Rheumatic Valvular Heart Disease Research Articles

RIGHT VENTRICULAR DYSFUNCTION AND TRICUSPID VALVE SURGICAL CORRECTION: ROOM FOR STRESS ECHOCARDIOGRAPHY?

Abstract We report the case of a 50–years–old young woman with multi–operated rheumatic valvular heart disease; aortic, mitral, and tricuspid commissurotomy (1994); aortic valve replacement with bioprosthesis for endocarditis (1998); mitro–aortic replacement with mechanical prosthesis and tricuspid valve plastic repair (1999); mitral valve replacement and re–do of tricuspid plastic repair (2003). Concomitant conduction pathway disease (BAV II type 1 and RBB). The patient was admitted in June 2023 for wet & warm NYHA IV right heart failure with severe peripheral congestion and ascites. On echocardiography: LV with systo–diastolic compression, EF 51%; normo–functioning aortic prosthesis; dilated (TDA 24 cm2), hypokinetic (TAPSE 9mm,S‘ 4 cm/s,FAC 25%) right ventricole (RV), with poor load adaptation (load adaptation index 16, RVCPI 108 mm*mmHg, ePAPI 1.1); torrential IT, caval plethora with systolization of hepatic venous flow. Medical therapy was initiated with intravenous bolus diuretics, nitroglycerin and inotropic support (dobutamine 2.5 y). In order to define the best therapeutic strategy in the persistence of torrential IT and RV dysfunction we performed: trans–oesophageal echocardiography, showed massive IT from ring dilatation and wide flail of the septal flap not suitable for edge–to–edge correction, total–body angioTC, with no relevant findings, right cardiac catheterization, which documented pulmonary pressure and arteriolar resistances within limits (wedge 12 mmHg,PAP25/15/18 mmHg,RAP 11 mmHg,PAPI 0. 9,RVSWI 4.8) with reduced cardiac index (2.14 l/min/cm2) and stress–echocardiography with dobutamine that showed presence of RV contractile reserve (FAC 28%>39%). In consideration of the functional properties of the tricuspid valve, absence of pulmonary hypertension and given the presence of RV contractile reserve, patient underwent tricuspid valve replacement surgery with a bioprosthesis (SJ Epic 27 mm) in mini–thoracotomy with smooth postoperative course. At 3 months follow–up showed functional recovery (NYHA II), with good prosthetic function and partial reverse remodeling of the RV (TDA 14 cm2, FAC of 30%). In conclusion, by documenting right ventricular contractile reserve, stress echocardiography proved to be an important aid in predicting absence of RV failure in the immediate post–surgical period, presenting attractive prospects in the assessment of RV functional reserve in patients undergoing to corrective tricuspidal surgery.

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.

Changing trends in clinical characteristics and in-hospital mortality of patients with infective endocarditis over four decades

BackgroundInfective endocarditis continues to be a significant concern and may be undergoing an epidemiological transition. MethodsWere studied 1804 consecutive episodes of infective endocarditis between 1978 and 2022. The mean age was 48 ( ± 19), and 1162 (64%) patients were male. Temporal trends in demographic data, comorbidities, predisposing conditions, microorganisms, complications and in-hospital death have been studied over the decades (1978–1988, 1989–1999, 2000–2010 and 2011–2022). The outcomes and clinical characteristics were modeled using nonlinear cubic spline functions. FindingsValve surgery was performed in 50% of the patients and overall in-hospital mortality was 30%. From the first to the fourth decade studied, the average age of patients increased from 29 to 57 years (p < 0.001), with significant declines in the occurrence of rheumatic valvular heart disease (15% to 6%; p < 0.001) and streptococcal infections (46% to 33%; p < 0.001). Healthcare-associated infections have increased (9% to 21%; p < 0.001), as have prosthetic valve endocarditis (26% to 53%; p < 0.001), coagulase-negative staphylococcal infections (4% to 11%; p < 0.001), and related-complications (heart failure, embolic events, and perivalvular abscess; p < 0.001). These changes were associated with a decline in adjusted in-hospital mortality from 34% to 25% (p = 0.019). InterpretationIn the 44 years studied, there was an increase in the mean age of patients, healthcare-related, prosthetic valve, coagulase-negative staphylococci/MRSA infections, and related complications. Notably, these epidemiological changes were associated with a decline in the adjusted in-hospital mortality.

Kytococcus Schroeteri Prosthetic Valve Endocarditis Complicated by Aortic Pseudoaneurysm: A Rare Complication from A Rare Agent

Kytococcus schroeteri is a rarely described slow-growing gram-positive coccus, with recent association with Infective Endocarditis cases. A 29-year-old male with prior history of rheumatic valvular heart disease and HIV infection, previously submitted to two cardiac surgeries, the last one 12 years ago with mechanical mitral and aortic valve implantation plus tricuspid annuloplasty was evacuated from Cape Verde with congestive heart failure and no features of infection. The diagnostic workup revealed an aortic paravalvular leak and a large pseudoaneurysm as well as a severe tricuspid regurgitation. The patient underwent surgery with Bentall procedure and a mechanical tricuspid valve implantation. The microbiologic exam of the removed aortic valve using 16sRNA sequencing showed a Kytococcus schroeteri, revealing its association with a severe complicated case of prosthetic valve endocarditis

Coronary artery disease in patients with rheumatic valvular heart disease- An analysis from eastern India

IntroductionThere is insufficient information on the angiographic characteristics of individuals with rheumatic valvular heart disease (VHD) from eastern India. The objective of this research is to gather important data in this area to aid the best surgical outcomes for patients with rheumatic VHD. Materials and methods978 consecutive patients with rheumatic VHD, scheduled for surgical intervention, were recruited. Result and conclusionMitral valve involvement was observed in 66.1 %, aortic valve in 7.3 % and both valves in 26.6 %. Patients with CAD had significantly higher proportions of severe aortic stenosis (AS). Therefore, addressing the risk factors for CAD is crucial in patients with rheumatic VHD.

Unveiling the Shadows: Exploring Factors Behind The Lack of Awareness of Rheumatic Heart Disease Among Diagnosed Patients

Objectives: To assess reasons for lack of awareness regarding rheumatic heart disease among patients diagnosed with rheumatic heart disease.&#x0D; Methodology: In this cross-sectional study was conducted at the outpatient department of a tertiary care cardiac centre. We included consecutive patients of either gender between 18 to 60 years of age with the established diagnosis of RHD. Their knowledge and awareness regarding the disease itself and regarding its primary and secondary prevention and treatment options was assessed with the help of a structured self-developed questionnaire. Collected data was entered and analyzed using IBM SPSS 19.&#x0D; Results: A total of 502 patients were enrolled with almost equal number of male and female patients. Mean ± SD for patient age was 37.3 ± 10.9 years. Majority had received primary school education or above. 40% of the patients were not aware of rheumatic valvular heart disease as their diagnosis. Less than half of patients knew childhood fever and sore throat as cause of their disease. 72.6% of the patients were not aware of prophylactic treatment for the disease. 77.2% were referred to a cardiologist after more than four weeks. 47.9% of patients were not properly counselled about their disease.&#x0D; Conclusion: There was a very high incidence of lack of awareness regarding RHD among affected patients. Moreover, there was high incidence of inadequate physician-patient counselling about the disease and late referral to cardiologist. Healthcare providers should educate their patients, fostering community-based interventions this ultimately will lead to decrease morbidity and mortality among patients diagnosed with RHD and will help in early detection and prevention of RHD.

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

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.

Sex-related differences for uric acid in the prediction of cardiovascular events in essential hypertension. A population prospective study.

Uric acid (UA) is an independent prognostic factor for cardiovascular events, but there are no data demonstrating a different risk profile between women and men. Thus, we tested whether UA is associated with a possible sex-related difference in fatal and non-fatal cardiovascular events. In this prospective population-based study we enrolled 1,650 never-treated Caucasian hypertensive outpatients referred to Catanzaro University Hospital (Italy). Inclusion criteria were newly diagnosed hypertensive patients, aged 20years or more. Exclusion criteria were secondary form of hypertension, previous cardiovascular events, rheumatic and non-rheumatic valvular heart disease, prosthetic valves, cardiomyopathies, type-2 diabetes, chronic kidney disease, malignant diseases, gout arthritis and secondary forms of hyperuricemia, liver diseases, peripheral vascular diseases, and heart failure. Anthropometric, clinical, and biochemical parameters were measured. UA prognostic role was investigated by Cox regression analyses. Receiver-operating characteristic curve analyses and area under the curve were used to determine the predictive validity and the optimal cut-off point of UA. We investigated following endpoints: coronary events (fatal and nonfatal myocardial infarction, unstable angina, coronary revascularization procedures, coronary death); fatal and nonfatal stroke; all-cause mortality and major adverse cardiovascular events (MACE). We enrolled 830 males and 820 females aged 52.2 ± 11.3years. During 9.5 ± 3.1years follow-up, there were 424 new clinical events (2.71%): 250 coronary (1.59%), 118 (0.75%) cerebrovascular, and 56 (0.40%) deaths. Comparison between groups demonstrated a higher and significant difference in incidence rate in females for MACE (3.08 vs 2.33%, P = 0.001), coronary (1.82 vs 1.36%, P = 0.014) and cerebrovascular events (0.93 vs 0.57%, P = 0.006). UA at multiple Cox regression analysis resulted a strong and significant predictor of coronary events (HR = 1.493;95% CI 1.375-1.621), cerebrovascular events (HR = 1.256;95% CI 1.109-1.423), MACE (HR = 1.415;95% CI 1.328- 53 1.508), and all-cause mortality (HR = 1.469;95% CI 1.237-1.745) in the whole population and in both groups with a HR higher in females. The best estimated cut-off values of uric acid for males and females predicted these endpoints equally well, but it was always lower in females than males. We demonstrate, that UA operates with a sex-related impact and best cut-off value in predicting cardiovascular outcomes and all-cause mortality, reflecting a possible sex difference in disease pathophysiology.

Clinical profile of atrial fibrillation in hospitalized patients: experience from two tertiary centers of Bangladesh

Background: Chronic rheumatic heart disease (RHD), particularly mitral stenosis, is traditionally thought to be the dominating cause of atrial fibrillation (AF) in Bangladesh. But over the past decades, parallel to the changes in dominating disease pattern, rheumatic fever and possibly RHD has declined in the country. Also, the current practice of anticoagulation in AF here is not known. The study was carried out to explore the current aetiology and clinical profile of AF in hospitalized patients. Methods: This cross-sectional study included 302 consecutive adult patients with AF admitted in 2 hospitals in Dhaka, Bangladesh. History, clinical examination and investigations including transthoracic echocardiography were done to find out the aetiology, type of AF, selected complications and the pharmacotherapy including anticoagulation practice in hospitalized AF patients. Results: The mean age of the patients was 54.00 ± 12.46 years (range 14 to 85 years). The most common etiology was rheumatic valvular heart disease (47.7%), followed by ischaemic heart disease (IHD) (29.5%) and hypertensin (5.0%). Majority (249, 82%) had coarse AF and only 18% had fine AF. Thirteen (4.3%) patients presented with stroke and 7 (2.3%) had left atrial thrombus. The most common drugs used were beta blocker (32.78%), digoxin (32.45%) and combination of beta blocker and digoxin (23.84%). Anticoagulant was used in 56.95% cases. Among the anticoagulants, warfarin was most commonly prescribed (69.18%), followed by rivaroxaban and apixaban in 15.69% and 13.95% cases, respectively. Conclusion: RHD is still the dominating cause of AF in hospitalized patients in Bangladesh. Despite high prevalence of rheumatic valvular AF, anticoagulants are underused. Warfarin is far more commonly used than the direct oral anticoagulants (DOACs). BIRDEM Med J 2023; 13(3): 143-148

Abstract P3126: Atrial Fibrillation Is Associated With Decreased Claudin-5 In Cardiomyocyte

Background: Although it is critically important to understand the underlying molecular and electrophysiological changes that predispose to the induction and maintenance of atrial fibrillation (Af), the underlying mechanism of Af is still poorly defined. Af is characterized as the electrophysiological and membrane integrity abnormality of the atrial cells, and claudin-5, a tight junction protein, may be involved in the pathophysiology of Af, however, the role of claudin-5 in Af is unknown. Methods and Results: Cardiac tissues from the left atrial appendage were obtained from AF patients with rheumatic valvular heart disease undergoing modified radiofrequency ablation maze procedure with approval from local human research ethic review and normal left atrial appendages were obtained from non-AF donors. Western blot, immunofluorescence and transmission electron microscope showed the expression of claudin-5 significantly decreased in cardiomyocytes from left atrium of AF patients compared to non-AF donors. Then proteomics analysis was performed to screen the specific protein expression and signal pathway changed in AF heart tissue vs. non-AF heart tissue, and showed that 83 proteins were downregulated and 102 proteins were upregulated in the left atrial appendage of AF patients. Among them, DAG, CACNA2D2, MYL2 were downregulated and MCU was upregulated. KEGG pathway analysis showed these changes would lead to hypertrophic and dilated cardiomyopathy. Finally, claudin-5 shRNA AAV was injected in mouse left ventricle to knockdown claudin-5 in cardiomyocytes to observe whether change of claudin-5 affects the protein expression in KEGG pathway analysis. We found claudin-5 deficiency caused severe ventricular dilation, ST elevation and arrythmia, and the protein level of DAG, CACNA2D2 and MYL2 were downregulated and MCU was upregulated. Co-immunoprecipitation also confirmed the specific protein-protein interaction between these targeted proteins and claudin-5. Conclusion: We demonstrated that the decrease of claudin-5 in the left atrium of AF patients with rheumatic valvular heart disease. The mechanism of AF might be associated with claudin-5 downregulation-induced decrease of DAG, CACNA2D2, MYL2 and increase of MCU in cardiomyocytes.

Long-term mortality risk of valvular heart disease adults over 35 years old in Chinese communities

Objective: To investigate the risk and influencing factors of long-term mortality of valvular heart disease (VHD) adults aged 35 years and over in Chinese communities. Methods: A cohort study was carried out. The data of the subjects who underwent echocardiography were collected from the Chinese Hypertension Survey between 2012 and 2015 and survival outcomes were followed up between 2018 and 2019. Kaplan-Meier survival curves were plotted and compared using log-rank test. Cox proportional hazards models were used to analyze the influence of VHD on mortality. Results: During an average follow-up time of (4.6±0.9) years, a total of 23 237 participants (10 881 males and 12 356 females) were pooled into the final analysis from 5 eastern, 5 central, and 4 western provinces, cities and autonomous regions in China, with a mean age of (56.9±13.2) years. Among the included participants, 1 004 had VHD (467 males and 537 females), with a mean age was of (68.1±12.6) years. In the Kaplan-Meier analysis, participants with VHD had a significantly increased risk of all-cause mortality (log-rank χ2=351.82, P<0.001) and cardiovascular mortality (log-rank χ2=284.14, P<0.001) compared with those without VHD. Multivariate Cox regression analysis showed that compared with those without VHD, the participants with rheumatic VHD had a 45% increased risk of all-cause mortality (HR=1.45, 95%CI: 1.12-1.89) and degenerative VHD increased the risk of cardiovascular mortality by 69% (HR=1.69, 95%CI: 1.19-2.38). The risk factors of cardiovascular mortality for VHD were age 55 years and over (55-<75 years: HR=4.93, 95%CI: 1.17-20.85;≥75 years: HR=11.92, 95%CI: 2.85-49.80) and diabetes mellitus (HR=1.71, 95%CI: 1.00-2.93). Conclusions: VHD is a risk factor of all-cause mortality and cardiovascular mortality among adults aged 35 years and over. Age 55 years and over and diabetes mellitus are adverse prognostic factors for patients with VHD.

Delta of Egypt Atrial Fibrillation Registry Phase Two

Background: Atrial Fibrillation (AF) is the most frequent cardiac arrhythmia found in clinical practice. The assessed frequency of AF in adults is between 2% and 4%, with greater incidence and frequency rates in developed nations [1,2]. AF prevalence increases with advancing age, and with some cardiac and non-cardiac disorders, also it may exist in the absence of any conditions [2]. We aimed to determine case characteristics, practice patterns, management strategies and outcomes of atrial fibrillation in the delta area of Egypt.&#x0D; Methods: This registry-based cross-sectional study included 1000 atrial fibrillation patients (with any AF patterns) who were allowed to enter ER in cardiac centers and hospitals in middle Delta of Egypt from April 2020 to March 2021.&#x0D; Results: 267 patients (26.7%) were unstable. Heart failure, hypertension, and coronary disease were still prevalent comorbidities in our AF dataset, where hypertension accounts for over 50% of all AF cases. Rheumatic valvular heart disorder was a major underlying disease for the development of AF, still about 25.5% by echocardiography. Lone AF still high 20.6%. CHA2DS2VASc score ≥2 is 83.5%. A high proportion of cases were treated with pharmaceuticals for rate control nearly 52.7% of the cases and nearly 30.3% of the cases were given pharmacological medications for the cardioversion to the sinus rhythm and a small proportion of the cases were given electrical cardioversion nearly 7%.&#x0D; Conclusions: Coronary disease, hypertension, and heart failure were still usual comorbidities in AF. Rheumatic valvular heart disease is still about 25.5% of the total registry. Amiodarone is the most prevalent antiarrhythmic medications (AAD) used. lone AF still high 20.6%. minimal use of novel oral anticoagulant (OAC).

Extra cardiac perforation following failed percutaneous transvenous mitral commissurotomy

Percutaneous transvenous mitral commissurotomy (PTMC) is the procedure of choice for select patients with mitral valve disease who have favorable valve architecture and meet the requirements for balloon valve dilatation. Complications following PTMC are rare (&lt;3%). A 56-year-old woman with rheumatic valvular heart disease, severe mitral stenosis and moderate mitral regurgitation in atrial fibrillation underwent elective PTMC. She developed an extra-cardiac perforation during PTMC because of abnormal catheter course, and underwent emergency mitral valve replacement with extra-cardiac perforation repair. Catheter-related complications following PTMC are rare but not unheard of. Prompt management of immediate complications result in favorable outcomes.

Screening for the prevalence of rheumatic heart disease among school children in Egypt.

In low-income nations, Rheumatic valvular heart disease remains a major cause of morbidity and premature deaths. Accurate prevalence data in Egypt are still lacking yet highly desirable to facilitate health care planning. An cluster sample of school children in eastern Egyptian Governorates was examined clinically and echocardiographically (using abbreviated protocol) for detection of rheumatic valvular heart disease based on 2012 World Heart Federation criteria (the Doppler and the morphological criteria) for diagnosis. According to echocardiography interpretation, participants were categorized as having definite rheumatic heart disease (RHD), borderline RHD or no RHD. A total of 1680 students aged between 6 and 18 years were screened, 119 echocardiographic studies were non-interpretable; so, a total of 1560 studies were evaluated. From the total screened students, 1560 studies were adequate and interpretable according to the criteria specified in the methods section. This revealed a prevalence of 2.3% of the sample with RHD without adding the equivocal cases. The most prevalent lesion as detected by echocardiography was mitral regurgitation (29% of definite RHD cases). Rheumatic valvular heart disease remains prevalent in Egypt and the findings of this study should influence early detection, primary and secondary prevention, and adequate future national health plans.

A Retrospective Study on Drug and Dietary Patterns in Patients With Severe Rheumatic Valvular Heart Disease in Eastern India.

Background India has a high prevalence of rheumatic valvular heart diseases. Empirical treatment in rheumatic heart disease curtails morbidity and mortality. Less is known about the drug and dietary management of severe rheumatic heart disease at the pretertiary care level, which forms the building stone in the management of rheumatic heart disease. The present study was carried out to evaluate the drug and dietary patterns of patients with severe rheumatic valvular heart disease at a pretertiary care level, which is the backbone of the management of rheumatic heart disease. Methodology This cross-sectional study was carried out in a tertiary care center in Eastern India between May 2020 and May 2022 across 1,264 study subjects. The drug and dietary patterns of the patients with severe rheumatic valvular heart disease during their index visit to the cardiac department were studied and analyzed.Patients aged less than 18 years; patients with mild or moderate rheumatic valvular heart diseases; patients with coexisting end-stage organ disease (chronic liver disease and chronic kidney disease), malignancy, and sepsis; and patients not willing to participate in the study were excluded. Results Most of the patients were on diuretic therapy, and diuretic therapy was overprescribed across the patients with mitral regurgitation, aortic stenosis, and aortic regurgitation. Most of the patients across each spectrum of rheumatic valvular heart disease were lacking the cornerstone therapy such as beta-blockers in mitral stenosis and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation. The recommended injectable benzathine penicillin prophylaxis was prescribed in a very small number of patients (5%), and most of the patients were on oral penicillin prophylaxis (95%) in spite of its reportedhigh failure rate in prophylaxis. Empirical rationale prescriptions in severe rheumatic valvular heart disease were lacking in the pretertiary care level in Eastern India. Conclusion Each spectrum of severe valvular heart disease was lacking the cornerstone therapy such as beta-blockers in mitral stenosis and ACE inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation along with recommended injectable benzathine penicillin prophylaxis. Diuretics and digoxin were overprescribed across the spectrum of rheumatic heart disease. Improvement of this essential gap in the treatment of severe rheumatic heart disease would bring down morbidity and improve mortality in the future.

Knowledge and Awareness of Rheumatic Valvular Heart Disease among Diagnosed Patients

Objectives: To assess the knowledge about valvular heart disease among the patients who are already diagnosed with rheumatic valvular heart disease (RVHD). Methodology: In this cross-sectional study was conducted at the outpatient of a tertiary care cardiac centre. We included consecutive patients of either gender between 18 to 60 years of age with the established diagnosis of RVHD. Their knowledge and awareness regarding the disease itself and regarding its primary and secondary prevention and treatment options was assessed with the help of a structured self-developed questionnaire. Results: Among the study sample of 505 patients, 255 (50.5%) were male and overall mean age was 37.3 ± 10.9 years. A majority (90.3%) of the patients had household income of ≤ PKR 40,000 and 35.3% were illiterate. More than 41% were not aware of their diagnosis, 40% were aware of childhood infection as the cause of RVHD. About 40% of the patients could not recall history of fever/sore throat in past. About 19.8% of the patients considered percutaneous transvenous mitral commissurotomy as complete cure for RVHD and 46.3% of the patients were not aware of a prophylactic treatment. Only 33.9% considered the need to maintain good dental hygiene as part of the prophylactic treatment. Conclusion: High incidence of lack of awareness regarding their disease and its prophylaxis in our study population is alarming. To improve the RHD awareness, sessions and seminars should be arranged in the general population. Further studies are required to identify the cause and hence identifying measures to improve awareness.

ETIOLOGICAL PROFILE OF PATIENTS WITH ATRIAL FIBRILLATION WITH SPECIAL REFERENCE TO VALVULAR HEART DISEASES.

Background : Atrial brillation is the most commonly encountered quivering or irregular heart beat(arrhythmia) in our population and it is the disordered supraventricular (atrial) event characterised by irregular heart rhythm, thereby altered atrial electrical and mechanical function. Atrial brillation often inuences the quality of life as atrial brillation may be associated with disability, anxiety, cognitive impairment, chest pain, hospitalization and even absence from work. Many diseases have been implicated to the development of atrial brillation; amongst which Rheumatic valvular heart disease, systemic hypertension, ischemic heart disease, thyroid disease is very important. Alcohol and smoking add up to risk factors leading to development of atrial brillation. Although various studies had been reported from different parts of the country, not much clinical data is available on etiological and clinical prole of Atrial fribillation in north eastern part of the country hence this study has been undertaken. In this Hospital ba Materials and Methods: sed observational Study conducted in the department of Medicine, Jorhat Medical College and Hospital, Jorhat, Assam among 90 patients etiology of valvular and non-valvular atrial brillation was taken into account. In our study, mean age of study populat Results: ion was 46.5±5.09 years, for valvular etiology mean age 34.8± 2.05 years, for non valvular mean age 51.64± 3.08 years. 55.57% of study population were males, 44.43% were females. Valvular atrial brillation was found in 30% cases, non valvular etiology found in 70% cases.

IgG2 rules: N-acetyl-β-D-glucosamine-specific IgG2 and Th17/Th1 cooperation may promote the pathogenesis of acute rheumatic heart disease and be a biomarker of the autoimmune sequelae of Streptococcus pyogenes.

Antecedent group A streptococcal pharyngitis is a well-established cause of acute rheumatic fever (ARF) where rheumatic valvular heart disease (RHD) and Sydenham chorea (SC) are major manifestations. In ARF, crossreactive antibodies and T cells respond to streptococcal antigens, group A carbohydrate, N-acetyl-β-D-glucosamine (GlcNAc), and M protein, respectively, and through molecular mimicry target heart and brain tissues. In this translational human study, we further address our hypothesis regarding specific pathogenic humoral and cellular immune mechanisms leading to streptococcal sequelae in a small pilot study. The aims of the study were to (1) better understand specific mechanisms of pathogenesis in ARF, (2) identify a potential early biomarker of ARF, (3) determine immunoglobulin G (IgG) subclasses directed against GlcNAc, the immunodominant epitope of the group A carbohydrate, by reaction of ARF serum IgG with GlcNAc, M protein, and human neuronal cells (SK-N-SH), and (4) determine IgG subclasses deposited on heart tissues from RHD. In 10 pediatric patients with RHD and 6 pediatric patients with SC, the serum IgG2 subclass reacted significantly with GlcNAc, and distinguished ARF from 7 pediatric patients with uncomplicated pharyngitis. Three pediatric patients who demonstrated only polymigrating arthritis, a major manifestation of ARF and part of the Jones criteria for diagnosis, lacked the elevated IgG2 subclass GlcNAc-specific reactivity. In SC, the GlcNAc-specific IgG2 subclass in cerebrospinal fluid (CSF) selectively targeted human neuronal cells as well as GlcNAc in the ELISA. In rheumatic carditis, the IgG2 subclass preferentially and strongly deposited in valve tissues (n = 4) despite elevated concentrations of IgG1 and IgG3 in RHD sera as detected by ELISA to group A streptococcal M protein. Although our human study of ARF includes a very small limited sample set, our novel research findings suggest a strong IgG2 autoantibody response against GlcNAc in RHD and SC, which targeted heart valves and neuronal cells. Cardiac IgG2 deposition was identified with an associated IL-17A/IFN-γ cooperative signature in RHD tissue which displayed both IgG2 deposition and cellular infiltrates demonstrating these cytokines simultaneously. GlcNAc-specific IgG2 may be an important autoantibody in initial stages of the pathogenesis of group A streptococcal sequelae, and future studies will determine if it can serve as a biomarker for risk of RHD and SC or early diagnosis of ARF.

Building cardiac surgical programs in lower-middle income countries

ObjectivesMedical care in low-income countries is often limited by inadequate resources, treatment facilities, and the necessary infrastructure for healthcare delivery. We hypothesized that the development of an independently functioning, internationally supported Kenyan cardiac surgical training program could address these issues through targeted investment. MethodsA review was conducted of the programmatic structure and clinical outcomes from January 2008 to October 2021 at Tenwek Hospital, Bomet, Kenya. Program development phases included (1) cardiovascular care provided by 1 full-time US board-certified cardiothoracic surgeon; (2) short-term volunteer surgical teams from the United States and Canada; and (3) development of a cardiothoracic residency program based on the Society of Thoracic Surgeons training curriculum. Patient demographics and outcomes were analyzed throughout each phase of program development. ResultsA total of 817 cardiac procedures were performed during the study period, including 236 congenital (28.8%) and 581 adult (71.1%) procedures. Endemic rheumatic valvular heart disease predominated (581 patients, 62.3%). Local surgical team case volume grew over the study period, overtaking visiting team volume in 2019. Perioperative mortality was 2.1% and consistent between the visiting teams and the locally trained teams. Surgical training via a 3-year cardiothoracic residency is now in its fourth year, with the 2 graduates now retained as full-time teaching staff. ConclusionsGlobal health partnerships have the potential to address unmet needs in cardiac care within low- and middle-income countries. These data support the concept that acceptable clinical outcomes and consistent growth in volume can be achieved during the transition toward fully independent cardiac surgical care.

Changes in Cardiovascular Disease Burden in China after Release of the 2011 Chinese Guidelines for Cardiovascular Disease Prevention: A Bayesian Causal Impact Analysis

Objective: This study aimed to investigate the effects of the 2011 Chinese Society of Cardiology guidelines (2011 CSC guidelines) on the overall and subtype specific cardiovascular disease (CVD) burden in China. Methods: We conducted a Bayesian causal impact analysis to investigate changes in the burden of CVD overall and 13 subcategories, before and after release of the 2011 CSC guidelines, by using publicly available data during 1990–2019. Results: The 2011 CSC guidelines were associated with moderate declines in CVD mortality (5.7%; equivalent to 161 per 100,000) and DALYs (2.9%; 1429 per 100,000), but small increases in incidence and prevalence, with an approximately 1-year lagged effect. Similar impact patterns were observed for ischemic stroke, cardiomyopathy and myocarditis, and aortic aneurysm. Release of the 2011 CSC guidelines increased intracerebral hemorrhage incidence, but sharply decreased rheumatic, ischemic, and non-rheumatic valvular heart disease mortality and DALY rates. The burden of other CVD subcategories was unchanged. Health worker numbers, population size, disposable income, hospital admission rates, and crude death rates were critical contributors to CVD burden beyond the 2011 CSC guidelines. Conclusion: The 2011 CSC guidelines decreased the burden of CVD and several subcategories. However, efforts to enhance health promotion and strengthen healthcare remain urgently needed in China.