Recent advances in the diagnosis of rheumatic heart disease

Abstract

The diagnosis of rheumatic heart disease requires recognition of the etiology of the process and evaluation of myocardial, endocardial and pericardial lesions, as well as of possible lingering activity of the rheumatic process. The question whether the patient is a rheumatic at all may often be answered by history and physical examination. The presence of myocardial damage is frequently determined by study of the electocardiogram. Various laboratory tests and the clinical picture are of help in the diagnosis of active rheumatic carditis. Pericardial adhesions are likely in patients with a history of pericarditis. However, constrictive pericarditis of rheumatic etiology is extremely rare. Murmurs should be evaluated carefully (1) because children and adolescents may present systolic murmurs of undetermined nature, possibly innocent and (2) because rheumatic carditis may cause not only an apical or pulmonic systolic murmur but also an apical middiastolic or presystolic murmur. The differential diagnosis between the apical diastolic murmur of mitral stenosis and that of “relative” stenosis caused by carditis is aided by phonocardiography. The differentiation between “pure” mitral stenosis and mitral insufficiency plus stenosis may be necessary in relation to possible surgical repair of the valve. The following diagnostic methods are briefly reviewed: (1) Physical examination and low frequency tracing, (2) auscultation and phonocardiography, (3) electrocardiography and vectorcardiography, (4) ballistocardiography, (5) pressure tracings of the left atrium, (6) esophagocardiograms, (7) roentgenograms and roentgenkymograms, (8) electrokymograms. In general, “pure” insufficiency or stenosis is recognized without difficulty by means of physical data plus electrocardiography, phonocardiography and roentgenology. On the other hand, demonstration of associated mitral insufficiency in a case of mitral stenosis may be difficult and use of the various subsidiary diagnostic methods may be necessary. A ventricular pressure pattern (positive plateau-like wave) is transmitted to the left atrium in cases of mitral insufficiency. Esophagocardiography, roentgenkymography, electrokymography, direct measurements of atrial pressure and digital exploration permit recognition of this abnormal pressure wave which causes systolic expansion of the atrium. Electrokymography is the simplest of the five procedures. While it is a valuable diagnostic method (technical failures are discussed; personal data are given), it tends to overemphasize the disturbance although calibration and analysis of the tracings may remedy this. Digital exploration tends to underestimate the insufficiency, for reasons given. Therefore, if technical difficulties can be surmounted, pressure measurements with closed chest and no anesthesia may become the most accurate method. The various technical aids for diagnosis of an associated aortic, pulmonic or tricuspid defect are discussed.