Rheumatic Valve Lesions Research Articles

Echocardiographic assessment of morphofunctional and hemodynamic changes of rheumatic mitral valve dysfunction in the young. Morphological changes in rheumatic valve lesions

Background- Rheumatic fever and its sequel rheumatic heart disease remain a major health problem across the globe. This investigation aims to analyse the mitral valve morphofunctional changes, stratified by severity, and the magnitude of the mitral regurgitation and stenosis through a simplified echocardiographic scoring system in patients with rheumatic heart disease. Methods- As cross-sectional echocardiographic study was carried out in 98 consecutive patients with confirmed rheumatic heart disease. Patients undergoing outpatient clinical care over an 18-month period (mean follow-up period of 9,7±2,9 years) were selected for echocardiographic investigation. After a double-blind echocardiograms review, the inter-rater reliability was calculated (Kappa=0.875 (0.775- 0.974; CI 95%). The morphofunctional data of mitral apparatus were scored on a rating scale from one to fifteen, encompassing three categories (1-5: mild; 6-10: moderate; 10-15: severe) to quantify the degrees of severity. Pearson's Chi-squared test with Yates' continuity correction were performed for comparative analysis and the Wilcoxon test and the Cliff's Delta effect size was calculated to examine differences related to morphological features. Results- The majority of patients had rheumatic heart disease with clinical evidence and twenty patients (20,4%) had subclinical disease.The thickening of both mitral valve leaflets and the restrictive motion of the posterior leaflet were most frequently found in contrast with the low percentage of chordal and/or commissural fusion. The degree of the anterior mitral valve leaflet thickening was proportional to the magnitude of the mitral valve regurgitation (p=0.021). The higher degrees of mitral valve dysfunction were associated with more severe carditis (mitral valve regurgitation, p: 0.000; mitral valve stenosis, p: 0.031). No association was found between the severity of valvular lesions and patient age or length of the disease (p=0.320). The presence of beading was only observed in the acute phase (p=0,000); coaptation defect of the mitral valve was associated with significant left ventricle enlargement (p=0.000). The morphofunctional score of mitral apparatus, stratified by severity, was associated with the magnitude of mitral valve regurgitation (p=0,000) and of mitral valve stenosis (p=0,031) also quantified by severity. The highest scores were observed in patients with the most severe degrees of carditis (p=0,000); however, no association was found with either, the patients’ age (p=0.373) or the duration of the disease (p=0.361). Conclusions- In the analysis of severity of the mitral apparatus deformities and the resulting valve dysfunction, the morphofunctional score stratification was highly associated with the magnitude of mitral regurgitation and stenosis. In this young cohort, the higher scores were associated to severe carditis, but not to the patients’ age or the duration of the disease. Taking into account the low prevalence of severe valve dysfunctions, these results highlight the importance of early intervention and adequate prevention.

Persisting burden and challenges of rheumatic heart disease.

Rheumatic heart disease (RHD) is the result of episodes of acute rheumatic fever with valvular (and other cardiac) damage caused by an abnormal immune response to group A streptococcal infections, usually during childhood and adolescence. As a result of improved living conditions and the introduction of penicillin, RHD was almost eradicated in the developed world by the 1980s. However, being a disease of poverty, its burden remains disproportionately high in the developing world, despite being a fundamentally preventable disease. Rheumatic heart disease generates relatively little attention from the medical and science communities, in contrast to other common infectious problems (such as malaria, HIV, tuberculosis), despite the major cardiovascular morbidity/mortality burden imposed by RHD. This relative neglect and paucity of funding have probably contributed to limited fundamental medical advances in this field for over 50 years. Given the importance of prevention before the onset of major valvular damage, the main challenges for RHD prevention are improving social circumstances, early diagnosis, and effective delivery of antibiotic prophylaxis. Early identification through ultrasound of silent, subclinical rheumatic valve lesions could provide an opportunity for early intervention. Simple echocardiographic diagnostic criteria and appropriately trained personnel can be valuable aids in large-scale public health efforts. In addition, a better understanding of the immunogenic determinants of the disease may provide potential routes to vaccine development and other novel therapies.

Contemporary trends in mitral valve surgery in East China: a 10-year experience.

Contemporary nationwide data from mainland China on trends in mitral valve surgery are scarce. The purpose of the present study was to review a single-center experience with mitral valve surgery over a 10-year period in East China. Between July 2009 and June 2019, 3238 consecutive patients who underwent mitral valve surgery in our center were retrospectively reviewed. The patients were evenly divided into three periods: July 2009 to October 2012 (period I), November 2012 to February 2016 (period II), March 2016 to June 2019 (period III). The 3238 patients included 536 (16.6%) who had mitral valve repair and 2702 (83.4%) who had mitral valve replacement. Early mortalities for mitral valve repair and mitral valve replacement were 0.2% and 0.9%, respectively. There were trends towards a higher proportion of degenerative valve lesions (24.6%, 35.8%, 54.7% in periods I, II, and III, respectively) and a lower proportion of rheumatic valve lesions (71.0%, 62.6%, 38.0%) in more recent years. The proportions of minimally invasive surgery (0.7%, 2.1%, 30.2%), mitral valve repair (8.3%, 15.4%, 27.5%), use of a bioprosthesis (10.1%, 17.0%, 23.1%), and concomitant tricuspid valve procedures (13.2%, 28.5%, 46.0%) increased dramatically, while early mortality remained constant during the 10-year period (1.0%, 0.3%, 0.9%). In the past 10 years, the spectrum of mitral valve disease experienced a trend towards more degenerative valve lesions and less rheumatic valve lesions in East China. Mitral valve repair, bioprostheses, tricuspid valve repair, and minimally invasive surgery have been more often applied in recent years.

PT288 The Concept and Design of Definerhd: A Study to Evaluate the Progression of Subclinical Rheumatic Valve Lesions Diagnosed Through Echocardiographic Screening

PT288 The Concept and Design of Definerhd: A Study to Evaluate the Progression of Subclinical Rheumatic Valve Lesions Diagnosed Through Echocardiographic Screening

Risk Factors Associated with Left-Sided Cardiac Valve Calcification: A Case Control Study

Objectives: To identify risk factors associated with cardiac valve calcification that is easily detectable through routine blood tests in patients who received valve replacement therapy. Methods: Four hundred patients with valvular heart disease who underwent valve replacement surgery between December 2009 and January 2013 were enrolled in this study. Of these, 77 had valve calcification; the other 323 did not. Multivariate logistic regression analysis was used to assess for risk factors associated with valve calcification. Results: In our study population, rheumatic valve lesions were the most common reason for valve replacement. Degenerative nonstenotic valve lesion was a protective factor and degenerative stenotic valve lesion was a strong risk factor for valve calcification. Serum levels of gamma-glutamyl transferase (GGT) of between 30 and 46 IU/l and >90 IU/l and total bilirubin (TBIL) of between 15 and 20 μmol/l were positively correlated with valve calcification. Meanwhile, serum calcium (Ca²⁺) levels of between 2.3 and 2.4 mmol/l were negatively correlated with rheumatic valve calcification. Conclusions: Degenerative stenotic lesion is a risk factor and degenerative nonstenotic lesion a protective factor for cardiac valve calcification. Serum GGT and TBIL levels are positively correlated and serum Ca²⁺ levels negatively correlated with rheumatic cardiac valve calcification.

Letter by Beniwal and Bhaya Regarding Article, “Rheumatic Heart Disease Screening by Echocardiography: The Inadequacy of World Health Organization Criteria for Optimizing the Diagnosis of Subclinical Disease”

To the Editor: Marijon and colleagues1 base their arguments on a phenomenon not observed by them during their study on rheumatic heart disease (RHD). They assume that “pathophysiologically, repeated rheumatic carditis can result in subvalvular or valvular thickening before the development of leaflet retraction and thereby regurgitation.” They further state, “In adding the diagnostic criterion of morphological valve changes, otherwise well defined in more advanced rheumatic valve lesions, we have detected many children with subclinical RHD but without significant valve regurgitation who would not be eligible for secondary RHD prophylaxis under current international guidelines.” A phenomenon of dissociation between mild- to moderate-grade RHD-like valve abnormalities and significant regurgitation in …

Aortic valve incompetence and replacement in rheumatoid arthritis.

Five cases of aortic incompetence and nodular seropositive rheumatoid arthritis are presented. Four cases underwent aortic valve replacement. Two of these had granulomatous involvement of the aortic cusps similar to subcutaneous rheumatoid nodules, and another showed a nonspecific fibrosis. One case had definite coincidental rheumatic aortic and mitral heart disease. Two patients had undergone pericardectomy previously for constrictive pericarditis. Good results were obtained in all four operated cases and cardiac surgery enabled continuation of rehabilitation for the rheumatoid arthritis, including major orthopaedic procedures. A review of 22 cases from the literature with rheumatoid granulomata within the aortic valve shows that they are associated with mitral valve granulomata in 63-6%. Congestive cardiac failure was found in 75%. Macroscopical evidence of aortic incompetence was seen in 36-8% and of aortic stenosis in 15-8%. Associated pericarditis occurred in 59-1%, which was severe or complicated in 13.6%. The associated arthritis was severe in 77-8% with subcutaneous nodules (71-5%), rheumatoid factor (83-6%), and episcleritis (66-6%). From these cases and a review of the literature the following points are emphasized. (1) Both the granulomatous and nonspecific aortic valvulitis of rheumatoid arthritis may result in significant haemodynamic abnormality. (2) The valve lesions found are often clinically and macroscopically indistinguishable from rheumatic valve lesions. (3) Granulomata, when present, are usually found in the valve cusp or ring and only occasionally in the aortic wall. (4) Associated joint disease, although usually severe, may be mild. (5) The valve lesion may be accompanied by a severe pericardial involvement--either tamponade or constriction. (6) Aortic valve replacement for aortic incompetence in rheumatoid arthritis is both feasible and worthwile, despite severe joint disease.

Early stage of tricuspid stenosis

Twelve patients are presented with rheumatic valve lesions and a typical tricuspid diastolic rumble presenting inspiratory accentuation. All the patients, except one, were in sinus rhythm. No tricuspid diastolic gradient was found when they were first catheterized. An intracardiac diastolic rumble with inspiratory accentuation was recorded in the right atrium or ventricle, or both. Five of the patients were recatheterized after an interval of 1 to 3 years, and, although the clinical picture was unchanged, small tricuspid gradients were recorded. A diminution of cardiac output and an increase of right atrial mean pressure were also observed. It should be accepted that, at an early stage of tricuspid stenosis, a tricuspid gradient may be absent while the auscultatory and phonocardiographic signs may be the only indication of the tricuspid lesion.

The incidence of rheumatic and congenital heart disease among school children of louisville, KY

1. 1. A study is presented of the incidence of rheumatic and congenital heart disease among 41,905 school children from 6 through 14 years of age who yearly attend the schools of Louisville, Ky. 2. 2. A total of 221, or 0.52 per cent, had rheumatic or congenital heart lesions; this included 0.54 per cent of the white and 0.45 per cent of the negro children. 3. 3. Rheumatic heart disease accounted for 69 per cent of the 221 cases. 4. 4. Rheumatic heart disease occurred in 0.33 per cent of the white and 0.35 per cent of the negro pupils. 5. 5. Congenital heart lesions were found in 0.18 per cent of the white and 0.05 per cent of the negro children. 6. 6. Rheumatic valve lesions were approximately equally common in both sexes of both races. No cases were encountered in siblings. 7. 7. Although the incidence was not higher in the slum clearance areas of the city, there was a greater incidence of rheumatic lesions in children from the “poorer” than from the “better” districts.