Update on rheumatic heart disease

Myocardial fibrosis in rheumatic heart disease: emerging concepts and clinical implications

Rheumatic heart disease (RHD) remains a significant cardiovascular burden in the world even though it is no longer common in affluent countries. Centuries of history surrounding this disease provide us with a thorough understanding of its pathophysiology. Infections in the throat, skin, or mucosa are the gateway for Group A Streptococcus (GAS) to penetrate our immune system. A significant inflammatory response to the heart is caused by an immunologic cascade triggered by GAS antigen cross-reactivity. This exaggerated immune response is primarily responsible for cardiac dysfunction. Recurrent inflammatory processes damage all layers of the heart, including the endocardium, myocardium, and pericardium. A vicious immunological cycle involving inflammatory mediators, angiotensin II, and TGF-β promotes extracellular matrix remodeling, resulting in myocardial fibrosis. Myocardial fibrosis appears to be a prevalent occurrence in patients with RHD. The presence of myocardial fibrosis, which causes left ventricular dysfunction in RHD, might be utilized to determine options for treatment and might also be used to predict the outcome of interventions in patients with RHD. This emerging concept of myocardial fibrosis needs to be explored comprehensively in order to be optimally utilized in the treatment of RHD.

A new surgical technique for left atrial reduction in giant left atrium

Objective

The study objective was to evaluate the safety and clinical and echocardiographic outcomes of a new surgical technique in adult patients diagnosed with a giant left atrium.

Methods

We analyzed a cohort of patients who underwent left atrium reduction surgery between January 2016 and June 2020 performed by a specialized surgical team in 2 national reference centers in Lima, Peru. We assessed the major adverse valvular-related events and the New York Heart Association functional class as primary clinical outcomes. Also, our primary echocardiographic endings were the diameter, area, and volume of the left atrium. We assessed these variables at 3 time periods: baseline (t0), perioperative period (t1), and extended follow-up (t2: 12 ± 3.4 months). We carried out descriptive and bivariate exploratory statistical analysis for dependent measures.

Results

We included 17 patients, 70.6% of whom were women. Rheumatic mitral valve disease (76.5%) was the main etiology. We performed 14 (82.4%) mitral valve replacements and 3 repairs. Major adverse valvular-related events occurred in 1 patient (5.9%) (hemorrhagic stroke) at t1. A significant reduction in the size of the left atrium was observed: diameter (77 mm vs 48 mm, P < .001), area (75 cm² vs 31 cm², P < .001), and volume (332 cm³ vs 90 cm³, P < .001). Compared with t0 and t1, these echocardiographic findings remained without significant changes during t2.

Conclusions

Our surgical left atrium reduction technique was associated with improved clinical functionality and reduced left atrium measures in patients with a giant left atrium undergoing mitral valve surgery.

The Immune and Inflammatory Basis of Acquired Pediatric Cardiac Disease

Children with acquired heart disease face significant health challenges, including a lifetime of strict medical management, multiple cardiac surgeries, and a high mortality risk. Though the presentation of these conditions is diverse, a unifying factor is the role of immune and inflammatory responses in their development and/or progression. For example, infectious agents have been linked to pediatric cardiovascular disease, leading to a large health burden that disproportionately affects low-income areas. Other implicated mechanisms include antibody targeting of cardiac proteins, infection of cardiac cells, and inflammation-mediated damage to cardiac structures. These changes can alter blood flow patterns, change extracellular matrix composition, and induce cardiac remodeling. Therefore, understanding the relationship between the immune system and cardiovascular disease can inform targeted diagnostic and treatment approaches. In this review, we discuss the current understanding of pediatric immune-associated cardiac diseases, challenges in the field, and areas of research with potential for clinical benefit.

Mitral valve surgery for rheumatic heart disease: replace, repair, retrain?

PURPOSE OF REVIEW

Rheumatic heart disease (RHD) affects over 30 million people worldwide. Substantial variation exists in the surgical treatment of patients with RHD. Here, we aim to review the surgical techniques to treat RHD with a focus on rheumatic mitral valve (MV) repair. We introduce novel educational paradigms to embrace repair-oriented techniques in cardiac centers.

RECENT FINDINGS

Due to the low prevalence of RHD in high-income countries, limited expertise in MV surgery for RHD, technical complexity of MV repair for RHD and concerns about durability, most surgeons elect for MV replacement. However, in some series, MV repair is associated with improved outcomes, fewer reinterventions, and avoidance of anticoagulation-related complications. In low- and middle-income countries, the RHD burden is large and MV repair is more commonly performed due to high rates of loss-to-follow-up and barriers associated with anticoagulation, international normalized ratio monitoring, and risk of reintervention.

SUMMARY

Increased consideration for MV repair in the setting of RHD may be warranted, particularly in low- and middle-income countries. We suggest some avenues for increased exposure and training in rheumatic valve surgery through international bilateral partnership models in endemic regions, visiting surgeons from endemic regions, simulation training, and courses by professional societies.

Acute Congestive Heart Failure in a Young Woman

We describe the case of an adult First Nations woman employed as a daycare worker who presented with clinical symptoms, signs, and imaging suggestive of acute heart failure. In our report, we discuss the likely diagnosis of acute rheumatic fever. Novel teaching points: The incidence of rheumatic fever in Canada is likely underestimated, and it is important to consider the diagnosis of acute rheumatic fever in individuals presenting with acute heart failure. More research is needed in Canada to further identify groups most at risk for developing this disease.

İnvestigation of endothelial dysfunction in children with acute rheumatic fever

Background:

Acute rheumatic fever (ARF) is an important cause of valvular heart disease in children. Endothelial dysfunction plays an important role in the pathogenesis of valvular heart diseases. The role of endothelial dysfunction in valvular heart diseases due to ARF is not exactly known. In ARF, autoimmune injury, inflammation, oxidative stress, and impairment of nitric oxide in valvular endothelium may be the causes of endothelial dysfunction. The purpose of this study is to evaluate endothelial dysfunction and arterial stiffness in children with ARF.

Materials and Methods:

Thirty-six patients diagnosed with ARF (the mean age was 11.80 ± 2.82 years) and 36 volunteered individuals with similar age, sex, and body mass index were included in the study. The study groups were compared in terms of M-mode echocardiography parameters, carotid arterial strain (CAS), beta-stiffness index (βSI), and flow-mediated dilation (FMD).

Results:

In patients with ARF, there was a decrease in FMD% (10.36 ± 7.26 and 12.76 ± 4.59; P < 0.001) compared to the control group. In addition, CAS (0.16 ± 0.06 and 0.18 ± 0.08; P = 0.44) and βSI (3.65 ± 1.61 and 3.57 ± 2.38; P = 0.24) were similar in the patient and the control groups. Furthermore, no correlation was detected between decreased FMD value and mitral regurgitation (r = −0.07; P = 0.66), aortic regurgitation (r = −0.04; P = 0.78), CAS (r = −0.08; P = 0.61), and βSİ (r = −0.20; P = 0.22).

Conclusion:

In our study, a decrease in FMD value, which is a marker of endothelial dysfunction, was found in children with rheumatic carditis.

Individualized Immunological Data for Precise Classification of OCD Patients

Obsessive⁻compulsive disorder (OCD) affects about 2% of the general population, for which several etiological factors were identified. Important among these is immunological dysfunction. This review aims to show how immunology can inform specific etiological factors, and how distinguishing between these etiologies is important from a personalized treatment perspective. We found discrepancies concerning cytokines, raising the hypothesis of specific immunological etiological factors. Antibody studies support the existence of a potential autoimmune etiological factor. Infections may also provoke OCD symptoms, and therefore, could be considered as specific etiological factors with specific immunological impairments. Finally, we underline the importance of distinguishing between different etiological factors since some specific treatments already exist in the context of immunological factors for the improvement of classic treatments.

A predictor for mitral valve repair in patient with rheumatic heart disease: the bending angle of anterior mitral leaflet

Background

Mobility and flexibility of anterior mitral leaflet (AML) are considered to be the important factor for mitral valve (MV) repair in rheumatic population, we try to use the bending angle of AML to quantify its' mobility and flexibility and investigate whether it can predict the success of rheumatic MV repair or not.

Methods

Total 54 patients underwent rheumatic MV surgeries with mild lesions of subvalvular apparatus from August, 2017 to November, 2017 at the author institution, we divided the patients into MV repair and MV replacement groups which included directly MV replacement and repair attempt but failed repairing transfer to replacement intraoperatively. Patients' MV structure was carefully evaluated on transthoracic echocardiography (TTE) and scored by the Wilkins score (WS) preoperatively. The bending angle of AML was measured during systole and diastole at different level before surgery.

Results

The differences of patients' demographic characteristics between repair group and replacement group were not statistically significant (P value >0.05) and the differences among B-angle, T-angle, Bs-angle, C-angle of AML between repair group and replacement groups were not statistically significant (P value >0.05). Only BT-angle in repair group was significantly larger than that of replacement group (21.56°±3.84°, 10.29°±6.02°, respectively, P<0.001), therefore the BT-angle was tested as a predictor of reparability by observing the receiver operating characteristic (ROC) curve (ROC area: 0.944, standard error: 0.06, 95% CI: 0.826-1), BT-angle of AML on preoperative transthoracic echo of 15.5° or more predicts feasibility of rheumatic MV repair with 100% sensitivity and 85.7% specificity in patients with mild lesions of subvalvular apparatus. Logistic regression for a single area of calcification (diameter <0.8 cm) at commissure were shown that: β: 0.08, Exp (β): 1.083, P: 0.777>0.05, the minor single calcified area at commissure had no effect on reparability of rheumatic MV disease. The differences of total WS and each component score between repair group and replacement group were not statistically significant (P value >0.05). By observing the ROC curve for total WS (ROC area: 0.508), the WS cannot be a predictor for the rheumatic MV repair.

Conclusions

The bending angle of AML which was considered as quantification of mobility and flexibility of AML can be a predictor for MV repair in patients with rheumatic heart disease (RHD). The small single area of commissural calcification had no effect on reparability of rheumatic MV disease. WS cannot appropriately predict the outcome of rheumatic MV repair.

Rheumatic Heart Disease in the Twenty-First Century

Rheumatic heart disease (RHD) is a chronic valvular disease resulting after severe or repetitive episodes of acute rheumatic fever (ARF), an autoimmune response to group A Streptococcus infection. RHD has been almost eliminated with improved social and health infrastructure in affluent countries while it remains a neglected disease with major cause of morbidity and mortality in many low- and middle-income countries, and resource-limited regions of high-income countries. Despite our evolving understanding of the pathogenesis of RHD, there have not been any significant advances to prevent or halt progression of disease in recent history. Long-term penicillin-based treatment and surgery remain the backbone of a RHD control program in the absence of an effective vaccine. The advent of echocardiographic screening algorithms has improved the accuracy of diagnosing RHD and has shed light on the enormous burden of disease. Encouragingly, this has led to a rekindled commitment from researchers in the most affected countries to advocate and take bold actions to end this disease of social inequality.

Valvular aspects of rheumatic heart disease

Acute rheumatic fever and rheumatic heart disease remain major global health problems. Although strategies for primary and secondary prevention are well established, their worldwide implementation is suboptimum. In patients with advanced valvular heart disease, mechanical approaches (both percutaneous and surgical) are well described and can, for selected patients, greatly improve outcomes; however, access to centres with experienced staff is very restricted in regions that have the highest prevalence of disease. Development of diagnostic strategies that can be locally and regionally provided and improve access to expert centres for more advanced disease are urgent and, as yet, unmet clinical needs. We outline current management strategies for valvular rheumatic heart disease on the basis of either strong evidence or expert consensus, and highlight areas needing future research and development.