BACKGROUND: Rheumatic heart disease with persistent atrial fibrillation (RHD-AF) is associated with increased morbidity. However, there is no standardized approach for the maintenance of sinus rhythm (SR) in them. We aimed to determine the utility of a stepwise approach to achieve SR in RHD-AF.
METHODS: Consecutive patients with RHD-AF from July 2021 to August 2023 formed the study cohort. The stepwise approach included pharmacological rhythm control and/or electrical cardioversion (Central illustration). In patients with recurrence, additional options included AF ablation or pace and ablate strategy with conduction system pacing or biventricular pacing. Clinical improvement, NT-proBNP, 6-Minute Walk Test (6MWT), heart failure (HF) hospitalizations, and thromboembolic complications were documented during follow-up.
RESULTS: Eighty-three patients with RHD-AF (mean age 56.13 ± 9.51 years, women 72.28%) were included. Utilizing this approach, 43 (51.81%) achieved and maintained SR during the study period of 11.04 ± 7.14 months. These patients had improved functional class, lower NT-proBNP, better distance covered for 6MWT, and reduced HF hospitalizations. The duration of AF was shorter in patients who achieved SR, compared to those who remained in AF (3.15 ± 1.29 vs 6.93 ± 5.23, p = 0.041). Thirty-five percent (29) maintained SR after a single cardioversion over the study period. Only one underwent AF ablation. Of the 24 who underwent pace and ablate strategy, atrial lead was implanted in 22 (hybrid approach), and 50% of these achieved and maintained SR. Among these 24, none had HF hospitalizations, but patients who maintained SR had further improvement in clinical and functional parameters.
CONCLUSIONS: RHD-AF patients who could achieve SR with a stepwise approach, had better clinical outcomes and lower HF hospitalizations.

Rheumatic heart disease (RHD) is the underlying cause of a significant proportion of atrial fibrillation (AF) in the low- and middle-income countries, while nonvalvular AF is the most common cause of AF in high-income countries. RHD is also common among African Americans, migrants, and the indigenous population of high-income countries. The onset of AF in RHD patients is a clinical marker of worse outcomes and is associated with significant morbidity and mortality. Despite RHD being a major cause of morbidity and mortality in the young in many parts of the world, it is often neglected by policymakers, the media, and even the medical fraternity. Stroke risk assessment using various risk scores has not been systematically evaluated in rheumatic AF patients. Rate control may not be ideal for symptom control in rheumatic AF patients considering the young age and an active lifestyle. There is limited information regarding the nonpharmacological management of rheumatic AF. The current management guidelines based on nonvalvular AF do not apply to rheumatic AF patients who are often younger, are women, and have fewer comorbidities. This review critically looks at specific areas such as stroke prevention with reference to direct oral anticoagulants, cardioversion, rate and rhythm control strategies, and the role of nonpharmacological methods in rheumatic AF management. Future recommendations must be cognizant of local health care systems and resourcing considering the geographic distribution of the disease.

BACKGROUND: There is a high incidence of atrial fibrillation (AF) in patients with isolated rheumatic mitral regurgitation (MR). The histopathologic changes in the atria of patients with isolated rheumatic MR with and without AF are unknown.
OBJECTIVE: We aimed to determine the histological findings in patients with isolated severe rheumatic MR with and without AF.
METHODS: Patients with severe isolated rheumatic MR undergoing valve replacement surgeries underwent endocardial biopsies from right atrial appendage, left atrial appendage, right free wall, left free wall, left posterior wall, and mitral valve. Group I consisted of patients in sinus rhythm (SR), and Group II included patients with AF. We analyzed and compared these 10 histological features in the biopsies of patients in Groups I and II.
RESULTS: Of the 25 patients, 12 were in Group I and 13 in Group II. In Group I, patients had severe myocyte hypertrophy (60% vs. 18%, p = .04) that was significantly more in the right atrium (22.7% vs. 11.4%, p = .059). Interstitial adipose tissue deposition was more common in Group I (30% vs. 25%, p = .06). Interstitial fibrosis was evenly distributed at all sites without significant difference between the two groups. Group II patients had a higher prevalence and severity of vacuolar degeneration (91% vs. 60%, p = .09).
CONCLUSIONS: Patients with isolated severe rheumatic MR and AF have more vacuolar degeneration in the atrial tissue. Patients with SR have myocyte hypertrophy and interstitial adipose tissue deposition. Interstitial fibrosis is uniformly distributed in patients in SR and AF.

BACKGROUND: Patients with rheumatic mitral stenosis (MS) and atrial fibrillation (AF) are at risk for thromboembolism and restoration of sinus rhythm (SR) may be the preferred strategy. Percutaneous balloon mitral valvotomy (PBMV) improves hemodynamics, but may not be enough to restore SR.
METHODS: Prospective randomized study aimed at evaluating efficacy of early direct current cardioversion (DCCV) following successful PBMV in patients with long-standing AF. Group 1 (n=20) had patients of rheumatic MS with AF who underwent successful PBMV. Group 2 (n=15) patients were DC cardioverted and administered oral Amiodarone for 6 weeks. Primary endpoint was maintenance of SR after 6 months. Secondary endpoints were functional capacity, number of embolic episodes, adverse drug effects, and all-cause mortality.
RESULTS: In Group 2, all patients underwent successful cardioversion. At a mean follow-up of 7.6 months, 95% in Group 1 were in AF. In Group 2, 87% patients were in SR and 13% had reverted to AF. Difference in rate of SR was 0.82 (95% CI 0.2, 1.01) (p=0.001), with relative risk of 7.1 (1.95, 25.9, 95% CI, p=0.001) for patients to be in AF who underwent only successful PBMV, i.e. Group 1. There was significant improvement in quality of life (SF36) score in Group 2 (p=0.001), with no deaths, stroke, or adverse drug effects in either group.
CONCLUSIONS: In patients with rheumatic MS and AF, early DCCV and a short-duration oral Amiodarone, following successful PBMV, may be a reasonable strategy to attain long-term SR.