2017 ESC/EACTS guidelines39 | 2014 and 2017 update AHA/ACC38 40 | ||
Medical therapy | |||
Patients with moderate-to-severe MS and persistent AF should be kept on VKA treatment and not receive NOACs. | – | Anticoagulation with a VKA is indicated for patients with rheumatic MS and AF. | I B-NR |
The use of NOACs is not recommended in patients with AF and moderate-to-severe MS. | III C | ||
Heart rate control can be beneficial in patients with MS and AF and fast ventricular response. | IIa C | ||
Indications for AF ablation | |||
Surgical ablation of AF should be considered in patients with symptomatic AF who undergo valve surgery. | IIa A | A concomitant maze procedure is reasonable at the time of mitral valve repair or replacement for treatment of chronic, persistent AF. | IIa C |
Surgical ablation of AF may be considered in patients with asymptomatic AF who undergo valve surgery, if feasible, with minimal risk. | IIb C | A full biatrial maze procedure, when technically feasible, is reasonable at the time of mitral valve surgery, compared with a lesser ablation procedure, in patients with chronic, persistent AF. | IIa B |
Indications for PMC | |||
PMC should be considered in asymptomatic patients without unfavourable clinical and anatomical characteristics for PMC and new-onset or paroxysmal AF. | IIa C | PMC may be considered for asymptomatic patients with severe MS (mitral valve area ≤1.5 cm², stage C) and valve morphology favourable for PMC in the absence of left atrial thrombus or moderate-to-severe MR who have new onset of AF. | IIb C |
AF, atrial fibrillation; AHA/ACC, American Heart Association/ American College of Cardiology; EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; MS, mitral stenosis; NOAC, non-vitamin K antagonists oral anticoagulants; PMC, percutaneous mitral comissurotomy; VKA, vitamin K antagonists.