV, and are either not candidates for surgery or are at high risk for surgery (level of evidence: C).PMBV may be considered for asymptomatic patients with moderate or severe MS and valve morphology favourable for PMBV who have new onset of atrial fibrillation in the absence of left atrial thrombus or moderate to severe MR (level of evidence: C)PMBV may be considered for symptomatic patients (NYHA functional Class II, III, or IV) with mitral valve (MV) area >1.5 cm2 if there is evidence of hemodynamically significant MS based on pulmonary artery systolic pressure >60 mm Hg, pulmonary artery wedge pressure of 25 mm Hg or more, or mean MV gradient higher than 15 mm Hg during exercise (level of evidence: C). PMBV may be considered as an alternative to surgery for patients with moderate or severe MS who have a non-pliable calcified valve and are in NYHA Class III or IV (level of evidence: C).PMBV is not indicated for patients with mild MS (level of evidence: C). PMBV should not beperformed in patients with moderate to severe MR or left atrial thrombus (level of evidence: C).In patients with non-favorable valve morphology and severe pulmonary hypertension (PAP- > 60 mm Hg), commisurotomy or mitral valve replacement is considered.Medical therapy of valvular heart diseaseLesionSymptom controlNatural historyMitral stenosisBeta blockers, non-dihydropyridine calcium channel blockers, or digoxin for rate control of AF; cardioversion for new- onset AF and HF; diuretics for HFQWarfarin for AF or thromboembolismQ; PCN for RF prophylaxisQMitral regurgitationDiuretics for HFQ Vasodilators for acute MRQWarfarin for AF or thromboembolism Vasodilators for HTNQAortic stenosisDiuretics for HFQNo proven therapyAortic regurgitationDiuretics and vasodilators for HFQVasodilators for HTNQ
Diltiazen to control ventricular rate
Start warfarin and follow-up with repeat echocardiography
EC followed by percutaneous balloon mitral valvuloplasty
Open mitral commissurotomy with clot removal
C.V.S.