The Diagnosis and Management of Chronic Rheumatic Heart Disease—An Australian Guideline

Echocardiographic Screening for Rheumatic Heart Disease: A Brief History and Implications for the Future

Transthoracic echocardiography is the gold standard for early detection of rheumatic heart disease (RHD) in asymptomatic children living in high-risk regions. Advances in technology allowing miniaturisation and increased portability of echocardiography devices have improved the accessibility of this vital diagnostic tool in RHD-endemic locations. Automation of image optimisation techniques and simplified RHD screening protocols permit use by non-experts after a brief period of training. While these changes are welcome advances in the battle to manage RHD, it is important that the sensitivity and specificity of RHD detection be maintained by all echocardiography users on any device to ensure accurate and timely diagnosis of RHD to facilitate initiation of appropriate therapy. This review of the evolution of echocardiography and its use in the detection of rheumatic valve disease may serve as a reminder of the key strengths and potential pitfalls of this increasingly relied-upon diagnostic test.

Rheumatic heart disease in The Gambia: clinical and valvular aspects at presentation and evolution under penicillin prophylaxis

BACKGROUND

Rheumatic heart disease (RHD) remains the leading cause of cardiac-related deaths and disability in children and young adults worldwide. In The Gambia, the RHD burden is thought to be high although no data are available and no control programme is yet implemented. We conducted a pilot study to generate baseline data on the clinical and valvular characteristics of RHD patients at first presentation, adherence to penicillin prophylaxis and the evolution of lesions over time.

METHODS

All patients registered with acute rheumatic fever (ARF) or RHD at two Gambian referral hospitals were invited for a clinical review that included echocardiography. In addition, patients were interviewed about potential risk factors, disease history, and treatment adherence. All clinical and echocardiography information at first presentation and during follow-up was retrieved from medical records.

RESULTS

Among 255 registered RHD patients, 35 had died, 127 were examined, and 111 confirmed RHD patients were enrolled, 64% of them females. The case fatality rate in 2017 was estimated at 19.6%. At first presentation, median age was 13 years (IQR [9; 18]), 57% patients had late stage heart failure, and 84.1% a pathological heart murmur. Although 53.2% of them reported history of recurrent sore throat, only 32.2% of them had sought medical treatment. A history suggestive of ARF was reported by 48.7% patients out of whom only 15.8% were adequately treated. Two third of the patients (65.5%) to whom it was prescribed were fully adherent to penicillin prophylaxis. Progressive worsening and repeated hospitalisation was experienced by 46.8% of the patients. 17 patients had cardiac surgery, but they represented only 18.1% of the 94 patients estimated eligible for cardiac surgery.

CONCLUSION

This study highlights for the first time in The Gambia the devastating consequences of RHD on the health of adolescents and young adults. Our findings suggest a high burden of disease that remains largely undetected and without appropriate secondary prophylaxis. There is a need for the urgent implementation of an effective national RHD control programto decrease the unacceptably high mortality rate, improve case detection and management, and increase community awareness of this disease.

<p>Clinical, Echocardiographic Characteristics and Management Practices in Patients with Rheumatic Valvular Heart Disease</p>

Background

Rheumatic heart disease (RHD) is the long-term consequence of acute rheumatic fever (ARF), continues unabated among middle-income and low-income countries. Thus, this study aimed to assess clinical characteristics, echocardiographic characteristics, and management practice of RHD patients.

Methods

Hospital-based prospective cross-sectional study was used. The data were collected from medical records of consecutive patients admitted to medical wards during the study period. The data were cleaned and analyzed using SPSS version 20. Descriptive statistics were used to describe the data. Chi-square was used to compare proportions between categorical variables.

Results

Forty-seven patients with a median (IQR) age of 28.0 (17.0-40.0) years were included. Pan systolic murmur was reported in 91.50% of patients. Forty-two (89.4%) of patients were presented with congestive heart failure and 23 (48.9%) with atrial fibrillation. Mitral valve leaflet thickening and calcification with restriction of motion were reported in 91.5% of patients. Mitral regurgitation (MR) (87.2%) and stenosis (MS) (85.1%) were the most common valvular lesions. The combinations of three (MR+MS+TR) 14 (29.8%) and four (MR+MS+TR+AR) 13 (27.7%) valve diseases were most commonly reported. Diuretics (95.7%), anticoagulants (38.3%), digoxin (36.2%), and beta-blockers (34.0%) were among the commonly prescribed medications.

Conclusion

Rheumatic heart disease affected younger adults. Pansystolic murmur was reported in nearly all patients. Congestive heart failure and atrial fibrillation were common clinical presentations. Morphologic changes in mitral valve and pathologic mitral regurgitation were the most common echocardiographic reports. Cardiovascular medications were commonly utilized for symptomatic management of complications Therefore, echocardiography should be done routinely for patients with RHD, focusing on younger adults, to facilitate diagnosis and treatment before complications develop.

Subtle Myocardial Dysfunction and Fibrosis in Children with Rheumatic Heart Disease: Insight from 3D Echocardiography, 3D Speckle Tracking and Cardiac Magnetic Resonance Imaging

Rheumatic heart disease (RHD) is a major cause of morbidity and mortality in developing countries, so early diagnosis and treatment can reduce morbidity and mortality resulting from subsequent valvular damage. The aim of this study was to detect subtle myocardial dysfunction among children with RHD with preserved left ventricular systolic function. This is a cross-sectional case-control study that was conducted on 30 children with RHD (who had valvular affection of any degree and were not in activity) compared to 23 healthy children. After history taking and cardiac examination, 2D echocardiography, tissue Doppler imaging, 3D-echocardiography and 3D speckle tracking echocardiography were done to both groups, whereas cardiac magnetic resonance imaging was done only to the patient group. The 3D-derived left ventricular end-diastolic volume and sphericity index among patients were significantly increased when compared to controls [131.5 (101.5 to 173.7) vs. 69 (58 to 92), P = 0.001, and 0.46 (0.36 to 0.59) vs. 0.33 (0.29 to 0.38), P = 0.001, respectively]. The 3D-derived ejection fraction and longitudinal strain did not differ significantly among both groups. The 3D-derived global circumferential strain was higher in patients when compared to controls [- 14 (- 16 to - 10) vs. - 11(- 13 to - 10), P = 0.04]. None of the examined patients demonstrated late enhancement myocardial fibrosis. In children with RHD and preserved systolic function, subtle systolic dysfunction could not be detected using conventional and novel non-conventional methods. This may indicate that the myocardial affection during the acute stage of rheumatic carditis is minimal with almost complete resolution.

Rheumatic fever and rheumatic heart disease in Bangladesh: A review

Rheumatic fever (RF) and rheumatic heart disease (RHD) are the most-common cardiovascular disease in young people aged <25 years, globally. They are important contributors to cardiovascular morbidity and mortality in Bangladesh. Classical risk factors, i.e. poverty, overcrowding, ignorance, and insufficient health care services were responsible for the high incidence and prevalence of these diseases over the last century. In concert with the progresses in socioeconomic indicators, advances in health sectors, improved public awareness, and antibiotic prophylaxis, acute RF came into control. However, chronic RHD continues to be prevalent, and the actual disease burden may be much higher. RHD predominantly affects the young adults, seriously incapacitates them, follows a protracted course, gets complicated because of delayed diagnosis and is sometimes maltreated. The treatment is often palliative and expensive. Large-scale epidemiological and clinical researches are needed to formulate evidence-based national policy to tackle this important public health issue in future.

Improved Long-Term Survival for Rheumatic Mitral Valve Repair Compared to Replacement in the Young

Background:

Mitral valve (MV) repair offers potential advantages over replacement in patients with rheumatic heart disease (RHD). We present the first long-term study that compares MV repair with replacement in children with RHD.

Methods and Results:

Single institute retrospective review of patients with RHD under 20 years of age, who underwent their first isolated MV surgery between 1990 and 2006. Of the 81 patients, 98% were Māori or Pacific Islander. The median age was 12.7 (3-19) years. The MV was repaired in 59%, a mechanical valve replacement (MVR) took place in 35% and bioprosthetic valve replacement in 6% of the patients. Follow-up data were available for 91.4% of the patients with mean follow-up of 7.6 years (range 0-19.4 years), a total of 620 patient years. Actuarial survival at 10 and 14 years for patients with MVR was 79% and 44%, compared to 90% and 90% for patients who underwent repair ( P = .06). Actuarial freedom from late reoperation at 10 and 14 years for patients with MVR was 88% and 73%, compared to 76% and 76% for patients with repair ( P = .52). Actuarial freedom from thrombotic, embolic, and hemorrhagic events at 10 and 14 years for patients with MVR was 63% and 45%, compared to 100% and 100% for patients with repair P < .01).

Conclusion:

This study shows that MV repair is superior to replacement for RHD in the young with follow-up to 19 years. Repair offers a survival advantage, greater freedom from valve-related morbidity, and long-term durability that equals that of MVR.