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Management of atrial fibrillation in patients with rheumatic mitral stenosis
  1. Bernard Iung1,2,
  2. Antoine Leenhardt1,2,
  3. Fabrice Extramiana1,2
  1. 1 Cardiology Department, Bichat Hospital, AP-HP, Paris, France
  2. 2 Paris Diderot University, Sorbonne Paris Cité, Paris, France
  1. Correspondence to Professor Bernard Iung, Cardiology Department, Bichat Hospital, AP-HP, 75018 Paris, France; bernard.iung{at}


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.

  • mitral stenosis
  • atrial fibrillation
  • transcatheter valve interventions
  • valve disease surgery
  • atrial arrhythmia ablation procedures

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  • Contributors BI, AL and FE drafted different parts of the manuscript. All of them revised and approved the final draft.

  • Competing interests BI received Speaker’s fee from Edwards Lifesciences.

  • Provenance and peer review Commissioned; externally peer reviewed.