Abstract 14916: Clinical and Socioeconomic Factors Associated With Time to Surgery and Preoperative Mortality in Surgery-Eligible Patients With Rheumatic Valvular Heart Disease in Uganda

Abstract

Background: There is a considerable gap between those needing and receiving surgery among people with rheumatic heart disease (RHD) in Uganda. Nevertheless, risk factors associated with time to surgery and preoperative mortality among those in need of surgery remain poorly understood. Methods: A cohort of patients with RHD who met criteria for valve surgery was assembled using the Uganda National RHD Registry (Jan. 2009- Aug. 2022). Kaplan-Meier estimates and multivariable Cox proportional hazards models were constructed to estimate time to surgery and death for those awaiting surgery. Results: 1,452 patients met surgical indication for valvular RHD. Median age was 20 years (interquartile range [IQR] 13-36), and 30.4% were male. 29.4% had multiple concurrent valve indications. During a median follow-up of 357 days (IQR 21-1029), 30.6% died while awaiting surgery and 13.5% obtained surgery. Median time to surgery was 9.3 years. Multivariable time to surgery model adjusted for age, socioeconomic factors, and HIV status revealed significantly increased likelihood of surgery in men vs. women (hazard ratio [HR] 1.78; 95% CI 1.21-2.64), college/university vs. none/primary school education (HR 3.60; 95% CI 1.88-6.89), and history of atrial fibrillation (HR 2.78; 95% CI 1.63-4.76), but decreased likelihood of surgery in age ≥18 years (HR 0.49; 95% CI 0.32-0.77) and NYHA class III/IV vs. I/II (HR 0.51; 95% CI 0.32-0.83). Median preoperative time to death was 4.6 years. Following stratification by NYHA class I/II and III/IV and adjustment for age, sex, and socioeconomic class, the following predictors were associated with increased mortality in both models: history of infective endocarditis (HR 2.38; 95% CI 1.05-5.39), RV dysfunction (HR 2.44; 95% CI 1.13-5.27), pericardial effusion (HR 1.68; 95% CI 1.27-2.21), surgical indication for multiple valves (HR 1.77; 95% CI 1.41-2.21), and atrial fibrillation (HR 1.47; 95% CI 1.03-2.10). Conclusions: Our analysis revealed a low rate of surgical intervention and high mortality rate in a high-risk population of Ugandans living with advanced RHD and operative indication. Unsurprisingly, sex and socioeconomic status remain barriers to receipt of surgery that must be addressed to achieve equity in this neglected disease.