Rheumatic Heart Disease Patients Research Articles

Prevalence and associated factors of atrial fibrillation among patients with rheumatic heart disease attending public referral hospitals in Bahir Dar city, Northwest Ethiopia, 2023

BackgroundAtrial fibrillation (AF) is a supraventricular arrhythmia associated with uncoordinated atrial activation. Atrial fibrillation is complication of rheumatic heart disease and is associated with substantial morbidity and mortality. It is a growing public health problem and economic and social burden. Studies investigating the prevalence and factors associated with atrial fibrillation among chronic rheumatic heart disease patients in Ethiopia are scarce. Therefore, this study aimed to determine the prevalence and factors associated with atrial fibrillation in patients with chronic rheumatic heart disease.Methods and materialsA hospital-based cross-sectional study was conducted. A total of 410 patients were selected using a systematic random sampling method. The data were entered into Epi-Data version 4.6 and subsequently exported to SPSS version 26 software for analysis. A binary logistic regression model was applied to identify significant variables related to AF.ResultsIn this study, 410 patient charts were reviewed. The prevalence of atrial fibrillation was 43% (95% CI of 38% up to 48%). Male (AOR = 3.81, 95% CI 2.00-7.26), age greater than 30 years (AOR = 7.26, 95% CI 3.93–13.41), heart failure (AOR = 4.65, 95% CI 2.39–9.04), mitral valve stenosis (AOR = 6.36, 95% CI 2.92–13.87), and left atrial diameter enlargement (AOR = 3.41, 95% CI 1.64–7.09) were associated with atrial fibrillation.Conclusions and recommendationsAtrial fibrillation leads patients to frequent hospital admission and increases hospital mortality. As a result, health care professionals need to pay more attention to and apply more clinical treatment for older patients, those with heart failure, those with mitral valve stenosis, and those with left atrial diameter enlargement-associated causes of atrial fibrillation.

Efficacy and Safety of Warfarin Utilisation in Rheumatic Heart Disease Patients With Mechanical Heart Valves in Remote Northwest Queensland

Efficacy and Safety of Warfarin Utilisation in Rheumatic Heart Disease Patients With Mechanical Heart Valves in Remote Northwest Queensland

Inflammatory Response Genes' Polymorphism Associated with Risk of Rheumatic Heart Disease.

Rheumatic heart disease (RHD) caused by group A streptococcus infection is one of the most important reasons of cardiovascular morbidity and mortality in low- and middle-income countries. Aberrant host immune response modulated by polymorphisms in inflammatory response genes plays an important role in RHD pathogenesis. This study aimed to determine risk-associated polymorphic variants in inflammatory response genes in Caucasian RHD patients. A total of 251 Caucasian RHD patients and 300 healthy donors were recruited for this study, and 27 polymorphic sites in 12 genes (TLR1, TLR2, TLR4, TLR6, IL1B, IL6R, IL6, IL10, IL12RB1, IL12B, TNF and CRP) were analyzed using allele-specific PCR. It was demonstrated that the polymorphic variants rs1800871 and rs1800872 in the IL10 gene, rs 1130864, rs3093077 and rs1205 in the CRP gene, rs375947 in the IL12RB1 gene, rs 5743551 and rs5743611 in the TLR1 gene, and rs3775073 in the TLR6 gene can modify RHD risk in a gender- and age-dependent manner. The obtained results can be used to determine the personalized risk of RHD in healthy donors during medical examination or screening, as well as to develop appropriate early prevention strategies targeting RHD in the risk groups.

INDEX ASSESSMENT OF PERIODONTAL TISSUES AND DETERMINATION OF TREATMENT NEEDS IN PATIENTS WITH CHRONIC RHEUMATIC HEART DISEASE

This study addresses the pressing scientific and practical issue in modern dentistry: enhancing dental care effectiveness for patients with chronic rheumatic heart disease. The purpose of this research is to comprehensively assess the condition of tooth-supporting tissues and quantify inflammatory phenomena in periodontal tissues among patients with chronic rheumatic heart disease, as well as to determine the necessary extent of periodontal care based on periodontal indices. Participants and methods. The periodontal tissues of 719 patients with chronic rheumatic heart disease from the Rheumatology Department of Lviv Regional Clinical Hospital, along with 290 clinically healthy individuals in the comparison group, were examined. To evaluate the clinical course of dystrophic-inflammatory periodontal diseases in patients with chronic rheumatic heart disease, we examined 267 individuals in the main group who had generalized periodontitis, categorized as follows: 42 patients with initial stage (I degree), 115 with moderate (II degree), and 110 with severe (III degree) periodontitis. The comparison group comprised 70 patients diagnosed with generalized periodontitis, among them, 21 had initial-stage disease, 29 had moderate-stage disease, and 20 had severe-stage disease. During the analysis, the oral hygiene was assessed by applying hygienic indices by J.C. Green and J.R. Vermillion (OHI-S, 1964) and Fedorov-Volodkina. The Muhlemann and Son index was used to objectively measure gingival papillary bleeding (RVI); the papillary-marginal-alveolar index (PMA) in the Parma modification, in combination with the Schiller-Pysarev test (1989), was employed to evaluate gingival inflammation. The periodontal index (PI) by A.L. Russel (1956) was used to assess the state of periodontal tissues, and pathological changes were recorded using the periodontal screening PSR test. Results were scored, and based on established criteria and scores, the need for treatment and its extent were determined. Results and discussion. According to the results of dental examinations in patients with chronic rheumatic heart disease, a high prevalence of periodontal diseases was found, reaching 92.49%. This was 13.18% higher compared to the prevalence in the control group. Dystrophic-inflammatory conditions with advanced severity levels were predominant, as evidenced by the index indicators. In chronic rheumatic heart disease patients, the average periodontal index was 6.11±0.10, compared to 4.14±0.19 in clinically healthy individuals (p < 0.05). Moreover, a higher lesion of periodontal tissues was observed in younger age groups. As the duration of rheumatic disease increased, the frequency of detecting generalized periodontitis also increased, with this condition being diagnosed in all subjects with a 10-year history of rheumatic disease. Conclusion. The Analysis of the research data on the condition of periodontal tissues, along with objective index assessments, reveals the following: periodontal diseases are more prevalent in individuals with chronic rheumatic heart disease, particularly affecting younger age groups. The severity and progression of these diseases are influenced by the course of the underlying condition. This underscores the presence of pathogenetic conditions that contribute to the rapid progression of the dystrophic-inflammatory process in periodontal tissues. It also emphasizes the importance of providing specialized periodontal care to patients with chronic rheumatic heart disease, with the level of care directly linked to the course and duration of the systemic disease.

A study protocol to characterise pathophysiological and molecular markers of rheumatic heart disease and degenerative aortic stenosis using multiparametric cardiovascular imaging and multiomics techniques.

Rheumatic heart disease (RHD), degenerative aortic stenosis (AS), and congenital valve diseases are prevalent in sub-Saharan Africa. Many knowledge gaps remain in understanding disease mechanisms, stratifying phenotypes, and prognostication. Therefore, we aimed to characterise patients through clinical profiling, imaging, histology, and molecular biomarkers to improve our understanding of the pathophysiology, diagnosis, and prognosis of RHD and AS. In this cross-sectional, case-controlled study, we plan to recruit RHD and AS patients and compare them to matched controls. Living participants will undergo clinical assessment, echocardiography, CMR and blood sampling for circulatory biomarker analyses. Tissue samples will be obtained from patients undergoing valve replacement, while healthy tissues will be obtained from cadavers. Immunohistology, proteomics, metabolomics, and transcriptome analyses will be used to analyse circulatory- and tissue-specific biomarkers. Univariate and multivariate statistical analyses will be used for hypothesis testing and identification of important biomarkers. In summary, this study aims to delineate the pathophysiology of RHD and degenerative AS using multiparametric CMR imaging. In addition to discover novel biomarkers and explore the pathomechanisms associated with RHD and AS through high-throughput profiling of the tissue and blood proteome and metabolome and provide a proof of concept of the suitability of using cadaveric tissues as controls for cardiovascular disease studies.

Impact of Tricuspid Repair on Surgical Death in Patients Undergoing Mitral Valve Surgery Due to Rheumatic Disease

BackgroundTricuspid valve repair during mitral valve replacement surgery remains a controversial topic. The risk-benefit ratio in some populations remains uncertain, especially in rheumatic heart disease patients. Therefore, we aimed to evaluate the impact of concomitant tricuspid repair on surgical mortality in patients undergoing cardiac surgery due to rheumatic mitral valve disease who have moderate to severe functional tricuspid regurgitation. MethodsThis is a prospective cohort study from January 1, 2017, to December 30, 2022. All patients over 18 years of age who underwent cardiac surgery to correct rheumatic mitral valve disease with concomitant moderate to severe tricuspid regurgitation were included. The primary outcome was a surgical death. In an exploratory analysis, clinical and echocardiographic data were obtained 2 years after the procedure. ResultsOf the 144 patients included, 83 (57.6%) underwent tricuspid valve repair. The mean age was 46.2 (±12.3) years with 107 (74.3%) female individuals, the median left ventricular ejection fraction was 61.0% (55-67), and systolic pulmonary artery pressure (sPAP) was 55.0 mmHg (46-74), with 45 (31.3%) individuals with right ventricular dysfunction. The total in-hospital mortality was 15 (10.4%) individuals, and there was no difference between the groups submitted or not to tricuspid repair: 10 (12.0%) vs. 5 (7.5%); p = 0.46, respectively. There was an association with one variable independently: the sPAP value, relative risk 1.04 (1.01-1.07), p = 0.01. The estimated cut-off value of sPAP that indicates higher early mortality through the receiver operating characteristic curve (area 0.70, p = 0.012) was 73.5 mmHg. ConclusionsPerforming tricuspid repair in individuals who were undergoing cardiac surgery to correct rheumatic mitral valve disease was not associated with increased surgical mortality. Our results suggest the safety of tricuspid repair even in this high-risk population, reinforcing the recommendations in current guidelines.

The Prevalence and Predictors of Atherosclerotic Coronary Artery Disease in Rheumatic and Non-rheumatic Valvular Heart Disease Patients.

The paradox of concurrent coronary artery disease (CAD) among patients with rheumatic and non-rheumatic valvular heart disease (RVHD; non-RVHD) is unclear. We aimed to evaluate the impact of the RVHD and non-RVHD on the prevalence of CAD and various risk factors, assess the number of diseased coronaries, clinical profile and the possible predictors of CAD in these patients, which may clarify the paradox and provide an insight for the prevention of CAD. The records of 106 valvular heart disease patients who had undergone valve replacement surgery at the King Faisal Cardiac Centrefrom January 2014 to October 2019 were evaluated. The clinical data and established risk factors were compared andlogistic regression analyses were performed to identify plausible predictors of CAD. Transthoracic echocardiographic diagnosis of 106 patients confirmed, 43 had RVHD (56.4 ± 8 years), of whom six (13.9%) had CAD with the highest mitral valve regurgitation (p < 0.01), and 63 had non-RVHD (60.0 ± 12 years). Of these, 31 patients showed the highest CAD (49.2%). Single- and triple-vessel disease was most common in RVHD and non-RVHD patients with concurrent CAD (33.3%; 41.9%, respectively), while non-RVHD patients also had quadruple vessel disease. The mean age of the RVHD and non-RVHD patients with coexisting CAD was significantly higher (66.7 ± 5; 66.7 ± 8 years) than those without CAD (46.1± 12.0; 54.7± 20, respectively). RVHD patients showed a significantly lower prevalence of diabetes, dyslipidaemia, hypertension, inflammatory cells, hepatorenal function markers, ejection fraction, and regional wall motion abnormality compared to RVHD patients with coexisting CAD (p < 0.01). Bivariate analysis indicated white blood cells, monocytes, neutrophils, gamma-glutamyl-transferase (GGT), bilirubin and blood urea nitrogen (BUN) to be significantly lower in RVHD patients. Predictors of high risk of CAD were BUN and hyperlipidaemia for RVHD and BUN, creatinine and GGT for non-RVHD patients. The prevalence of CAD in Saudi RVHD patients was significantly lower than in the Western countries, whereas non-RVHD was higher. The low prevalence may partly be attributed to age, reduced mitral regurgitation, and low frequency of risk and inflammatory factors.

Co-Existence of Sickle Cell Disease with Rheumatic Heart Disease

Sickle Cell Disease (SCD) is common in some part of India especially area inhabited by the Dravidian Tribal Population. Co-existence of Sickle Cell Disease with Rheumatic Heart Disease is not uncommon. The clinical findings in sickle cell anemia closely simulate those of rheumatic heart disease. This poses an important diagnostic challenge for the clinicians. Availability of 2-D Echocardiography has made it simpler to diagnose rheumatic heart disease in patients with sickle cell anemia whenever there is mixed symptoms &amp; signs in a patient. We hereby report a case of Sickle Cell Disease with Rheumatic Heart Disease.

Abstract TP274: Challenging the Guidelines or Merely an Observation on Transthoracic Echocardiography

Introduction: Accurate detection of left atrial appendage (LAA) clot is critical in patients before Balloon Mitral Valvotomy (BMV). There is an elevated risk of thrombus formation and ischemic stroke in Rheumatic Heart Disease (RHD). The yearly prevalence of new stroke is 3-7.5% in RHD. Transesophageal Echocardiogram (TEE) has traditionally been the gold standard for LAA clot detection. But it is semi-invasive and have risks. The need for alternatives in this clinical context has prompted this comparative study. Hypothesis: Visualizing LAA on Transthoracic Echocardiogram (TTE) is facile in severe mitral stenosis due to increased LAA size, which is vital for stroke prevention. Methods: In this comparative study, we assessed the diagnostic accuracy of TTE as a non-invasive alternative to TEE for LAA clot detection in patients scheduled for BMV. A total of 150 patients admitted to a tertiary hospital underwent both TTE and TEE before BMV, with TEE as the reference standard for evaluation. Results: The mean age of our study population was 41.4 years, the majority were females (64.7%). The incidence of thrombus in TEE was 30%, with a significant difference in females (37%) vs. males (17%). TTE missed LAA clots in 18.8%, this discrepancy rate was 6% in males and 26% in females, signifying a significant reduction in clot detection in females. TEE exhibited no such limitations in clot detection between genders. TTE displayed sensitivity of 98% and specificity of 81%. The accuracy rate of TTE was 43.3%.Pearson Correlation coefficient and Fishers Exact test confirms significance. The non-invasive nature of TTE, devoid of procedural complexities, positions it as a Cost-effective option. Conclusion: Our study provides compelling evidence supporting the hypothesis that TTE is an effective and practical alternative to TEE for LAA clot detection in RHD patients Further studies are needed in this regard so that the current Class 1C recommendation for TEE before any BMV may need to be revised.

Associations of &lt;i&gt;TLR&lt;/i&gt; gene polymorphism with the risk of rheumatic heart disease

Aim of the study was to investigate the associations between TLR gene polymorphism and the risk of rheumatic heart disease (RHD).Material and methods. 251 RHD patients (190 females and 61 males) and 300 healthy donors (190 females and 110 males), whose age was 57 [29; 77] and 53 [21; 80] years (median [lower quartile; upper quartile]), respectively, were recruited in the presented study. Eight polymorphic variants in the TLR gene were genotyped by realtime PCR.Results. We found no statistically significant differences in the frequency of eight polymorphic variants in the TLR1, TLR2, TLR4 and TLR6 genes in the general group of patients. Stratification by gender and age showed that the frequency of the C/C genotype of the TLR1 gene (rs5743551) was increased in females with RHD (11.6 %) compared to the control group (5.3 %); a risk effect was determined for recessive inheritance patterns (odds ratio 2.43, 95 % confidence interval 1.07–5.52, p = 0.029). Moreover, the combination of polymorphic variants TLR2 (rs5743708) – TLR4 (rs4689791) – TLR1 (rs5743551) – TLR2 (rs3804099) showed the greatest significance in RHD risk.Conclusions. Future research on the different populations will allow to discover the general patterns of RHD pathogenesis, which will finally lead to the establishment of therapeutic targets for treatment of streptococcal infection and RHD prevention.

Correlation between circulating fibrosis biomarkers with left atrial function and left atrial volume index in rheumatic mitral stenosis.

Mitral stenosis is the most common rheumatic heart disease (RHD) disorder worldwide, including in Indonesia. This pathological condition causes left atrial pressure, leading to left atrial fibrosis that affects the structure and function of the left atrial as well as the clinical condition. The aim of this study was to assess the correlation between circulating fibrosis biomarkers with net atrioventricular compliance (Cn) as a parameter of left atrial function, and left atrial volume index (LAVI) as a parameter left atrium structure of changes. A cross-sectional study was conducted at Panti Rahayu Hospital and Permata Bunda Hospital, Purwodadi, Central Java, with a total of 40 RHD patients with severe mitral stenosis. The ELISA was used to measure the levels of carboxy-terminal propeptide of type I procollagen (PICP), matrix metalloproteinase I (MMP-1), tissue inhibitor matrix metalloproteinase 1 (TIMP-1), and transforming growth factor-β1 (TGF-β1). The left atrial function was assessed by measuring Cn, and the LAVI parameters were measured to assess left atrium structure/size. The mean levels of circulating fibrosis biomarkers were as follows: PICP 153.96±89.12 ng/mL; MMP-1 1.44±2.12 ng/mL; MMP-1/TIMP-1 ratio 0.38±0.54 and TGF-β1 2.66±1.96 pg/mL. From the echocardiographic evaluation, the mean Cn was 5.24±1.93 mL/mmHg and the mean LAVI was 152.55±79.36 mL/m2. There were significant correlation between MMP-1 and MMP-1/TIMP-1 ratio with Cn (r=0.345 and r=0.333, respectively; both had p<0.05). PICP and TGF-β1 biomarkers did not significantly correlate with Cn (p>0.05). Meanwhile, none of the biomarkers had a significant correlation with LAVI (p>0.05). This study highlights that MMP-1 and MMP-1/TIMP-1 ratio are potentially to be used as markers to determine the Cn in RHD patients with severe mitral stenosis. However, further studies with a higher sample size are needed to confirm this finding.

Potential Role of NT-proBNP and Tissue Doppler Indices to Assess the Severity of Rheumatic Heart Disease: A Cross-sectional Study

Introduction: Rheumatic Heart Disease (RHD) remains the primary cause of acquired Valvular Heart Disease (VHD) in developing countries. The role of Tissue Doppler Indices (TDI) in RHD is understudied. This study aims to fill evidence gaps identified by the American College of Cardiology/American Heart Association in the management of Valvular Heart Disease (VHD) by analysing newer echocardiographic techniques {Tissue Doppler Imaging (TDI)} and biochemical markers (NT-proBNP) against clinical parameters {New York Heart Association (NYHA)} in an understudied patient group. Aim: To evaluate the role of TDI and its association with the functional class of dyspnoea and serum NT-proBNP levels in RHD. Materials and Methods: This cross-sectional study was conducted in the Cardiology and Medicine departments, Central Gujarat, Western India, from January 2021 to June 2022. Fifty-seven consenting adult patients with RHD who underwent echocardiography with Standard Echocardiographic Techniques (SET) to stratify VHD severity were included. Patients were divided into three sub-groups: a) Isolated MR and MR with mild/moderate MS (n=23); b) Isolated MS and MS with mild MR (n=29); and c) Isolated MS and MS with mild or moderate MR (n=48). TDI parameters (e’, a’, e’/a’, and E/e’) at medial mitral, lateral mitral, and tricuspid annuli, NYHA classification, and serum NT-proBNP levels were analysed. The Analysis of Variance (ANOVA) was used to assess the association between NYHA class and clinical and NT-proBNP parameters. The Pearson correlation coefficient was employed to determine linear relationships between NT-proBNP and TDI parameters. Results: The mean age was 45.4±16 years, with the age groups 20-40 years (n=20) and 40-60 years (n=22) having a nearly equal distribution. The female-to-male ratio was 1.48 (34/23). In subgroup C, the a’ velocity decreased from 13.74±3.92 cm/s in NYHA I to 5.17±1.98 cm/s in NYHA IV (p=0.0312), and the e’/a’ ratio increased from 0.96±0.40 in NYHA I to 2.41±1.00 in NYHA IV (p=0.0210). These changes paralleled trends in a’ value (p=0.0306) and e’/a’ ratio (p=0.0157) with increasing NTproBNP levels. Conclusion: At the tricuspid annulus, the e’/a’ ratio and a’ velocity can complement NT-proBNP in cases where there is a discrepancy between the clinical status of the patient and the severity of the valve lesion as determined by SET. Larger-scale studies are needed to further evaluate the association between TDI parameters and long-term clinical outcomes, as well as to identify the optimal timing for surgical intervention in RHD patients.

Discrepancies in Management and Outcomes of Rheumatic Heart Disease Patients with Mitral Valve Stenosis at a Tertiary Care Centre

Discrepancies in Management and Outcomes of Rheumatic Heart Disease Patients with Mitral Valve Stenosis at a Tertiary Care Centre

Clinical Profile and Outcomes of Rheumatic Heart Disease Patients Undergoing Surgical Valve Procedures in Uganda.

Chronic valvular heart disease is a well-known, long-term complication of acute rheumatic fever (ARF), which remains a major public health problem in low- and middle-income countries. Access to surgical management remains limited. Outcomes of the minority proportion of patients that access surgery have not been described in Uganda. To describe the volume and type of rheumatic heart disease (RHD) valvular interventions and the outcomes of operated patients in the Uganda RHD registry. We performed a retrospective cohort study of all valve surgery procedures identified in the Uganda RHD registry through December 2021. Three hundred and sixty-seven surgical procedures were performed among 359 patients. More than half were among young (55.9% were ≤20 years of age), female (59.9%) patients. All patients were censored at 15 years. The median (IQR) follow up period was 43 (22,79) months. Nearly half of surgeries (46.9%) included interventions on multiple valves, and most valvular operations were replacements with mechanical prostheses (96.6%). Over 70% of the procedures were sponsored by charity organizations. The overall mortality of patients who underwent surgery was 13% (47/359), with over half of the mortalities occurring within the first year following surgery (27/47; 57.4%). Fifteen-year survival or freedom from re-operation was not significantly different between those receiving valve replacements and those receiving valve repair (log-rank p = 0.76). There has been increasing access to valve surgery among Ugandan patients with RHD. Post-operative survival is similar to regionally reported rates. The growing cohort of patients living with prosthetic valves necessitates national expansion and decentralization of post-operative care services. Major reliance on charity funding of surgery is unsustainable, thus calling for locally generated and controlled support mechanisms such as a national health insurance scheme. The central illustration (Figure 1) provides a summary of our findings and recommendations.

Abstract 18242: Mitral Valve Repair vs. Mitral Valve Replacement in Rheumatic Heart Disease Patients: A Systematic Review and Meta-Analysis

Background Mitral valve repair (MVP) is recommended over mitral valve replacement (MVR) for mitral valve disease. However, its benefits in rheumatic heart disease (RHD) patients are unclear. We conducted this meta-analysis to compare perioperative and long-term clinical and safety outcomes of MVP vs. MVR. Methods: MEDLINE, Google Scholar, and Scopus were searched from inception till June 2023 comparing clinical outcomes with MVP vs. MVR in RHD patients. Primary outcomes were early mortality and long-term survival. Secondary outcomes were freedom from reoperation, freedom from valve related adverse events, postoperative infective endocarditis (IE), thromboembolic events (TEE), and hemorrhagic events. The outcome measures were summary random effects risk ratio (RR) and hazard ratios (HR) with 95% confidence intervals. Results: A total of 19 studies with 10,724 RHD patients (3,495 MVP vs. 7,229 MVR; mean age: 38.3 years for MVP vs. 43.5 years for MVR) were included. MVP was associated with significantly lower early mortality (RR 0.62 [0.45, 0.85]; p=0.003), and long-term mortality (HR 0.53 [0.37, 0.76]; p=0.0006). Upon meta-regression analysis, only increasing age was associated with early mortality (Coeff: 0.0194, p=0.037). However, MVP was associated with significantly lower freedom from reoperation at both 5- (RR 0.88 [0.83, 0.93]; p&lt;0.0001) and 10-year (RR 0.90 [0.83, 0.98]; p=0.01) follow-ups. Freedom from valve related adverse events was higher in the MVP group at 10-year follow-up (RR 1.15 [1.06, 1.24]; p=0.0006) with no significant difference at 5-year follow-up (RR 1.03 [0.94, 1.14]; p=0.50). No significant difference was seen for IE (RR 1.03, p=0.91) and hemorrhagic events (RR 0.70, p=0.05). TEE were significantly lower in the MVP group (RR 0.59 [0.44, 0.78]; p=0.0003). Conclusion: In RHD, MVP reduced early- and long-term mortality and achieved greater freedom from valve related adverse events. However, there was a higher risk of reoperation in MVP.

Abstract 16681: Echocardiogram-Based Screening and Prevalence of Rheumatic Heart Disease in Children and Adolescents From Endemic Areas: A Systematic Review and Updated Meta-Analysis

Background: Rheumatic heart disease (RHD) is the leading cause of cardiac death in children, posing a significant burden to health systems, particularly in developing countries. Echocardiogram is a sensitive tool to identify early RHD patients, who may benefit from secondary prevention. Therefore, we performed an updated meta-analysis to determine the prevalence of latent RHD using echocardiogram-based screening performed in endemic regions across the globe. Methods: PubMed, Embase, Cochrane, and Lilacs databases were searched for cross-sectional studies reporting the prevalence of RHD in individuals aged 5-20 years, through echocardiogram-based screening programs in endemic areas. Studies with screening based on auscultation were excluded. Echocardiography-detected RHD was considered as borderline or definite by World Heart Federation (WHF) criteria and possible, probable or definite by World Heart Organization (WHO) criteria. We used random-effects models to assess the prevalence of RHD according to the geographic distribution. Results: A total of 57 studies were included, with a total of 224,100 screened subjects. WHF criteria for RHD echocardiographic diagnosis were used in 46 studies, WHO criteria in 6, and others in 3. The overall prevalence of echocardiography detected RHD was 23 per 1,000 individuals (95% CI 18 to 29 per 1,000), with a pooled prevalence of definitive RHD of 9 per 1,000 individuals (95% CI 7 to 12 per 1,000). Analysis of the prevalence of echocardiography detected RHD in different continents yielded an overall prevalence of 21 per 1,000 (95% CI 14 to 31 per 1,000) in Africa, 28 per 1,000 (95% CI 18 to 42 per 1,000) in Oceania, 21 per 1,000 (95% CI 15 to 30 per 1,000) in Asia, and 22 per 1,000 (95% CI 6 to 76 per 1,000) in Latin America. Conclusion: Screening programs incorporating echocardiography found a significant prevalence of RHD, in the range of 20 to 30 per 1,000 children and adolescents screened in endemic areas across different continents.

Model-Based Assessment of Elastic Material Parameters in Rheumatic Heart Disease Patients and Healthy Subjects

Non-invasive measurements are important for the development of new treatments for heart failure, which is one of the leading causes of death worldwide. This study aimed to develop realistic subject-specific computational models of human biventricles using clinical data. Three-dimensional finite element models of the human ventricles were created using cardiovascular magnetic resonance images of rheumatic heart disease (RHD) patients and healthy subjects. The material parameter optimization uses inverse modeling based on the finite element method combined with the Levenberg–Marquardt method (LVM) by targeting subject-specific hemodynamics. The study of elastic myocardial parameters between healthy subjects and RHD patients showed an elevated stiffness in diseased hearts. In particular, the anisotropic material behavior of the healthy and diseased cardiac tissue significantly differed from one another. Furthermore, as the LVEF decreased, the stiffness and its orientation-dependent parameters increased. The simulation-derived LV myocardial circumferential and longitudinal stresses were negatively associated with the LVEF. The sensitivity analysis result demonstrated that the observed significant difference between the elastic material parameters of diseased and healthy myocardium was not exclusively attributable to an increased LVEDP in the diseased heart. These results could be applied to future computational studies for developing heart failure treatment.

Mitral Stenosis Berat pada Penyakit Jantung Rematik

Rheumatic Heart Disease (RHD) has high morbidity and mortality. Cardiac valve disorders after rheumatic fever are the leading cause of heart failure in children and young adults. A comprehensive understanding of RHD can help early diagnosis and provide optimal management in the future. It has been reported that a 55-year-old man came to the heart clinic of Bhayangkara Hospital Denpasar for routine control of heart disease. The patient has been diagnosed with rheumatic heart disease since 2018. The patient complains of shortness of breath when walking long distances and doing strenuous activities. The patient was diagnosed with CHF FC II ec RHD + MS moderate-severe (Wilkins score 8) + AF NVR (CHA2DS2VASc 3) and treated with heart failure and antiplatelet medication. Mitral stenosis due to RHD produces the typical pathological features seen in Transthoracic echocardiography (TTE), including fibrous thickening and calcification of the valve leaflets, fusion of the commissures, and thickening and shortening of chordae tendineae. Chronic stress overload on the LA due to MS can cause LA dilatation and trigger AF. RHD patients with AF are recommended for anticoagulation for stroke prevention. Patients with acute rheumatic fever clinical features should be evaluated further and given long-term therapy to prevent more severe heart problems.Keywords: atrial fibrillation, mitral stenosis, rheumatic heart disease

Incidental Diagnosis of Rheumatic Myocarditis during Cardiac Surgery-Impact on Late Prognosis.

Rheumatic fever (RF) and rheumatic heart disease (RHD) are still highly prevalent, particularly in low- and middle-income countries. RHD is a neglected and underdiagnosed disease for which no specific laboratory diagnostic test is completely reliable. This is a retrospective observational study, which included 118 patients with RHD who underwent cardiac surgery from 1985 to 2018. The aim of this investigation was to evaluate the clinical, epidemiological, echocardiographic and pathological characteristics in two cohorts of RHD patients: one cohort with Aschoff bodies present in their pathological results and the other without such histopathological characteristics. No conventional clinical and laboratory tests for RHD myocarditis were able to identify active carditis during the preoperative phase of valve repair or replacement. Patients who had Aschoff bodies in their pathological results were younger (median age of 13 years (11-24 years) vs. 27 years (17-37 years), p = 0.001) and had higher rate of late mortality (22.9% vs. 5.4%, p = 0.043). In conclusion, the presence of Aschoff bodies in pathological findings may predict increased long-term mortality, emphasizing the importance of comprehensive pathology analysis for suspected myocarditis during heart surgery.

A Review of Cardiac Surgical Procedures and Their Outcomes for Paediatric Rheumatic Heart Disease in Western Australia

Surgical intervention is an important treatment modality for advanced rheumatic heart disease (RHD). This study aimed to describe patient characteristics and outcomes from cardiac surgery for RHD in patients referred to the only tertiary paediatric hospital in Western Australia. An analysis of patient characteristics and cardiac surgery outcomes in patients with RHD was undertaken, using data from clinical cardiac databases, medical notes, and correspondence from rural outreach clinics. 29 patients (59% female, 97% Aboriginal, Māori or Pacific Islander) underwent 41 valve interventions over 34 cardiac surgeries for RHD between 2000-2018. Median age at first surgery was 12.2 (range 4-16) years. Severe mitral regurgitation (MR) was the most common indication for primary surgery (62%), followed by mixed mitral regurgitation/aortic regurgitation (21%) and severe aortic regurgitation (17%). Mitral valve repair was the most common valve intervention (56%). Two patients had mitral valve replacement (MVR) at first operation, two patients had MVR at second operation and two had MVR at third operation. There was no early mortality. One patient required early (<30 days) reoperation for aortic valve repair failure. Two patients had late reoperations at 3.3 and 6.1 months after the first procedure for MR. Four (14%) patients experienced documented ARF recurrences. Late mortality occurred in 3 (10%) patients, all due to cardiac causes. On last follow-up echocardiogram 5 patients (17%) had moderate MR and none had severe MR. This is the first study to describe characteristics and outcomes in WA paediatric patients having surgery for RHD. Outcomes are comparable to similar studies, with favourable long-term survival.