Rheumatic Valvular Disease Research Articles

Safety and Effectiveness of Oral Anticoagulants in Atrial Fibrillation: Real-World Insights Using Natural Language Processing and Machine Learning.

Background/Objectives: We assessed the effectiveness and safety of vitamin K antagonists (VKAs) versus direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) using artificial intelligence techniques. Methods: This is a retrospective study in 15 Spanish hospitals (2014-2020), including adult AF patients with no history of anticoagulation, thrombosis events, rheumatic mitral valvular heart disease, mitral valve stenosis, or pregnancy. We employed EHRead® technology based on natural language processing (NLP) and machine learning (ML), along with SNOMED-CT terminology, to extract clinical data from electronic health records (EHRs). Using propensity score matching (PSM), the effectiveness, safety, and hospital mortality of VKAs versus DOACs were analyzed through Kaplan-Meier curves and Cox regression. Results: Out of 138,773,332 EHRs from 4.6 million individuals evaluated, 44,292 patients were included, 79.6% on VKAs and 20.4% on DOACs. Most patients were elderly [VKA 78 (70, 84) and DOAC 75 (66, 83) years], with numerous comorbidities (75.5% and 70.2% hypertension, 47.2% and 39.9% diabetes, and 40.3% and 34.8% heart failure, respectively). Additionally, 60.4% of VKA and 48.7% of DOAC users had a CHA2DS2-VASc Score ≥4. After PSM, 8929 patients per subgroup were selected. DOAC users showed a lower risk of thrombotic events [HR 0.81 (95% CI 0.70-0.94)], minor bleeding [HR 0.89 (95% CI 0.83-0.96)], and mortality [HR 0.80 (95% CI 0.69-0.92)]. Conclusions: Applying NLP and ML, we generated valuable real-world evidence on anticoagulated AF patients in Spain. Even in complex populations, DOACs have demonstrated a better safety and effectiveness profile than VKAs.

A Comprehensive Study of Risk Factors, Etiology, and Infarction Patterns in Cerebrovascular Accidents at a Tertiary Care Hospital in India.

Background Stroke is a debilitating cerebrovascular condition characterized by sudden neurological deficits. The incidence of stroke is rising in India, posing significant public health concerns. This study aims to examine the risk factors and etiology of stroke using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification and analyze infarct areas in cerebrovascular accidents (CVA) at a tertiary care hospital. Methodology This cross-sectional, hospital-based observational study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to Be University), Pune, India, from January 2023 to January 2024. The study included 100 adult patients diagnosed with CVA based on clinical and radiological criteria. Patients aged 18 years and older were eligible, while those with a history of head trauma or those below 18 years were excluded. The investigation protocol included routine biochemical assessments and radiological investigations, such as computed tomography (CT), magnetic resonance imaging (MRI) with angiography or venography, and Doppler ultrasound of bilateral carotid arteries. Results The study population consisted of 100 patients, with 84 males (84%) and 16 females (16%). Age distribution showed 44% were over 60 years old, 23% aged 51-60 years, 15% aged 31-40 years, 14% aged 41-50 years, and 4% aged 21-30 years. Hypertension was the most prevalent risk factor, affecting 75% of patients, with a higher occurrence in males (62%), compared to females (13%). Smoking was observed in 51% of patients, and alcohol consumption was seen in 50%. Other significant risk factors included dyslipidemia (39%), diabetes mellitus (33%), chronic kidney disease (11%), ischemic heart disease (10%), atrial fibrillation (4%), valvular heart disease (4%), and pregnancy or postpartum conditions (2%). Ischemic stroke was predominant, occurring in 80% of patients, while hemorrhagic stroke occurred in 20%. High occurrences of ischemic strokes were noted in the frontal lobe (41%), parietal lobe (37%), occipital lobe (27%), and temporal lobe (26%), with the internal capsule region also showing significant numbers (27%). According to the TOAST classification, the most prevalent cause of stroke in this study was undetermined etiology with two or more causes, accounting for 32% of cases, followed by large artery atherosclerosis, which accounted for 30%. Cardioembolic stroke was identified in 11% of the patients, with 4% due to atrial fibrillation, 3% due to acute myocardial infarction, 3% due to rheumatic valvular heart disease, and 1% due to infective endocarditis. Conclusion This study highlights the significant prevalence of hypertension, smoking, alcohol consumption, and hyperhomocysteinemia as major risk factors for stroke. Ischemic strokes were predominant, with high occurrences in the cerebral lobes and gangliocapsular region. These findings emphasize the need for targeted prevention strategies, including managing hypertension and lifestyle modifications such as smoking cessation and reducing alcohol consumption, to mitigate the risk of stroke. Effective management of blood pressure, lipid levels, and blood glucose is crucial for stroke prevention. Recognizing gender-specific differences and addressing comorbidities through an integrated approach can enhance patient outcomes and reduce the burden of stroke.

Delayed iatrogenic atrial septal defect after implantation of a bicaval prosthesis device for the treatment of tricuspid regurgitation.

We present the case of a 71-year-old woman with rheumatic valvular disease who underwent mitro-aortic mechanical valve replacement and tricuspid annuloplasty in 2011. She required a dual-chamber pacemaker in 2012 and developed severe tricuspid regurgitation (TR), leading to percutaneous annuloplasty with Cardioband® system in 2021.

An Autopsy Case of Calcific Aortic Valve Disease in Sudden Death of a Young Man

Calcific aortic valve disease (CAVD) is an uncommon disease in young adults, unless there is a congenital anomaly in the aortic valve. We report a case of CAVD identified during the autopsy of a 26-year-old male soldier who died in his room while sitting on a chair. Macroscopic examination revealed multiple nodules in the semilunar cusps of the aortic valve, and that the commissure of semilunar valve cusps was slightly fused. Under microscopic examination, fibrotic nodules with neovascularization were identified in the fibrosa layer of the aortic valve, although neither calcification nor chronic inflammation were identified in the fibrotic nodule. Mitral valve prolapse and left ventricular hypertrophy with interstitial fibrosis were also identified. Microscopic examination of CAVD typically shows calcified nodules in the fibrosa layer of the valve, but fibrosis alone, without calcification, can be observed in the early stage of the disease. Death from CAVD is rare in young adults, so careful examination must be taken not to misdiagnose this condition with rheumatic valvular disease, which is relatively common in this population.

Simple Criteria, Yet the Dearth Utilization-Antithrombotic Management Practice among Atrial Fibrillation Patients at Hawassa University Comprehensive Specialized Hospital, Hawassa, Sidama, Ethiopia.

Atrial fibrillation (AF) is associated with significant mortality and morbidity from stroke and thromboembolism. Despite the availability of effective oral anticoagulation medication, AF patients remain at a high risk of stroke if not treated properly. The purpose of this study was to evaluate antithrombotic therapy practices in patients with AF in the adult cardiac clinic at Hawassa University Comprehensive Specialized Hospital (HUCSH). It was a retrospective document review study. Total charts of 119 patients who had follow-up at the adult cardiac clinic with a history of documented AF from January 1 to December 30, 2018, were included. Indicators for antithrombotic therapy based on the congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74, and sex category (female) (CHA2DS2-VASc) score were recorded. A p value of 0.05 was considered statistically significant. Data analysis was done using SPSS 23 software. In this study, about 55% of patients with AF were receiving the appropriate antithrombotic treatment. The patients were 48 ± 18.2 years old. Of these, 70% were women. The most frequent underlying cardiac etiology was chronic rheumatic valvular heart disease (50%), followed by cardiomyopathy (14%). In nonvalvular AF, the mean CHA2DS2VASc score was 4.0 ± 1.07. In valvular AF compared to nonvalvular AF, the need for appropriate antithrombotic therapy was substantially greater (p 0.0001). Only 8 (13.6%) of the warfarin-using patients had adequate anticoagulation. The study's findings in regard to antithrombotic usage and maintenance of appropriate antithrombotics for stroke prevention in our patients revealed a discrepancy between recommendations and practice. Therefore, we demand that patients with AF who meet the criteria utilize antithrombotics properly to prevent stroke. Warfarin-taking patients' subpar optimum anticoagulation has to be addressed. Lastly, we advocate proper CHA2DS2-VASc score utilization for nonvalvular heart disease. A regular INR follow-up is also advised for patients who have started taking warfarin.

Real-world insights on anticoagulation therapies in non-valvular atrial fibrillation: a comprehensive electronic health record-based study using natural language processing and machine learning

Abstract Background Limited evidence exists regarding real-world practices and outcomes of oral anticoagulation in patients with Non-Valvular Atrial Fibrillation (NVAF). Purpose To conduct a retrospective real-world data (RWD) study using Natural Language Processing (NLP) and Machine Learning (ML) on Electronic Health Records (EHRs) to evaluate the efficacy and safety of Direct Oral Anticoagulants (DOACs) and vitamin K antagonists (VKAs) in NVAF patients. Methods Retrospective study in 15 Spanish hospitals between 2014-2020 including adult NVAF patients treated with oral anticoagulants without anticoagulation history, recent thrombotic events, rheumatic mitral valvular heart disease, mitral valve stenosis, venous thromboembolism, nor pregnancy. We employed EHRead®, a free text analysis engine utilizing NLP and ML to extract RWD from EHRs based in SNOMED CT (standardized coding system). Free-text information was extracted and organized in an anonymized database for population-based descriptive and comparative analysis. After matching patients using propensity-score matching (PSM), we used Kaplan-Meier curves to compare VKA vs DOAC efficacy on thrombotic prevention, safety, and mortality. Results After evaluating 138,773,332 EHRs from 4.6 million patients, 44,292 NVAF patients were included; 35,267 (79.6%) treated with VKA and 9,025 (20.4%) with DOAC. Half of them were men (53.0%) with a mean (SD) age of 76.3 (12.7) years. VKA-treated patients tended to be older, with more cardiovascular comorbidities and higher CHA2DS2-VASc scores than DOACs-treated patients (Table 1). Using PSM, 8,930 patients were matched per subgroup with standardized mean differences below 10% for all confounders. The comparative analysis showed that DOAC-treated patients had a significant lower risk of thrombotic, minor bleeding events, and mortality than VKA-treated ones, with no significant differences in major bleeding (Figure 1). Conclusion The application of NLP and ML allowed us to create an extensive, plausible, and detailed database of Spanish NVAF patients from RWD in EHRs. In our cohort, we found a higher efficacy and lower mortality and minor bleeding events with DOACs over VKAs, without differences in major bleeding events. This study was sponsored by Pfizer and Bristol Myers Squibb. JCS, MA & CS were paid consultants to Pfizer and Bristol Myers Squibb in connection with the development of this abstract. CAC & LMS are employes of the SAVANA who were paid consultants to Pfizer and Bristol Myers Squibb in connection with the development of this abstract. DA & SFC are employees of Pfizer.Table 1Figure 1

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.

Contemporary spectrum, characteristics, and outcomes of adult patients with rheumatic valvular disease in China: Insights from the China-VHD study

BackgroundRheumatic valvular disease (RVD) represents a significant health concern in developing countries, yet a scarcity of detailed data exists. This study conducts a comprehensive examination of RVD patients in China, exploring aspects of the disease's spectrum, characteristics, investigation, management, and outcomes. MethodsThe China Valvular Heart Disease (China-VHD) study, a nationwide, multicenter, prospective observational study, enrolled 13,917 adults with moderate-to-severe valvular heart disease from April to June 2018. Among these, 2402 patients with native RVD (19.7% of native VHD patients) were analyzed. ResultsAmong the RVD patients, the median age was 57 years (interquartile range 50–65), with 82.5% falling within the 40–70 age range; females were notably predominant (63.9%). Rheumatic etiology prevailed, particularly in southern regions (48.8%). Multivalvular involvement was observed in 47.4% of RVD cases, and atrial fibrillation emerged as the most common comorbidity (43.2%). Severe RVD affected 64.2% of patients. Valvular interventions were undertaken by 66.9% of RVD patients, predominantly involving surgical valve replacement (90.8%). Adverse events, encompassing all-cause mortality and heart failure hospitalization, occurred in 7.3% of patients during the 2-year follow-up. Multivariable analysis identified factors such as age, geographical region, low body mass index, renal insufficiency, left atrial diameter, and left ventricular ejection fraction <50% (all P < 0.05) associated with adverse events, with valvular intervention emerging as a protective factor (HR: 0.201; 95%CI: 0.139 to 0.291; p < 0.001). ConclusionsThis study delivers a comprehensive evaluation of RVD patients in China, shedding light on the spectrum, characteristics, investigation, management, and outcomes of this prevalent condition.

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.

Clinical and Evolutionary Profile of Patients with Rheumatic Valvulopathy Operated Versus Not Operated in Chad

Introduction: The aim of this study was to describe the clinical and evolutionary profile of patients with rheumatic valvulopathy, operated versus non-operated in Chad. Patient and methods: This was a prospective, multicenter cohort study carried out in the cardiology departments of the National Reference University Hospital Centre, cardiology Department, Renaissance University Hospital Center, and Bon Samaritain University Hospital, of N’Djamena city. It was spread over a six-year period, from January 1, 2015, to December 31, 2020. Were included in the study, all patients who had been seen on an outpatient basis and/or hospitalized for rheumatic valvular disease in the aforementioned in the aforementioned during the study period. The clinical and evolutionary characteristics of operated patients were compared with those of non-operated patients using, as required, Pearson’s chi2 test, Fisher’s exact test or Student’s t-test. The threshold of statistical significance was p&lt;0.05. Results: A total of 80 patients (22%) had undergone surgery out of the 364 included. Valve replacement by mechanical prosthesis accounted for 77% of procedures, and valve plasty for 45%. The mean age of operated patients was 33 vs. 31 for non-operated patients (p=not significant NS). Female gender was found in 57% of operated patients vs. 52% of non-operated patients (p=NS). Dyspnea on exertion was present on admission in 65% of operated patients vs. 82% of non-operated patients (p&lt;0.001). LVEF in operated patients was 61% vs 59% in non-operated patients (p=NS), mean LV end-diastolic diameter was 53.2 mm vs. 54.7 mm (p=NS) and PAPs were 43 mmHg vs 54 mmHg (p=0.0001). During follow-up, 36% of operated patients vs. 47% of non-operated patients had a hemodynamic complication (p=0.07), 12% of operated patients had a thromboembolic complication vs. 5% of non-operated patients (p=0.01), 13% of operated patients had atrial fibrillation vs. 15% of non-operated patients (p=0.12). Ten (10) deaths (12%) were recorded among operated patient’s vs 28 deaths (10%) among non-operated patients (p=NS). Conclusion: Morbidity and mortality in patients with rheumatic valvular disease remain high, even in patients undergoing surgery. even in patients who have undergone surgery. While there is a need to make surgery accessible to as many patients as possible, good therapeutic education and improvement of the patient's care pathway are essential. Those are the keys to effective, safe care.

Abstract WP283: Association of High-Risk Cardioembolic Sources on Cardiac CT With Acute Ischemic Stroke: A Case-Control Study

Background: Cardiac CT is increasingly used to detect a source of cardioembolism in stroke patients. We assessed the association between sources of embolism on cardiac CT, which were predefined as high-risk, and acute ischemic stroke. Methods: We analyzed data from Mind the Heart, a prospective, single-center, observational cohort study, and included consecutive patients with a suspected stroke who underwent ECG-gated cardiac CT during the initial stroke imaging protocol. Cases were patients with a final diagnosis of acute ischemic stroke (AIS), established by an adjudication committee. Controls were patients with stroke mimics (SMi). We excluded patients with a transient ischemic attack. Cardiovascular radiologists diagnosed structural high-risk sources of cardioembolism on cardiac CT according to predefined criteria. High-risk sources on cardiac CT were: cardiac thrombi, signs of endocarditis, recent myocardial infarction, prosthetic valve abnormalities, atrial myxomata and signs of rheumatic valvular disease. We used logistic regression, adjusting for age, sex, history of atrial fibrillation, and history of myocardial infarction. Results: Of 607 included patients, 452 had AIS (74%, median age 72, 59% male) and 155 had a SMi (26%, median age 70, 46% male). Diagnoses in the SMi group were: seizures (45/155, 29%) peripheral vestibulopathy (22/155, 14%), functional neurologic symptoms (16/155, 10%), benign headache disorder (8/155, 5%), intoxication (7/155, 5%), and other diagnoses (57/155, 37%). Cardiac CT detected a structural high-risk cardioembolic source in 52/452 AIS patients (12%) and in 5/155 SMi patients (3%, three patients with seizures, one with peripheral vestibulopathy and one with traumatic brain injury, aOR: 4.1, 95%CI 1.7-12.1). Cardiac thrombi were the most commonly observed high-risk sources of embolism and were detected in 38 (8%) AIS patients and in 2 (1%) SMi patients (aOR 7.0, 95%CI 2.1-43.9). Discussion and conclusion: A high-risk source of cardioembolism was detected on cardiac CT four times more often in patients with acute ischemic stroke than in patients with a stroke mimic. These data substantiate the clinical relevance of using acute CT to search for sources of cardioembolism in ischemic stroke patients.

Valvulopathies of Rheumatic Origin: Management and Complications

Objective: The objective of this study is to gather information and studies about valvular heart disease of rheumatic origin and its clinical repercussions, management and complications. Methods: Integrative review, carried out between August 2024, using the digital library Scientific Electronic Library Online (SciELO), the Virtual Health Library (VHL) and PUBMED in the databases using the Boolean operators: AND and OR. The results were obtained through management with the Rayyan 16 QCRI application and were structured in PRISMA flowcharts. Results: With the search in the databases, 219 articles were found, of which 122 were selected for reading and, according to the objective of the present work, 7 articles were included in the research. Conclusion: In the studies observed, it is concluded that rheumatic valvular disease is a high-impact condition on the quality of life of patients who suffer from them and who influence in one way or another in the development of a country, as many manifest themselves in ages at which the person is economically active and the onset and exacerbations of symptoms translate into frequent work incapacity, hospitalizations and even more so if a surgical intervention is planned. It is important that the identification of clinical patterns by health professionals, with the early diagnosis and timely treatment.

Prevalence and pattern of rheumatic valvular heart disease in Africa: Systematic review and meta-analysis, 2015-2023, population based studies.

Rheumatic heart disease is a global health concern with a persistently high incidence in developing countries, including Africa. It has a significant economic, morbidity, and mortality burden, particularly for children and young adults during their most productive years. However, in the last ten years, the extent of its impact in Africa has remained unclear. Limited studies conducted on the continent have reported diverse prevalence rates of rheumatic heart disease. As a result of these, the study aimed to aggregate and synthesize findings from population-based studies to offer a comprehensive and updated overview of rheumatic heart disease prevalence and pattern at the African level. The studies were identified through a comprehensive literature search of the electronic databases, including PubMed, Google Scholar, Web searches, and manual searches. The descriptive information for the study is presented in the table, and the quantitative results are presented in forest plots. The Cochrane Q test and I2 test statistic were used to test heterogeneity across studies. The pooled estimate of the prevalence of rheumatic heart disease was computed by a random effects model. Out of 22 population-based studies analyzed using random-effects, the pooled magnitude of rheumatic heart disease was found to be 18.41/1000 (95% CI: 14.08-22.73/1000). This comprised definite cases of rheumatic heart disease at a prevalence rate of 8.91/1000 (95% CI: 6.50-11.33/1000) and borderline cases at a prevalence rate of 10.69/1000 (95% CI: 7.74-13.65/1000). The combined prevalence of rheumatic heart disease in males was almost equivalent to that in females. Mitral valve regurgitation was the predominant valve affected by rheumatic heart disease, accounting for approximately 73%. This study analysis found the prevalence of rheumatic heart disease in Africa is high. Because of this, policies and interventions should give attention to prioritize continuous population based active surveillance for early detection of cases to the reduction of rheumatic heart disease sequel, especially in the children and adolescent population.

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.

Echocardiographic features predict the performance of transthoracic echocardiography in ruling out infective endocarditis: a 5-year study

Abstract Background Transoesophageal echocardiography (TOE) remains the gold standard imaging modality to aid in the diagnosis of infective endocarditis (IE), but is resource intensive and confers patient risk. Transthoracic echocardiography (TTE) is a more accessible alternative, but previous studies report varying ability of TTE to effectively rule out disease. As a result, negative TTE is often still followed with TOE when clinical suspicion remains. However, these studies did not account for TTE quality and other echocardiographic features within the TTE that may decrease its diagnostic utility and thereby reduce its ability to effectively rule out disease. Understanding the risk of missing IE for a given negative TTE could avoid the need for subsequent TOE. Purpose Our aim is to devise and test the validity of a scoring system which can stratify TTEs by quality to predict TTE performance and inform the decision for whether follow-up TOE is necessary. Methods In this retrospective single-centre study, the Predictor of TTE Performance (PTP) scoring system was developed and applied to patients undergoing both TTE and TOE for suspected IE at our tertiary centre between May 2017 and May 2022. Within the scoring system, a point was allocated for the presence of each of the following on TTE: a mobile echodensity; poor image quality; more than mild regurgitation; a prosthetic valve or prosthetic intracardiac material; and other valvular abnormalities. Poor image quality was defined as any TTE that was unable to achieve good endocardial visualisation from at least two views. Valvular abnormalities warranting a point included congenital abnormalities such as bicuspid aortic valve and acquired abnormalities such as rheumatic valvular disease, mitral valve prolapse and valvular stenosis. The negative predictive value (NPV) for TTEs in each score category was analysed using TOE as the gold standard. Results A total of 362 patients with paired TTE/TOE were included for analysis. 60 (16.6%) had positive TOE, with the overall NPV of TTE being 88.5% (95% CI: 84.6–91.5%). Using the PTP scoring system, patients were stratified into low-risk (score of 0, n = 116), moderate-risk (score of 1, n = 140) and high-risk (score greater than 1, n = 106) groups. Increasing PTP score was associated with poorer TTE performance, with the low-risk, moderate-risk and high-risk categories having NPVs of 98.3% (95% CI: 93.9–99.7%), 90.2% (95% CI: 83.9–94.2%) and 72.3% (95% CI: 61.8–80.8%) respectively. Conclusion The ability of TTE to exclude IE is excellent when patients have no echocardiographic features that reduce TTE quality or predict increased risk for endocarditis. In patients with a low PTP score, negative TTE may render follow-up TOE unnecessary.

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.