Rheumatic Valvular Disease Research Articles

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

Spectrum of intracardiac thrombi in different clinical scenarios at a tertiary care center

Cardiologists frequently encounter intracardiac thrombi in the course of their work. Along with tumor and vegetation, it is one of the most frequent differential diagnoses for intracardiac masses. Cardioembolic stroke patients frequently have intracardiac thrombi in the left ventricle. Although the potential for cerebral emboli persists in a large population of patients with chronic left ventricular (LV) dysfunction, the risk of LV thrombus formation is highest during the first 3 months after acute myocardial infarction. The main risk factors for the development of left atrial thrombi are rheumatic valvular disease, especially mitral stenosis and atrial fibrillation. Right heart chamber thrombi may develop in situ or occur when peripheral venous clots that are on their way to the lungs become stuck, leading to acute pulmonary embolism, and their incidence ranges from 4% to 18%. We are presenting five cases that represent a broad range of clinical circumstances involving intracardiac thrombus. When performed during systole and diastole, echocardiography can detect thrombus as a discrete, echo-dense mass with clearly defined borders that is separate from the endocardium. Since dimensions, shape, regularity or irregularity, and homogeneity are all characteristic features that define the embolic risk and therapeutic management, the morphology and structure of thrombi should be carefully assessed.

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.

Efficacy and safety of transcatheter aortic valve replacement in the treatment of severe aortic stenosis

Objective: To investigate the efficacy and safety of transcatheter aortic valve replacement (TAVR) in the treatment of severe aortic stenosis. Methods: The clinical data of patients with severe aortic stenosis who underwent TAVR at the People's Hospital of Xinjiang Uygur Autonomous Region between September 2016 and September 2022 were retrospectively analyzed. Changes in aortic transvalvular pressure gradients, valve orifice area, and activity tolerance of patients before and after the surgery were compared. Moreover, postoperative complications and follow-up results from 30 days to 6 years after the surgery were recorded. Results: A total of 76 patients were included in the study (50 males and 26 females), with an average age of (71.3±7.6) years, including 16 rheumatic valvular diseases, 60 senile degenerative diseases, 46 bicuspid valves and 30 tricuspid valves. The success rate of the operation was 96.1% (73/76). Compared with that before the operation, the mean aortic transvalvular pressure gradients decreased [(8.5±2.8) mmHg vs (68.5±19.2) mmHg (1 mmHg=0.133 kPa),P<0.001], but the valve orifice area increased [(1.91±0.31) cm2 vs (0.65±0.21) cm2, P<0.001]. Likewise, six-minute walking test (6MWT) showed that walking distance was longer after the surgery [(430±13) m vs (201±28) m, P<0.001]. There were 1 case of retroperitoneal hematoma, 1 case of stricture balloon dilatation after femoral artery suture concomitant with postoperative puncture site infection, 1 case of femoral artery surgical incision, 2 cases of valve-in-valve (ViV) and 5 cases of perivalvular leakage (4 cases were mild and 1 case was moderate) after the surgery, respectively. Moreover, acute left main artery occlusion during operation occurred in 1 case, ventricular rupture during operation occurred in 1 case and the patient was transferred to valve replacement surgery and finally dead, delayed coronary artery occlusion and death happened in 1 case, and all of the above-mentioned 3 cases were due to surgical failure. Postoperative pacemaker implantation due to third-degree atrioventricular block was performed in 5 cases. There were 1 case of pulmonary embolism, 1 case of transient right limb disorder, 1 case of gastrointestinal bleeding and 1 case of urethral bleeding after the surgery, respectively. The patients were followed up for (1.0±0.1) years (30 days to 6 years), and the results showed that 2 cases died, including 1 case died suddenly at home (the cause of death was unknown) and 1 case died of acute heart failure 8 months after the surgery. Chronic heart failure occurred repeatedly in 6 cases. The quality of life of other patients improved significantly. Conclusion: TAVR is effective and safe for patients with severe aortic stenosis.

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).

EPIDEMIOLOGY OF CARDIOVASCULAR MORTALITY IN PATIENTS AGED UNDER 60 IN THE CARDIOLOGY DEPARTMENT FROM SEPTEMBER 2019 TO AUGUST 2022

Objective: The objectives of our study were to study the cardiovascular mortality of the active population, to analyze the epidemiological, clinical, paraclinical aspects, the complications and to determine the etiological aspects related to this mortality. Design and method: This was a descriptive and analytical retrospective study over 3 years from September 2019 to August 2022 in patients aged at least 15 and at most 60 years old hospitalized and deceased in the cardiology department of the General Idrissa POUYE hospital in Dakar. The data was recorded on a survey sheet and entered into the EPI Info 7.2.5.0 software, and the analysis carried out by the R. Studio software version 2022.12.0 + 353 and Excel 2019. The significance threshold retained was a p value &lt; 0.05. Results: Our study enrolled 73 dead patients, either a specific mortality of 8.8% and a proportional mortality of 39%. The predominance was male with a male/female sex ratio of 1.2. The average age was 44 years old. The cardiovascular risk factors found were dominated by physical inactivity (76.7%), hypertension (28.8%) and smoking (21.9%). Physical examination found signs of heart failure in 63% of cases. Biology noted above all anemia (59%), impaired renal function (25%) and high troponin in 87% of cases. The electrocardiogram essentially found arrhythmias (46.6%). The chest X-ray mainly showed cardiomegaly (49.3%), pleuro-pneumonopathy (33%). Echocardiography showed altered LVEF (81%), PAH (78%) and kinetic disorders (40%). Coronary angiography, performed in 4 patients, showed 2 bi-truncal lesions, 1 mono-truncular and 1 tri-truncular. The most used treatments were diuretics (63%), amines (47.9%), AVKs (42%), BBs (36%), ACE inhibitors or ARA2 (31%). Thrombolysis was performed in 5 SCA and 4 PE and angioplasty in 4 patients. The analytical study shows that the data most related to mortality were age, socio-economic level, ischemic heart disease (p = 0.034), rheumatic valvular disease, pulmonary embolism (p = 0.034), hypertension (p = 0.009), smoking (p = 0.011), diabetes (p = 0.011), dyslipidemia, bed rest (p = 0.001), morbid obesity (p = 0.001) and infection with COVID-19 (p = 0.017). Conclusions: The predominance of ischemic heart disease, pulmonary embolism and valvular heart disease in premature mortality statistics should encourage strengthening cardiovascular prevention.

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.

Aetiology and Clinical Profile of Giant Left Atrium – An Observational Study

Background: The predominant cause of giant left atrium (GLA) is rheumatic mitral valvular disease. GLA is commonly defined echocardiographically by measuring the left atrial diameter (LAD). In the context of changing epidemiology of rheumatic heart disease (RHD) globally, and introduction of left atrial volume index (LAVI), the aetiology of GLA and utility of LAVI for defining GLA may be necessary. Methods: The prospective observational study was carried out at a dedicated tertiary care cardiac centre of a developing country to know the aetiology and clinical pattern of GLA over 8 years. GLA was defined echocardiographically as a left atrium (LA) having a diameter ≥80 mm in the left parasternal long-axis view. Follow-up was made over the telephone. Results: Thirty cases of GLA were diagnosed over 8 years from 2013 to 2021. Twenty two were due to rheumatic heart disease (RHD), 7 due to MVP, and 1 due to flail anterior mitral leaflet. Mean LAD was 92.13 ± 16.72 mm, and the mean LAVI was 288.77 ± 134.40 ml/m2. LA thrombus was present in 5 patients, 6 had spontaneous echo contrast (SEC) in LA, 2 had both LA thrombus and SEC. Mean follow-up was 0.99 ± 1.06 years. Out of 15 patients, 5 died, while 10 were alive. Mean survival was 1.8 ± 1.17 years, ranging from less than 1 year to 4 years. Conclusion: RHD continues to be the predominant cause of GLA; however, MVP is also important. The cut-off value of LAVI for defining GLA needs further study. Cardiovasc j 2023; 15(2): 151-158

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.

Comparison of Pericardial and Prosthetic Rings for Mitral Repair: Are Pericardial Rings Durable in the Mid- to Long-Term Follow Up?

While prosthetic rings are commonly used for mitral valve repairs, autologous pericardium is an alternative ring material that can be used in these procedures. In this report, we aim to present a comparison of two types of rings used for mitral repair. Between January 2005 and January 2009, 107 patients who underwent mitral valve repair surgery were analyzed. Patients were divided into two groups, according to the type of ring that was used for mitral annular stabilization. Glutaraldehyde-treated pericardial rings were used for 31 patients (group 1), whereas prosthetic rings were used for 76 patients (group 2). Survival, freedom from reoperation, recurrent mitral regurgitation, and the effects of rheumatic mitral disease on these parameters were evaluated and compared for both groups. Follow-up time for our cohort was 4.24±0.4 years. There were four and seven late mortalities in groups 1 and 2, respectively, and five reoperations in each group. There was no significant difference between the groups, in terms of survival, freedom from reoperation, and recurrent mitral regurgitation (log-rank analyses for both groups were P = 0.777, P = 0.346, and P = 0.781, respectively). There was no significant difference in freedom from reoperation and recurrent mitral regurgitation for both groups, in terms of underlying rheumatic valvular disease and other types of pathology. Pericardial ring annuloplasty shows to be a considerable alternative technique for mitral valve repair procedures in the mid- to long-term follow up. Rheumatic mitral valves had poor outcomes, when compared with other types of structural valvular pathologies in cases where pericardial rings were used in the repair procedure.

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.

Hypertrophic Cardiomyopathy with Massive Cardiomegaly in Indian Young Adult: Autopsy Case Report

The sudden death of a bread winning adult in the family is devastating for any family. Even worse is when the adult dies in his young adulthood. Cardiovascular pathologies dominate the causes of sudden deaths in young adults more than the central nervous and respiratory systems. The enlarged heart or cardiomegaly at autopsy is the first indication of such cardiac pathology. Cardiomegaly may result from various pathologies such as hypertension, cardiomyopathies, rheumatic valvular diseases, etc. The resultant increase in the heart's weight due to the cardiac myocytes' adaptive response to meet the demand in the above conditions is known as cardiac hypertrophy. Although multiple reports on cardiomegaly were described from clinical settings based on imaging modalities like X-ray or echo cardiography, the data is lacking from forensic autopsies, especially from India. This is the first case report describing a young adult male of 30 years old who died due to massive cardiomegaly with a heart weight of 878 g from hypertrophic cardiomyopathy.

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.

Clinical and demographic profile of patients of rheumatic valvular heart disease

Background: Rheumatic heart disease (RHD) is a preventable structural heart disease involving cardiac valves affecting the young population of productive age-group having considerable morbidity and mortality due to associated complications. Aims and Objectives: To evaluate the clinic-demographical characteristics and complications of RHD patients and thus to build up a RHD valvular registry. Materials and Methods: In this study, we enrolled 570 consecutive patients diagnosed with rheumatic valvular affection as defined by echocardiographic criteria, and studied their demographic, valvular pathology, symptomatology, prophylaxis and complication profile. Results: Female patients dominated the population in number, mitral being the most affected valve, mitral stenosis the commonest lesion. Newly diagnosed patients constituting 20% of study population. One-fourth of the patients gave a proper history of acute rheumatic fever and oral prophylaxis was noted to be more compliant than parenteral. Case proportionality ratio for atrial fibrillation was highest with severe MS with AR and for pulmonary hypertension with severe MR with or without MS. Conclusion: RHD is a preventable disease and health professionals and policy making institutions at all levels should strive in unison to mitigate its incidence, disease severity and complications.

Long-Term Outcomes of the Maze Procedure Combined with Endoatriectomy for Patients with Calcified Left Atria.

Left atrial calcification (LAC) is found in long-lasting rheumatic valvular disease and is almost always accompanied by atrial fibrillation (AF). In the presence of LAC, endoatriectomy is required when performing the maze procedure. However, the technical feasibility of endoatriectomy and the long-term outcomes of the maze procedure in patients with LAC are uncertain. The medical records of 18 consecutive patients who underwent combined endoatriectomy and maze procedure were analyzed retrospectively. Accompanying operations were mitral valve replacement (n = 16) and commissurotomy (n = 2). There was 1 operative death from sepsis following mediastinitis. When patients were divided into "broad" (n = 11) and "limited" (n = 7) groups, with the extent of LAC either greater or less than half of the left atrium, respectively, there was no intergroup difference in postoperative complications. During follow-up (median, 11.4 years), AF recurred in 11 patients. At the last follow-up visits, electrocardiography revealed significantly fewer patients in the broad group maintaining sinus rhythm (1/11 vs 4/6, P = 0.03). The 10-year AF recurrence-free survival rates were 13.9% and 66.7% in the broad and limited groups, respectively (P = 0.01). The maze procedure combined with endoatriectomy seems technically feasible with acceptable long-term rhythm outcomes if the LAC extent is limited.

Sex Differences in the Etiology and Burden of Heart Failure across Country Income Level: Analysis of 204 Countries and Territories 1990-2019.

Heart failure (HF) is a global epidemic. To assess global sex differences in HF epidemiology across country income levels. Using Global Burden of Disease (GBD) data from 204 countries and territories 1990-2019, we assessed sex differences in HF prevalence, etiology, morbidity, and temporal trends across country sociodemographic index or gross national income. We derived age-standardized rates. Of 56.2 million (95% uncertainty interval [UI] 46.4-67.8 million) people with HF in 2019, 50.3% were females and 69.2% lived in low- and middle-income countries; age-standardized prevalence was greater in males and in high-income countries. Ischemic and hypertensive heart disease were top causes of HF in males and females, respectively. There were 5.1 million (95% UI 3.3-7.3 million) years lived with disability, distributed equally between sexes. Between 1990-2019, there was an increase in HF cases, but a decrease in age-standardized rates/100,000 in males (9.1%, from 864.2 to 785.7) and females (5.8%, from 686.0 to 646.1). High-income regions experienced a 16.0% decrease in age-standardized rates (from 877.5 to 736.8), while low-income regions experienced a 3.9% increase (from 612.1 to 636.0), largely consistent across sexes. There was a temporal increase in age-standardized HF from hypertensive, rheumatic and calcific aortic valvular heart disease, and a decrease from ischemic heart disease, with regional and sex differences. Age-standardized HF rates have decreased over time, with larger decreases in males than females; and with large decreases in high-income and small increases in low-income regions. Sex and regional differences offer targets for intervention.