Rheumatic Valvular Heart Disease Research Articles

The Changing Etiology Of Infective Endocarditis

ABSTRACT: One hundred four patients with Chronic Rheumatic Heart Disease were investigated to find out the prevalence of bacterial endocarditis in this group and to document the causative organ jam s and their sensitivity pattern. INTRODUCTION: Since the introduction of antibiotics in the mid forties, endocarditis has been going through an evolution. The changing etiology of endocarditis has been the subject of several reports.1’2 , ‘ According to these reports, in the economically advanced countries the age has shifted from the 2nd and 4th decade to the 5th and 6th decade with a mean at about 55 years. The etiology of the disease has changed with Strep. MATERIAL AND METHODS: All patients with chronic valvular rheumatic heart disease admitted consecutively to the medical C Ward of Khyber Hospital Peshawar were included in the study. After complete clinical assessment, samples of blood were taken from each patient on three consecutive days for blood culture. RESULTS: Of the 104 patients studied 60 were males and 44 females. A positive blood culture was obtained from 23 cases. None yielded a positive result in all three blood culture samples, and only one culture each was positive in all. In 10 (43.4%) a positive culture was obtained from the first culture bottle, in 5 (21.7%) the 2nd blood sample yielded a positive culture and in 8 (34.8%) the 3rd sample was the source of a positive culture. DISCUSSION: The results of the study show that the age distribution of our cases is the same as that of the preantibiotic-era in the developed countries. 1 5 Thirty-nine per cent of our endocarditis cases were in the 2nd and 3rd decade and 56.5% in the 3rd and 4th decade. The sex ratio in our cases is similar to that reported by Lerner and Wienstein (1966) and Garvey and Neu (1973). Although in our hospital admitted cases the number of females is generally lower than that of males, however, we have taken into account the sex ratio in all cases of rheumatic heart disease and have found that in the endocarditis cases the ratio is higher. ACKNOW LEDGEMENT: The authors are grateful to Dr. Tasleem Akhtar, Research Director, PMRC Research Centre, Khyber Medical College, for help in the preparation of this report and to Miss Mubarik Begum for typing the manuscript. The study was approved and financed by the Pakistan Medical Research Council.

RCD: a toolkit for rheumatic valvular and congenital heart defect diagnosis

Rheumatic valvular heart disease (RVHD) and congenital heart defect (CHD) are one of the major causes of child deaths in Pakistan. According to a survey, prevalence of RVHD in Pakistan is among the highest in the world and 3.9 % of children suffer from CHD annually. If the diagnostic treatment is done earlier, then the diseases can be controlled before reaching the critical stage. Due to the lack of physicians in poor countries, there is a need for an automatic diagnostic toolkit for congenital and RVHD so that the early and accurate diagnosis of disease could be made possible even in the absence of expert physicians. In this paper, a diagnostic toolkit for rheumatic valvular and congenital heart defect is designed and developed using feed-forward back-propagation network based on symptomatic and clinical parameters. The system is built using MatLab toolkit for neural networks and graphical user interface.

Rheumatic heart disease in Port Harcourt, Nigeria: clinical, demographic and echocardiographic features

Background : Rheumatic heart disease is endemic in developing countries especially sub- Saharan Africa. However, there is a growing impression that this disease has been eliminated. Availability of echocardiography with colour flow Doppler facilities has significantly improved diagnosis of cardiac diseases. This study aims at documenting the clinical and echocardiographic pattern of rheumatic heart disease in adult patients in Port Harcourt. Methods : A one-year (April 2009 to March2010) prospective analysis of the clinical profile and echocardiographic features of all the patients who had echocardiographically confirmed rheumatic valvular heart disease from our cardiac laboratory was undertaken. Trans-thoracic echocardiography was done using M-mode, two-dimensional, pulsed wave, continuous wave and colour flow Doppler techniques. Results : Twenty two cases of rheumatic valve disease were identified, thirteen males and nine females (M: F=1. 4:1). The age range was 17years to 68years with a mean age of 41.32 ± 16.14 years. The mean systolic blood pressure was 125.48 ± 26.46mmHg and mean diastolic blood pressure was 73.81± 18.57mmHg. The mitral valve was the most commonly involved valve (95.45%), one patient (4.54%) had only aortic valve involvement, eight (36.36%) had aortic and mitral valve involvement while thirteen (59.09%) had only mitral valve involvement. Fifteen patients presented in heart failure, three presented with palpitation and four presented with recurrent praecordial chest pain. Conclusion : Rheumatic heart disease remains prevalent among adult Nigerians in Port Harcourt presenting with heart disease. Males predominate and they present commonly in heart failure.

Does Gender Affect the Outcomes of Multiple Valve Heart Surgery?

Background: Multiple valve surgery exposes patients to major morbidity and mortality. Little is known about the effect of gender on the outcomes of multiple valve surgery. Methods: In 69 patients who had multiple valve surgery for rheumatic valvular heart disease, 51 patients had mitral and aortic valve replacement, 9 patients had mitral and aortic valve replacement and tricuspid valve repair, 4 patients had mitral valve replacement and tricuspid valve repair, 4 patients had mitral and tricuspid valve repair, and 1 patient had mitral and tricuspid valve replacement. Outcomes were evaluated with univariate analysis. Results: Women had significantly smaller body surface area and smaller left ventricular end-systolic area than men. Women and men had similar left ventricular ejection fraction and New York Heart Association functional class. Univariate analysis showed that in women (but not men), older age, atrial fibrillation, lower left ventricular ejection fraction, and New York Heart Association functional class II and III were associated with longer hospital and intensive care unit stay. In men (but not women), longer cardiopulmonary bypass time was associated with increased left ventricular end-systolic area at 12 months after surgery. Longer aortic cross-clamp time was associated with increased left ventricular end-systolic area in men but only weakly in women. Conclusion: We concluded that gender is an independent predictor of outcomes after multiple valve heart surgery.

Retrospective investigation of in-hospital patients diagnosed with chronic heart failure in Hubei province

ObjectiveTo evaluate the current status of chronic heart failure (CHF) in Hubei province and analyse the epidemiology of CHF including the general condition, aetiology and pharmacological therapy.MethodsData of in-hospital patients...

The Role of Echocardiography in the Management of Stroke

Echocardiography is increasingly being used as a screening test to identify sources of cardiogenic embolism in patients with ischemic stroke or transient ischaemic attack (TIA). However, no consensus exists presently on the utilization of this imaging facility in individuals with stroke. To evaluate the yield of transthoracic echocardiography in patients with ischaemic stroke with a view to providing guidance in its use in clinical management of stroke. One hundred and twenty-six consecutive stroke patients with 90 controls were recruited prospectively. Patients were examined echocardiographically for evidence of intramural thrombus, congenital defects, valvular heart disease, wall motion abnormalities and intra-cardiac masses using two-dimensional, m-Mode and Doppler facilities. Potential cardiac source of emboli (CSE) was identified in 23.0% of the stroke patients. Those who had CSE identified aged 53.0(20.8) years were younger (p=0.0001) than those who did not have CSE, 57.2 (13.5) years. Five (4.0%) patients had rheumatic valvular heart disease with demonstrable clots in the left atrium. On the other hand, four(3.2%) patients had RHD without thrombi seen. Two patients had biventricular thrombi. One of these patients had giant clots within the ventricles and multiple freely mobile thrombi in right ventricle without obvious cardiac structural defect. Young stroke or transient ischaemic attacks patients who have clinical signs suggesting the heart as the potential CSE should have low threshold for echocardiography. However, there is a need for rationalisation of request for echocardiography where such clinical signs are absent.

An unusual microorganism, Aerococcus viridans, causing endocarditis and aortic valvular obstruction due to a huge vegetation

Aerococcus viridans is not a common pathogen, and endocarditis due to A. viridans is very rare. A 44-year-old woman with persistent atrial fibrillation and rheumatic valvular heart disease was admitted with fever, sweating, weakness, and progressive shortness of breath. Transthoracic echocardiography (TTE) demonstrated a 8x9-mm vegetation attached to the right coronary cusp of the aortic valve, causing aortic obstruction. Blood cultures yielded A. viridans susceptible to penicillin. Despite optimal antibiotherapy, subsequent TTE controls revealed enlargement of the vegetation, reaching a size of 21x10 mm, and an increasing gradient across the aortic valve. The patient underwent successful aortic and mitral valve replacement and was stable in the postoperative period without any problem. This represents the first reported case of A. viridans endocarditis in which the size and location of vegetation caused obstruction to blood flow, indicating surgery.

Marked Regression of Aortic Plaque by Intensive Cholesterol-Lowering Therapy

A 65-year-old man with rheumatic combined valvular heart disease showed a persistent fever after cardiac catheterization. He was diagnosed with cholesterol embolism due to multiple mobile plaques in the descending thoracic aorta by transesophageal echocardiography (TEE) along with persistent eosinophilia, deteriorating renal function, and blue toe sign. He was treated with intensive cholesterol-lowering therapy for 3 years, resulting in marked regression of the aortic plaque on TEE.

Restoration of sinus rhythm in patients undergoing surgery for rheumatic valvular heart disease: is it worth the effort?

This editorial refers to ‘Efficacy of catheter ablation and surgical CryoMaze procedure in patients with long-lasting persistent atrial fibrillation and rheumatic heart disease: a randomized trial’, by X. Liu et al. doi:10.1093/eurheartj/ehq201 Acute rheumatic fever produces a pancarditis affecting the pericardium, epicardium, myocardium, and endocardium. Consequently, rheumatic heart disease (RHD) is a chronic inflammatory disorder that may involve most parts of the heart including valves and myocardial tissue. Atrial fibrillation (AF) in patients with RHD results from haemodynamic consequences of valvular or myocardial heart disease and from direct tissue injury of the atrial myocardium by the underlying inflammatory process.1 Thus, AF is highly prevalent and a major cause of morbidity including thromboembolism in patients with RHD.2,3 Prevention of AF and restoration of durable sinus rhythm might be a desirable goal in the management of patients with RHD. The efficacy and clinical value of catheter ablation in patients with structural heart disease is currently a matter of scientific debate. Reported clinical success rates following initial catheter ablation using pulmonary vein isolation (PVI) in patients with paroxysmal AF with no or minimal structural heart disease of ∼60–70%4,5 have not been … *Corresponding author. Tel: +43 77228045000, Fax: +49 8571980204, Email: Johann.Auer{at}khbr.at or auer4{at}tmo.at

Periostin advances atherosclerotic and rheumatic cardiac valve degeneration by inducing angiogenesis and MMP production in humans and rodents

Valvular heart disease (VHD) is the term given to any disease process involving one or more of the heart valves. The condition can be congenital or acquired, for example as a result of atherosclerosis or rheumatic fever. Despite its clinical importance, the molecular mechanisms underlying VHD remain unknown. We investigated the pathophysiologic role and molecular mechanism of periostin, a protein that plays critical roles in cardiac valve development, in degenerative VHD. Unexpectedly, we found that periostin levels were drastically increased in infiltrated inflammatory cells and myofibroblasts in areas of angiogenesis in human atherosclerotic and rheumatic VHD, whereas periostin was localized to the subendothelial layer in normal valves. The expression patterns of periostin and chondromodulin I, an angioinhibitory factor that maintains cardiac valvular function, were mutually exclusive. In WT mice, a high-fat diet markedly increased aortic valve thickening, annular fibrosis, and MMP-2 and MMP-13 expression levels, concomitant with increased periostin expression; these changes were attenuated in periostin-knockout mice. In vitro and ex vivo studies revealed that periostin promoted tube formation and mobilization of ECs. Furthermore, periostin prominently increased MMP secretion from cultured valvular interstitial cells, ECs, and macrophages in a cell type-specific manner. These findings indicate that, in contrast to chondromodulin I, periostin plays an essential role in the progression of cardiac valve complex degeneration by inducing angiogenesis and MMP production.

HLA Class I and Class II HLA DRB Profiles in Egyptian Children with Rheumatic Valvular Disease

Poststreptococcal sequelae, especially acute rheumatic fever/rheumatic heart disease continues to occur in significant proportions in many parts of the world, especially in less developed countries. An important factor in the study of rheumatic heart disease is the human genetic susceptibility to the disease. The aim of the present study was to detect the most prevalent HLA class I and class II types associated with risk of rheumatic heart disease in Egyptian children. Our study was performed on 100 patients with rheumatic valvular heart diseases and 71 control subjects. Patients were recruited from the Heart Institute, Embaba, Egypt. HLA typing for HLA class I was performed by serotyping and HLDR allele genotyping was performed using INNO-LiPA kits. In the study of HLA class I, there was a statistically significant increase in the B5 allele (P = 0.03; odds ratio, 3.46 [1.12-10.72]) in patients compared to controls, while B49 and B52 alleles (P = 0.004 and P = 0.02) were found in controls only. There was a statistically significant increase in HLA DR* 04-02, 3.46 (1.12-10.72) and HLA DR *10-0101 5.75 (1.27-25.98) in patients. Meanwhile HLA DR*1309120 was found only in controls (P = 0.02). Our study provides further information on the genetic predisposition for rheumatic valvular disease and the protective genotypes in rheumatic heart disease. Further insight into the molecular mechanisms of the disease will be a useful tool for predicting clinical outcome in those patients and, thus, potentially offer new means and approaches to treatment and prophylaxis, including a potential vaccine.

Is EuroSCORE applicable to Indian patients undergoing cardiac surgery?

Indian patients undergoing cardiac surgery have different demographics, clinical profile as well as risk profile, compared to the western population. The purpose of this study was to validate the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification model in Indian patients undergoing cardiac surgery in a single cardiac center. Data from 1000 consecutive adult patients undergoing cardiac surgery (coronary artery bypass grafting or valve surgery) were prospectively collected as per the EuroSCORE model. The model's validity was assessed on the basis of its calibration power (Hosmer-Lemeshow test) and discriminatory power [area under receiver operating characteristic curve]. The patients were divided into three risk groups on the basis of their EuroSCORE. The Hosmer-Lemeshow test revealed a good calibration power (P = 0.73) and the area under the ROC curve was 0.8278, suggesting a good discriminative power. The predicted mortality was similar to observed mortality in low- and moderate-risk patients but the observed mortality in high-risk patients (15.6%) was double that of predicted mortality (7.5%). The risk factors prevalent in European population were not observed in Indian population. EuroSCORE accurately predicts mortality in low and moderate-risk Indian patients undergoing cardiac surgery but is less predictive for high-risk Indian patients. Updating and improvisation of EuroSCORE by incorporation of risk factors associated with rheumatic valvular heart disease which is more prevalent in India, may enable it to accurately predict mortality in high-risk patients also.

Rheumatic valvular heart disease as seen at echocardiography in Ilorin, Nigeria

Rheumatic valvular heart disease as seen at echocardiography in Ilorin, Nigeria

Reduced bone density in patients on long‐term warfarin

Vitamin K is an essential factor for carboxylation of bone matrix protein. Low vitamin K may be associated with reduced bone mineral density (BMD). The issue of whether long-term sodium warfarin therapy as oral anticoagulant that antagonizes vitamin K, results in decreased bone density, is controversial. Our purpose in this study was to assess the effects of warfarin on BMD. We performed a case control study survey of bone density in 70 patients with rheumatic valvular heart disease 'mechanical valve replacement' on long-term warfarin compared with 103 randomly selected matched controls. There was a marked reduction in BMD (g/cm(2)) and T-score of lumbar spine between patients and controls (P = 0.048, 0.005). Duration of warfarin use was the only risk factor of significant importance respectively on spinal T-score (P < 0.03). Screening of patients on long-term warfarin for reduced bone density should be considered. We strongly suggest the prophylactic use of calcium-vitamin D supplements for these patients.

Unusual complication of a migrant pacemaker lead

We describe the case of a 74-year-old male with a history of rheumatic valvular heart disease and previous aortic and mitral valve replacements. A single-chamber pacemaker was implanted in 1994. Four years later, the electrode was found to be malfunctioning. A new right ventricular electrode was implanted and the original electrode was capped. Routine follow-up in 2008 showed that the capture threshold had increased. Further investigations showed that the original electrode had fractured into three segments. One of the fragments had migrated into the left pulmonary artery. A year later the patient had not suffered from any complications although the fragment had migrated further in to the lung. …

The surgical treatment of the rheumatic valvular heart disease with cardiac cachexia

目的 探讨并总结重症风湿性心脏病合并心脏恶病质患者围术期处理经验和特点,提高外科治疗的成功率.方法 回顾性分析近5年54例心脏恶液质瓣膜患者的围手术期治疗.结果 二尖瓣置换术17例,主动脉瓣及二尖瓣置换术35例,主动脉瓣、二尖瓣及三尖瓣置换术2例,同时行三尖瓣成形术52例,术后早期死亡4例(7.4%).结论 充分的术前准备、围术期营养支持,正确地选择好手术时机,加强术中处理,积极治疗术后并发症是提高手术疗效的关键。

Effect of single intraoperative dose of amiodarone in patients with rheumatic valvular heart disease and atrial fibrillation undergoing valve replacement surgery

Maintenance of sinus rhythm (SR) is superior to rate control in atrial fibrillation (AF). In order to achieve SR, we administered single-dose intravenous amiodarone intraoperatively and evaluated its effect on conversion of rheumatic AF to SR in patients undergoing valvular heart surgery. Patients were randomly assigned to amiodarone (n = 42) or control (n = 40) group in a double blind manner. The amiodarone group received amiodarone (3 mg/kg) intravenously prior to the institution of cardiopulmonary bypass and the control group received the same volume of normal saline. In the amiodarone group, the initial rhythm after the release of aortic cross clamp was noted to be AF in 14.3% (n = 6) and remained so in 9.5% (n = 4) of patients till the end of surgery. In the control group, the rhythm soon after the release of aortic cross clamp was AF in 37.5% (n = 15) (p = 0.035) and remained so in 32.5% (n = 13) of patients till the end of surgery (p = 0.01). At the end of first post-operative day 21.4% (n = 9) of patients in amiodarone group and 55% (n = 22) of patients in control group were in AF (p = 0.002). The requirement of cardioversion/defibrillation was 1.5 (+/-0.54) in amiodarone group and 2.26 (+/-0.73) in the control group (p = 0.014), and the energy needed was 22.5 (+/-8.86) joules in the amiodarone group and 40.53 (+/-16.5) in the control group (p = 0.008). A single intraoperative dose of intravenous amiodarone increased the conversion rate of AF to normal sinus rhythm, reduced the need and energy required for cardioversion/defibrillation and reduced the recurrence of AF within one day.

Synergistic effects of cyclic strain and Th1-like cytokines on tenascin-C production by rheumatic aortic valve interstitial cells

Tenascin-C (TN-C) is a key component of extracellular matrix (ECM) and its expression process is poorly understood during rheumatic heart valvular disease (RHVD). In this study, we found that interferon (IFN)-gamma, tumour necrosis factor (TNF)-alpha and TN-C concentrations in patients with RHVD were significantly higher than in normal controls. More IFN-gamma receptors and TNF receptors were found being expressed on rheumatic aortic valves interstitial cells than on non-rheumatic ones and their expression was patients' sera dependent. Antibodies neutralizing IFN-gamma or TNF-alpha could attenuate patients' sera-induced TN-C transcription by isolated rheumatic aortic valves interstitial cells. By application with different protein kinase inhibitors, we found that combined with cyclic strain, TNF-alpha and IFN-gamma induced TN-C transcription through the RhoA/ROCK signalling pathway. At the same time, p38 mitogen-activated protein kinase was involved in TNF-alpha and IFN-gamma induced TN-C transcription. TNF-alpha also increased TN-C mRNA level by additional PKC and ERK 1/2 activation. Our finding revealed a new insight into ECM remodelling during RHVD pathogenesis and new mechanisms involved in the clinical anti-IFN-gamma and anti-TNF-alpha therapy.

The Burden of Stroke in Pakistan

Epidemiologic literature on stroke burden, patterns of stroke is almost non existent from Pakistan. However, several hospital-based case series on the subject are available, mainly published in local medical journals. Despite the fact that true stroke incidence and prevalence of stroke in Pakistan is not known, the burden is assumed to be high because of highly prevalent stroke risk factors (hypertension, diabetes mellitus, coronary artery disease, dyslipidemia and smoking) in the community. High burden of these conventional stroke risk factors is further compounded by lack of awareness, poor compliance hence poor control, and inappropriate management/treatment practices. In addition certain risk factors like rheumatic valvular heart disease may be more prevalent in Pakistan. We reviewed the existing literature on stroke risk factors in community, the risk factor prevalence among stroke patients, patterns of stroke, out come of stroke, availability of diagnostic services/facilities related to stroke and resources for stroke care in Pakistan.

Nursing of patients with rheumatic valvular heart disease with atrial fibrillation treated with CoxIII labyrinth and simultaneous valve replacement operation

Objective To summarize the effect and experience of nursing of patients with rheumatic valvular heart disease with atrial fibrillation treated with Cox Ⅲ labyrinth and simultaneous valve replace-ment operation. Methods A retrospective analysis was carried out in the nursing of 58 patients with rheumatic valvular heart disease with atrial fibrillation treated with Cox Ⅲ labyrinth and simultaneous valve replacement operation in our hospital from April 2006 to July 2008. Results One patient died of periop-erative renal failure,one died of low cardiac output,one died of infectious endoearditis.Tbe mortality rate reached 5.2%.Other patients were discharged from hospital after completely cured.The survived patients maintained sinus rate during hospitalization days after operation and short-term follow-up after being dis-charged.Among 43 patients who completed follow-up of 6 months after operation,3 patients (7.0%) damon-strated atrial fibrillation,while others still kept sinus rate. Conclusions Attention should be paid to psy-chological nursing,respiratory tract preparation,cardiac function monitoring and nursing of anticoagulation treatment for patients treated with Cox Ⅲ labyrinth and simultaneous valve replacement operation. Key words: Atrial fibrillation; Labyrinth operation; Nursing; Valve replacement