Echocardiographic diagnosis of mitral insufficiency

Abstract

We were interested to read about the persistence of acute rheumatic fever in the intermountain area of the United States,1Veasy LG Tani LY Hill HR. Persistence of acute rheumatic fever in the intermountain area of the United States.J PEDIATR. 1994; 124: 9-16Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar and in particular the authors' view of the use of echocardiography in acute rheumatic fever. In New Zealand, where rheumatic fever is endemic among Maori and other Polynesians, we also frequently observe subclinical valvulitis by using echo-Doppler studies. We agree with Veasy et al.1Veasy LG Tani LY Hill HR. Persistence of acute rheumatic fever in the intermountain area of the United States.J PEDIATR. 1994; 124: 9-16Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar and others2Folger GM Hajar R Robida A Hajar HA Occurrence of valvar heart disease in acute rheumatic fever without evident carditis: colour flow Doppler identification.Br Heart J. 1992; 67: 434-438Crossref PubMed Scopus (88) Google Scholar that physiologic and abnormal left-sided valve regurgitation can be differentiated by using strict criteria: the regurgitant flow must be a substantial color jet of high velocity and be holosystolic (mitral regurgitation) or holodiastolic (aortic regurgitation). We also insist on confirming the valve regurgitation in two separate echocardiographic planes. We have tested these ideas in a controlled study of children with acute rheumatic fever and other febrile children. Independent review of Doppler echocardiograms resulted in detection of leaks earlier and with greater sensitivity than clinical examination, with no false-positive Doppler findings in the control subjects.3Abernethy MJ, Grant C, Greaves S, et al. Doppler echocardiography and the early diagnosis of carditis in acute rheumatic fever. Aust N Z J Med (in press).Google Scholar Having satisfied ourselves in a controlled study that we are not producing iatrogenic disease, we have concluded that silent or subclinical mitral or aortic regurgitation should be considered as evidence of carditis and thus a major Jones criterion4Shulman ST Kaplan EL Bisno AL et al.Jones criteria (revised) for guidance in the diagnosis of rheumatic fever.Circulation. 1984; 69: 203A-208ACrossref PubMed Scopus (501) Google Scholar in children in whom rheumatic fever is suspected. We believe that there is now sufficient evidence to allow the use of echocardiography to document valvular regurgitation without accompanying diagnostic auscultatory findings as the sole criterion for valvulitis in acute rheumatic fever.1Veasy LG Tani LY Hill HR. Persistence of acute rheumatic fever in the intermountain area of the United States.J PEDIATR. 1994; 124: 9-16Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar, 2Folger GM Hajar R Robida A Hajar HA Occurrence of valvar heart disease in acute rheumatic fever without evident carditis: colour flow Doppler identification.Br Heart J. 1992; 67: 434-438Crossref PubMed Scopus (88) Google Scholar, 3Abernethy MJ, Grant C, Greaves S, et al. Doppler echocardiography and the early diagnosis of carditis in acute rheumatic fever. Aust N Z J Med (in press).Google Scholar Practically speaking, a diagnosis of rheumatic fever is made only occasionally on the basis of echocardiographic findings alone. When clinical carditis, polyarthritis, or chorea provide a major Jones criterion for acute rheumatic fever, the role of echocardiography is to help define the degree of valvular regurgitation. Less often we see children with polyarthralgia and other minor manifestations of rheumatic fever, together with increased antistreptococcal titers. In our community, where rheumatic fever remains endemic, such a child has acute rheumatic fever until proved otherwise. There will be borderline judgments with any technique, but the most sensitive and accurate method of assessing valve function should not be ignored. 9/35/58248