Table 2

Recommendations of European and American guidelines on valvular heart disease concerning the management of MS and AF

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 AA 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 CA 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 CPMC 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.