Rheumatic Valvular Lesions Research Articles

Evaluation of Vitamin (D) Level in Children with Rheumatic Valvular Lesion

Evaluation of Vitamin (D) Level in Children with Rheumatic Valvular Lesion

Comparing the outcomes of rheumatic heart disease in pregnancy complicated with and without atrial fibrillation: A propensity score matched analysis

Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it. The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them. Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95%CI 66.3%-85.7%) compared to women without AF (17.3%(95%CI 13.3%-22.1%), P < .001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, P < .001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1-226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF. Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

Comparative Clinical Characteristics of Rheumatic Heart Disease Patients Undergoing Surgical Valve Replacement.

BackgroundTo assess the prevalence patterns of isolated/mixed rheumatic valvular lesions and associated risk factors among rheumatic heart disease (RHD) patients undergoing surgical valve replacement.MethodsAn analytical cross-sectional design was used. Purposive sampling was used to select 87 RHD patients who underwent a first-time valve replacement for mitral, aortic, or both valves between April 1 and October 20, 2016, at Punjab Institute of Cardiology, Lahore, Pakistan. Patients with systemic hypertension, diabetes mellitus type-II, congenital heart defects, coronary artery disease, non-rheumatic valvular degeneration, positive test for hepatitis C, or undergoing concomitant coronary artery bypass graft or a ‘redo’ valve replacement procedure were excluded.A proforma was used to collect preoperative data on patients’ demographics, laboratory investigations, electrocardiogram (ECG), and transthoracic echocardiography reports.ResultsAge (mean ± S.D.) was 32.79 ± 13.06 years, which was divided into four quartile-based groups. Forty-six (52.9%) cases were males. The majority (56.3%) of patients underwent mitral valve replacement. Mitral regurgitation (MR, 80%) was the most common lesion. Of 71 available ECGs, atrial fibrillation was observed in 46.5% cases. Increasing age group was negatively correlated with MR severity (τc = -0.188, p-value = 0.033) and positively with aortic stenosis (AS) severity (τc = 0.141, p-value = 0.010).No significant elevations were observed for anti-streptolysin O titer, C-reactive protein, and leukocyte count, though the erythrocyte sedimentation rate was abnormally high in 46.94% cases.ConclusionsMR was the most common lesion. MR was more severe in younger patients whilst AS was more severe in older cases. There is little evidence of ongoing residual inflammation.

Fate of Functional Mitral Regurgitation after Aortic Valve Replacement in Patients with Aortic Valve Stenosis

Objective: Functional mitral regurgitation(f-MR) is seen in varying degrees in aortic valve stenosis(AS). Repairing f-MR in the same session with aortic valve replacement(AVR) is controversial. Aim of this study is to reveal whether surgical intervention was necessary for f-MR or not, in the same session. Materials and Methods: 118 patients who underwent AVR due to AS with accompanying f-MR between 2013 and 2018 were evaluated retrospectively. Patients with coronary heart disease requiring surgery, degenerative and/or rheumatic mitral valvular lesions were excluded. Demographic data, pre/postoperative peak aortic valve gradient(AVG), mean AVG, mitral valve structure, f-MR degree, left ventricular end-diastolic(LVEDD)/end-systolic(LVESD) diameters, right(RAD)/left(LAD) atrial diameters, pulmonary artery pressures(tPAP), vena contracta(VC) and aortic valve velocities were analysed. Results: Mean age was 61,72±5,97. AS with aortic regurgitation and isolated AS was present in 18,64%(n=22) and 81,35%(n=96) of the patients. f-MR was mild in 66,10%(n=78), mild-moderate in 11,86%(n=14), moderate in 16,90%(n=20) and moderate-severe in 5,08%(n=6) of the patients, preoperatively. After AVR, f-MR was mild in 74,57%(n=88), mild-moderate in 6,77%(n=8), moderate in 18,64%(n=22) of the patients. No significant changes were present in ejection fraction(p=0,968), LAD(p=0,955) and RAD(p=0,264). Significant decreases were determined in peak-AVG(p=0,000), mean-AVG(p=0,000), LVEDD(p=0,000), LVESD(p=0,000), tPAP(p=0,021) and aortic valve velocity(p=0,000). Conclusion: We conclude that AVR is sufficient to reduce/eliminate f-MR to safer limits in patients with accompanying mild, mild-moderate and moderate f-MR. However, f-MR reduced only to moderate, in some patients with moderate-severe f-MR after AVR. So, we only recommend repairing mitral valve concurrently with AVR in patients having higher than moderate f-MR.

Prevelance of Rheumatic Valvular Lesion in Dilated Cardiomyopathy: A Study of 1182 Cases of Idiopathic Dilated Cardiomyopathy in a Tertiary Care Hospital

Prevelance of Rheumatic Valvular Lesion in Dilated Cardiomyopathy: A Study of 1182 Cases of Idiopathic Dilated Cardiomyopathy in a Tertiary Care Hospital

A study of spectrum of rheumatic heart disease in a tertiary care hospital in Central Nepal

Background and aimsRheumatic heart disease is one of the most common cause for heart failure and associated mortalities/morbidities in the young population in developing countries like Nepal imparting huge familial, social and manpower burden. Materials and methodsThis is a hospital based descriptive cross-sectional study during June 2014 to April 2016 over a period of 22months at College of Medical Sciences-Bharatpur including 235 patients with clinical and/or echocardiographic evidence of definite rheumatic heart disease. ResultsThe age of the patients ranged from 7 to 76years with mean age 39.82±4.2years with female preponderance (F:M=2.1:1) (p<0.01). Majority of the rheumatic heart disease patients belonged to 30–44years (28.78%) followed by 15–29years (25.75%) and 45–59years (25.00%). Majority belonged to the low socioeconomic status (60.60%) (p<0.05). The predominantly involved isolated valve was mitral in 110 patients (46.80%) followed by isolated aortic valve in 22 patients (9.36%) and 79 (33.62%) had dual valvular involvement. The common rheumatic valvular lesions were pure mitral stenosis in 32 (13.61%), isolated mitral regurgitation in 58 (24.68%), combined mitral stenosis/regurgitation in 36 (15.32%), combined mitral/aortic regurgitation in 23 (9.78%) and combined aortic stenosis/regurgitation in 18 (7.66%) patients with few overlappings. The common complications encountered were heart failure in 90 (38.30%) and arrhythmias in 124 (51.00%) patients.130 patients (55.32%) received injectable benzathine penicillin whereas 45 patients (19.15%) preferred oral penicillin V. Surgical intervention was done in 54 (22.97%) patients. 12 (5.10%) expired in the CCU during the course of treatment. ConclusionRHD is a leading cause of heart failure among young populations with requirement of prolonged duration of medical treatment and many of them requiring surgery.

Ketamine/propofol (ketofol) versus propofol/fentanyl for induction of general anesthesia in parturients with rheumatic valvular lesions undergoing elective cesarean section

In this study, we assumed that the addition of ketamine to propofol (ketofol) would maintain cardiac stability in parturients with valvular heart without any deleterious effect on the fetus, that is no respiratory depression for the baby and hence a better Apgar score. This open-label randomized study was carried out in the High-risk Obstetric Unit, Cairo University Hospitals, in collaboration with the Anesthesia Department. The study included full-term parturients, 36-38 weeks' gestational age, 25-40 years old with severe rheumatic valvular heart lesions (mitral stenosis, mitral regurge, aortic stenosis, aortic regurge) of functional class II or III according to the New York Heart Association Classification. At the time of induction, patients were allocated randomly to one of the two study groups: group K (n = 25) received intravenous ketamine 1 mg/kg combined with propofol 1 mg/kg. Group P (n = 25) received propofol 2 mg/kg and fentanyl 2 mg/kg. Mean arterial blood pressure (MAP), heart rate (HR), and central venous pressure were recorded at the following times:T1, T2, T3, T4, T5, and T6. Decrease in MAP was only significant in group P (P < 0.001 at T2 and T3). The magnitude decreases in MAP. The absolute value of MAP was significantly lower in group P after induction, intubation, and skin incision. The median decrease in MAP was significantly higher in group P after induction and intubation. HR increased significantly after induction of anesthesia and after endotracheal intubation in the two groups. It reverted to near baseline values thereafter. The magnitude decreases in HR. The absolute value of HR was significantly lower in group P after intubation and skin incision. Apgar scoring was significantly better (higher) in the ketofol group at 1 and 5 min. We can conclude that a combination of ketamine and propofol seems to be an appropriate choice for anesthesia of critically ill rheumatic cardiac parturients undergoing cesarean section. It proved to be effective and hemodynamically safe for such a critical situation.

The burden of antenatal heart disease in South Africa: a systematic review

BackgroundMaternal mortality in South Africa is rising, and heart conditions currently account for 41 per cent of indirect causes of deaths. Little is known about the burden of heart disease in pregnant South Africans.MethodsWe systematically reviewed the contemporary epidemiology and peripartum outcomes of heart disease in South African women attending antenatal care. Searches were performed in PubMed, ISI Web of Science, the EBSCO Africa-Wide database, the South African Union Catalogue, and the Current and Completed Research database (South Africa). References of included articles were also hand-searched. Studies reporting epidemiologic data on antenatal heart disease in South Africa were included. Data on morbidity and mortality were also collected.ResultsSeven studies were included in the systematic review. The prevalence of heart disease ranged from 123 to 943 per 100,000 deliveries, with a median prevalence of 616 per 100,000. Rheumatic valvular lesions were the commonest abnormalities, although cardiomyopathies were disproportionately high in comparison with other developing countries. Peripartum case-fatality rates were as high as 9.5 per cent in areas with limited access to care. The most frequent complications were pulmonary oedema, thromboembolism, and major bleeding with warfarin use. Perinatal mortality ranged from 8.9 to 23.8 per cent, whilst mitral lesions were associated with low birth weight. Meta-analysis could not be performed due to clinical and statistical heterogeneity of the included studies.ConclusionApproximately 0.6 per cent of pregnant South Africans have pre-existing cardiac abnormalities, with rheumatic lesions being the commonest. Maternal and perinatal morbidity and mortality continue to be very high. We conclude this review by summarising limitations of the current literature and recommending standard reporting criteria for future reports.

Pattern of Chronic Rheumatic Valvular Lesion in Patients Undergoing Echocardiography - A study of 510 cases

This observational study of 510 cases of chronic rheumatic valvular diseases was corded out in the Department of Cardiology in the National Center for Control of Rheumatic Fever and Heart Diseases (NCCRFAH1H from Jamiary 2007 to October 2007 with the main objective to find out the patient of distribution of rheumatic valvular lesion in the commtmlly and whether this trend is changing over time or not. All the patients underwent a thorough clinical examinations followed by electrocardiographic, radiographic and finally echocardiographic examinations. Nomdreinnaric cases of Wyatt', lesion and fimaional valvular lesion were excluded from the study. The study revealed that there were 52_5% female and 47.5% male with mean age of presentation of 32.86 x 12.90 years. isolated milral waive involrentelll WAS found in 57.25% cases. isolated aortic valve lesion in 8.8% cases and combined valve lesion in 33.9% rases. Mina) valve lesion van significantly higher in female population and aortic valve lesion in male population. Pure mitral stenasis was found in 22.9% cases.

Spectrum of cardiovascular disorders in a national referral centre, Ghana

Objective : To determine the pattern of cardiovascular disorders in Ghana. Design : A four-year prospective study. Setting : National Cardiothoracic Centre (NCTC), Korle-Bu Teaching Hospital, Accra, Ghana. Subjects : Seven hundred and eight subjects with cardiovascular disorders referred to the NCTC, Accra, were evaluated clinically and with ancillary laboratory tests, chest x-ray, and electrocardiography. Subjects were also assessed with the aid of two-dimensional echocardiography with doppler and colour flow mapping. Results : Hypertensive heart disease(n=133), rheumatic heart disease(n=123), idiopathic cardiomyopathy(n=103), congenital heart disease(n=90) and coronary artery disease(n=80) were the major causes of cardiovascular morbidity. The mean age of the subjects was 41.6 ± 0.8 years. The male to female ratio was 1.3:1.0. The peak incidence of cardiovascular disease occurred in the fifth decade. Subjects with coronary artery disease were relatively older and had the highest incidence of hypertension(66.3%), diabetes(22.5%), smokers(11.8%), hyperlipidaemia(8.8%) and regular alcohol use(12.5%). The commonest rheumatic valvular lesion was mitral regurgitation. Dilated cardiomyopathy was the commonest form of cardiomyopathy(n=56). Hypertrophic cardiomyopathy and endomyocardial fibrosis were seen in 25 and 22 subjects respectively. Ventricular septal defect, atrial septal defect, tetralogy of Fallot and patent ductus arteriosus were the commonest congenital lesions. The major cardiovascular disorders in children were congenital (n=27) and rheumatic heart(n=11). Idiopathic cardiomyopathy(n=1) was rare in children. Conclusion : Major causes of cardiovascular morbidity in Ghanaians were hypertension, rheumatic heart disease and cardiomyopathy. Congenital and rheumatic heart diseases were the commonest cardiovascular disorders in Ghanaian children. Idiopathic cardiomyopathy was rare in children.

Rheumatic Valvular Lesions: Surgical Interventions

This is a retrospective study of the patients with the diagnosis of Rheumatic Valvular Lesions, who had undergone surgical treatment at SGNHC between Aug 2001 and Jan 2004, The data was collected from the in-hospital records maintained for individual patient.

Aetiology of Heart Failure as Seen from a National Cardiac Referral Centre in Africa

572 consecutive patients with heart failure referred to the National Cardiothoracic Centre, Accra, Ghana, over a 4-year period were evaluated for the aetiology of heart failure using two-dimensional Doppler echocardiography with colour flow. The mean age of the subjects with heart failure was 42.3 ± 0.9 years. The male to female ratio was 1.2:1.0. Combined heart failure was seen in 50.5% of subjects. Peak incidence of heart failure occurred in the 5th decade. The main causes of heart failure were hypertension (21.3%; n = 122), rheumatic heart disease (20.1%; n = 115) and cardiomyopathy (16.8%; n = 96). Congenital heart disease and coronary artery disease accounted for 9.8 and 10% of cases, respectively. The commonest rheumatic valvular lesion was mitral regurgitation (78%). Dilated cardiomyopathy was the commonest form of idiopathic cardiomyopathy (67.7%; n = 65). Endomyocardial fibrosis and hypertrophic cardiomyopathy accounted for 22.9% (n = 22) and 9.4% (n = 9), respectively, of cardiomyopathies.

7205 Intercollegiate-british society of gastroenterology national colonoscopy (ibsn) audit: do colonoscopists follow the british society of gastroenterology guidelines regarding antibiotic prophylaxis?

Introduction: British Society of Gastroenterology (BSG) guidelines recommend antibiotic prophylaxis for endoscopic procedures if the patient is at high risk of endocarditis or of symptomatic bacteraemia because of immunosuppression or neutropenia. As part of the IBNC audit the practice of antibiotic prophylaxis was assessed in colonoscopists practising in 73 units (44 District General, 10 Teaching, 5 Paediatric, 14 Private). Results: Antibiotic prophylaxis for 19 clinical conditions were addressed by 228/236 colonoscopists. The number of colonoscopists who indicated they would give antibiotic prophylaxis to patients undergoing colonoscopy with conditions associated with a higher risk of endocarditis or symptomatic bacteraemia are: Prosthetic heart valve - 226/228 (99.1%), Previous endocarditis - 206/228 (90.4%), Surgically constructed systemic-pulmonary shunt or conduit - 97/228 (42.5%), Synthetic vascular graft less than 1 year old - 116/228 (50.9%), Severe neutropenia (neutrophils 9 /litre) - 179/228 (78.5%). 96/228 (42%) of colonoscopists were members of the British Society of Gastroenterology but there was no significant difference between members and non-members responses in these higher risk clinical conditions. The BSG guidelines designate 14 other clinical conditions as having moderate, low or no increased risk of endocarditis or symptomatic bacteraemia and where antibiotics are not recommended. The number of colonoscopists who indicated they would give antibiotics to patients undergoing colonoscopy with these conditions ranged from 173/228 (75.9%) for rheumatic valvular or congenital cardiac lesions, to 20/228 (8.8%) for an orthopaedic prosthesis. Conclusion: Not all patients with disorders associated with a higher risk of endocarditis or symptomatic bacteraemia receive prophylactic antibiotics prior to colonoscopy and prophylaxis is often administered inappropriately. More effective methods are required to improve awareness and implementation of prophylactic antibiotic guidelines.

A new technique for debridement in rheumatic valvular disease: the rasping procedure

Background. Valve repair is superior to valve replacement in terms of postoperative risk. However, the conventional techniques used for valve repair in patients with rheumatic valvular disease have not resulted in a good long-term outcome.Methods. We developed a novel “rasping procedure” using an electric rasper for debridement in rheumatic valvular diseases. Between April 1986 and December 1996, the rasping procedure was performed on the aortic valve (A-rasping) of 24 patients who exhibited moderate stenosis with mild regurgitation. Between June 1992 and December 1996, this procedure was performed on the mitral valve (M-rasping) of 12 patients who exhibited mitral stenosis with mild regurgitation.Results. Among the 24 patients on whom A-rasping was performed, 4 patients did not show any improvement after the A-rasping procedure, and required valve replacement. In each of the remaining 20 cases, the transvalvular pressure gradient decreased, and regurgitation disappeared, or was reduced to a trivial level. In all 12 patients on whom M-rasping was performed, the transvalvular pressure gradient significantly decreased, orifice area significantly increased, and the regurgitation disappeared. Postoperative echocardiographic examinations were performed during a mean follow-up period of 110 months in the patients who received A-rasping, and that of 50 months in the patients who received M-rasping. A significant change in the valve requiring subsequent surgery was not seen in any of the patients.Conclusions. The rasping procedure is an effective technique for excising rheumatic valvular hypertrophic lesions. It resulted in good intermediate to long-term outcome.

Digital Stethoscope

Early detection of heart diseases is a very important area of research and several diagnostic methods have been developed. In this article, a low cost diagnostic tool which analyses the digitized sound of the heart beat is presented. This could be used to detect abnormalities such as aortic and mitral stenosis, mitral and aortic regurgitation, and rheumatic valvular lesions. The instrument displays the heart sound and also maintains long term records of a patient for future use.

Pattern of Rheumatic Heart Disease in Adults in Maiduguri — North East Nigeria

The pattern of rheumatic heart disease in 84 adolescent and adult patients seen over a 9 year period (1982-1990) at the University of Maiduguri Teaching Hospital (UMTH) is presented. Over 70% were in second and third decades of life. Pure mitral incompetence and mixed mitral valve disease were the commonest valvular lesions. This pattern appears similar to those in other developing countries. Congestive cardiac failure was the commonest complication. Declining economic fortunes of the developing countries, over crowding, malnutrition and inadequate medical facilities may further perpetuate the condition. Early recognition and the management of rheumatic carditis and early valvular lesions will reduce the morbidity and mortality.

Diagnostic Value of Pain Chest Roentgenogram in Rheumatic Mitral Valvular Disease

Rheumatic fever and rheumatic heart disease are still important community health problem in developing countries. The aim of this diagnostic test was to determine the diagnostic role of plain chest roentgenogram in patients with rheumatic mitral valvular disease. Subjects were patients with rheumatic mitral disease without other vular lesions, congenital heart disease, or anemia, who visited the out-patient clinic, Department of Child Health, Cipto Mangunkusumo Hospital, Jakarta, between June and August 1995. There were 52 subjects enrolled to this study. Determination of type valve lesions, the presence of left atrial dilatation, and cardio-thoracic ratio (CTR) were performed from plain chest film by 2 pediatric radiologists using a semiquantitative table. The results were compared with echocardiographic findings used as gold standard. The chest plain roentgenogram accurancy in determining valvular lesion was 77 percent (CI90 percent, 67.4 percent-86.6 percent). Chest plain roentgenogram diagnostic index in discovering left atrial dilatation gave excellent result (more than 80 percent). The correlation between CTR and left ventricular mass (LVM) was 0.63 (p less than 0.001) in all rheumatic mitral valvular lesions. We conclude that plain chest roentgenogram still has its place in determining type of rheumatic mitral valvular lesion, and it has some help in the management of patients with rheumatic mitral valve disease.

The importance of tricuspid valve structure and function in the surgical treatment of rheumatic mitral and aortic disease.

A significant proportion of individuals with rheumatic disease have tricuspid valve involvement which may be clinically important and alter the medical or surgical approach to treatment. Therefore 50 patients with rheumatic left-sided valvular lesions who were referred for operative treatment were studied. Thirty patients had angiographically significant tricuspid regurgitation (group I) and 20 had a competent tricuspid valve (group II). Pre-operative cardiac assessment included Doppler echocardiography and contrast ventriculography. Patients with tricuspid regurgitation more commonly had mitral valve disease or combined mitral and aortic valve lesions, (P less than 0.001) and were more likely to have atrial fibrillation than those without tricuspid regurgitation (P less than 0.001). Pulmonary arterial systolic and mean right atrial pressures were higher in group I (both P less than 0.01). A close relationship was found between the angiographic and Doppler assessment of the degree of tricuspid regurgitation (P less than 0.01). Doppler-derived measurement of the right ventricular-right atrial systolic pressure difference correlated well with the systolic trans-tricuspid pressure difference measured at cardiac catheterization (y = 0.7x + 22, r = 0.67, P less than 0.001) and the pulmonary arterial systolic pressure (y = 0.8x + 27, r = 0.71, P less than 0.001). Rheumatic involvement of the tricuspid valve identified by pre-operative echocardiography was confirmed in five patients at surgery. Of the 13 patients with functional tricuspid regurgitation at operation, only two had been diagnosed as having organic disease by echocardiography. Furthermore, in all 18 cases where Doppler suggested grade 3 or 4+ tricuspid regurgitation, surgical repair or replacement of the valve was performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Histopathological studies on the myocardial fibrosis and vascular lesion of rheumatic valvular disease.

To clarify the types and frequency of myocardial fibrosis and vascular lesions caused by different types of the rheumatic valvular disease, 41 autopsied hearts with rheumatic valvular lesions were examined and the following results were obtained. As to myocardial fibrosis, 1) perivascular fibrosis, caused mainly by perivascular inflammation and partly by myocardial strain, varied in grade according to the types of the valvular disease, i.e., most severe in mitral regurgitation (MR) and combined valvular disease (CVD) and least in mitral stenosis (MS); 2) Aschoff's nodes: 3 typical and 8 atypical cases were found; 3) perimycial fibrosis due to myocardial strain: most severe in MR and CVD and least in MS; and 4) irregular patchy fibrosis, caused mainly by myocarditis and partly by ischemia, was noticed in all types of the valvular disease. As to vascular lesion, 1) angitis was found in 7 cases and most frequently in MR; and 2) thickening of the intima and media was found in all types of valvular disease. Thus, myocardial fibrosis and vascular lesion varied according to the types of valvular disease, and not only hemodynamic changes but also myocardial fibrosis and vascular lesions might determine the prognosis of the valvular disease.

Clinical aspects of rheumatic valvular disease

ECENT ADVANCES in clinical physiology, surgery, and pathology have made the recognition and management of rheumatic valvular disease an exact exercise in applied pathophysiology. This review is focused on what we regard as the basic principle of that exercise: That the functional anatomy of each rheumatic valvular lesion finds direct expression in both the natural history of that lesion and the clinical signs in each affected patient.