A 35-Year-Old Pregnant Woman Presents With Progressive Dyspnea and Palpitations

Case

A 35-year-old pregnant woman from South America presents to the emergency department at 28 weeks’ gestation complaining of progressive dyspnea and palpitations that have been worsening during the last 3 weeks.

On physical examination she has an irregularly irregular rhythm with a 3 out of 4 diastolic rumble at the apex. Lung auscultation reveals bibasilar crackles. She has mild jugular vein distention and 1+ pitting leg edema. Blood pressure is 90/60 mg Hg. A 12-lead electrocardiogram is performed and reveals atrial fibrillation (AF) with rapid ventricular rate. She is started on metoprolol and has marked improvement in her heart rate and blood pressure and feels better.

Bedside 2-dimensional echocardiogram shows a dilated left atrium with a mean mitral valve gradient of 10 mm Hg and a mitral valve area of 0.9 cm². There is mild mitral regurgitation with mobile leaflets and minimal calcification. Her ejection fraction is 55% to 60%. She is admitted to telemetry.

What is the next best treatment strategy?

A. Consult a cardiothoracic surgeon for mitral valve repair or replacement

B. Schedule her for a transesophageal echocardiogram (TEE) to rule out left atrial thrombus followed by direct current cardioversion if no thrombus is found

C. Start her on warfarin with a goal INR of 2 to 3

D. Perform an urgent percutaneous mitral balloon valvuloplasty to bridge her to delivery