Status of rheumatic heart disease in rural Pakistan

Lack of awareness of secondary rheumatic prevention in preoperative candidates for mitral valve surgery - alarming situation

BACKGROUND

We conducted this study to assess the compliance with secondary rheumatic prophylaxis among preoperative patients with rheumatic mitral valve disease undergoing valvular heart surgery at a tertiary care cardiac hospital in a developing country.

METHODS

This is a descriptive cross-sectional study conducted at a tertiary care cardiac hospital in Karachi, Pakistan. The inclusion criteria encompassed patients of any sex, aged between 18 and 80 years, who had been diagnosed with rheumatic mitral valve disease through transthoracic echocardiography and had undergone valvular heart surgery. The level of compliance with secondary rheumatic prophylaxis and barriers toward noncompliance was assessed during routine preoperative interview session. This preventive measure plays a crucial role in reducing the progression of the disease and improving patient outcomes.

RESULTS

Out of the 239 patients included in the study, 125 (52.3%) were females, with a mean age of 38.8 ± 11.8 years. The majority of patients (88.7%) came from rural areas. Among the patients, 79 (33.1%) received rheumatic prophylaxis, while 160 (66.9%) did not adhere to it regularly. The common barriers for receiving rheumatic prophylaxis were non availability (41.0%) and nonaffordability (40.6%). Additionally, 28.0% of patients had lacked awareness of the importance of rheumatic prophylaxis, and 2.5% expressed fear of injection site pain and subsequent symptoms.

CONCLUSIONS

A concerning level of noncompliance with secondary rheumatic prophylaxis was observed. The barriers identified in patients who did not receive rheumatic prophylaxis were primarily related to affordability, availability, lack of awareness, and fear of injection site pain and subsequent symptoms.

Current Clinical Profile of Acute Rheumatic Fever and Recurrent Acute Rheumatic Fever in Pakistan

Inclusion of echocardiography as diagnostic tool and polyarthralgia and monoarthritis as major criteria for high-risk populations in the Revised Jones Criteria 2015 is likely to surface substantial variability in clinical manifestations among various populations. This study aimed to compare clinical profile of patients presenting with first and recurrent episodes of acute rheumatic fever (ARF) using most recent criteria. 130 consecutive patients with ARF were included in the study from August 2019 to March 2022. World Heart Federation standardized echocardiographic criteria were used for cardiac evaluation. The socio-demographic variables, clinical details and relevant investigations were recorded. Median age was 13(6-26) years. Male to female ratio was 1.6:1. Majority was of low socioeconomic status (90%) and with > 5 family members in a house (83.8%). 27 patients (20.8%) were with ARF while 103 (79.2%) with recurrent ARF. Carditis was the most common presenting feature (n = 122, 93.8%), followed by polyarthralgia (n = 46, 35.4%), polyarthritis (n = 32, 24.6%), subcutaneous nodules (n = 10, 7.7%), monoarthritis (n = 10, 7.7%), and chorea (n = 5, 3.8%). Monoarthralgia was more common in ARF than recurrence (29.4% vs. 3.2%, p = 0.004). Carditis (97.1% vs. 81.5%, p = 0.01) and congestive cardiac failure (18.5% vs. 5.9%, p = 0.001) were more common in recurrent ARF than ARF. Diagnostic categorization of Jones criteria for different populations has highlighted important variability in clinical presentation of ARF. Monoarthralgia is common in first episode of ARF. Carditis is the most common feature in recurrent ARF. Polyarthralgia is seen with higher frequency that polyarthritis. Subcutaneous nodules seem to be more common in our population.

Echocardiography Assessment of Rheumatic Heart Disease: Implications for Percutaneous Balloon Mitral Valvuloplasty

Echocardiography is an important diagnostic imaging modality in recognizing rheumatic heart disease, a chronic sequelae of acute rheumatic fever. Left-sided heart valves, especially the mitral valve is typically affected, with stenosis or regurgitation as a consequence. Although assessment of valve area by 2D planimetry is the reference method for mitral stenosis severity, 3D planimetry provides more accurate measurement and diagnostic value. Careful selection of patients in terms of echocardiographic criteria is essential to ensure safety and success of the intervention and better long-term outcomes. Several echocardiographic scores based upon mitral valve mobility, thickening, calcification, and subvalvular thickening are developed to assess mitral valve anatomy and the feasibility of percutaneous mitral commissurotomy. 3D transesophageal echocardiography (TEE) provides detailed information of the mitral anatomy (commissural fusions, and subvalvular apparatus) before intervention. In addition, 3D TEE planimetry provides a more accurate measurement of the valve area compared with 2D echocardiography. Generally, huge annular calcification and lack of commissural fusion are unfavorable echocardiographic markers that increase the risk of complications and preclude the feasibility of percutaneous balloon mitral valvuloplasty. More contemporary prospective echocardiography research studies on patients with RHD from low- and middle-income countries are needed.

Rheumatic heart disease in school-attending Nepalese children: A descriptive analysis of the national heart screening database

OBJECTIVE

Rheumatic Heart Disease (RHD) remains a significant public health problem with high morbidity and mortality in children and young adults from lower-middle income countries like Nepal. However, a nation-wide database of the disease is lacking for designing effective future prevention and control programmes and strategies. The aim of our study is to estimate the prevalence of RHD in school-attending Nepalese children.

METHODS

We performed a cross-sectional descriptive analysis of a nationally representative database of Nepal Heart Foundation (NHF) national RHD screening programme which included school-attending Nepalese children between five and sixteen years of age. The screening was conducted between May 2015 and March 2020 in 236 schools, representing all seven provinces, across all three ecological zones of Nepal. Transthoracic two-dimensional echocardiography was performed in all eligible children with more than grade one murmur on cardiac auscultation. We estimated the prevalence of RHD among school-attending children as the number of RHD cases per 1000 school-attending children with a 95% confidence interval.

RESULTS

The database included a total of 107,340 children who were screened clinically, of whom 10,600 (9·9%) underwent transthoracic two-dimensional echocardiography. The overall prevalence of RHD was 2.22 cases per 1000 school-attending children (95% CI:1·94 - 2·50). The highest prevalence was observed among children living in the southern Terai ecological zone (2·89 per 1000, 95% CI (2·32-3·46)) of Nepal. Among the provinces, Karnali had the highest prevalence of RHD (3·45 per 1000, 95% CI (2·42-4·48)). Among the districts screened, Kalikot had the highest RHD prevalence (5.47 per 1000, 95% CI (3.02-7.92)).

CONCLUSION

Primordial, primary and secondary prevention programmes should pay special attention to southern Terai zone, particularly the under-privileged children from remote districts.

Can Sound Public Health Policies Stem the Tide of Burgeoning Epidemic of Cardiovascular Disease in South Asians?

PURPOSE OF REVIEW

To revisit the importance of prevention strategies and policies in reducing the burden of ischemic heart disease in South Asian countries.

RECENT FINDINGS

South Asia has seen rapid growth in its population with variable improvement in health indicators such as life expectancy at birth over the last three decades. Parallel to these improvements, there has been a stark rise in noncommunicable diseases (NCDs) but without a commensurate improvement in infrastructure/policies and health system interventions to address NCDs. South Asia is the epicenter of the cardiovascular disease (CVD) epidemic in Asia. It has a population that manifests accelerated atherosclerosis at a younger age. Poverty, lower health literacy, lack of health-promoting behaviors, poor urban design, rising air pollution, weak health systems, and lack and poor implementation of existing policies contribute to the continued rise in the incidence of CVD and the associated case fatality rates. A relatively young population presents an opportunity for implementation of prevention measures now which if not adequately utilized will result in an exponential rise in the CVD burden. There is a large gap between policymaking and implementation in this part of the world. Economic realities further constrain coverage of prevention policies; and therefore, stronger collaboration between governments, stakeholders, civil society, and regional and international funding agencies is needed to universally implement prevention strategies in South Asia.

Detection of subclinical rheumatic heart disease in children using a deep learning algorithm on digital stethoscope: a study protocol

INTRODUCTION

Rheumatic heart diseases (RHDs) contribute significant morbidity and mortality globally. To reduce the burden of RHD, timely initiation of secondary prophylaxis is important. The objectives of this study are to determine the frequency of subclinical RHD and to train a deep learning (DL) algorithm using waveform data from the digital auscultatory stethoscope (DAS) in predicting subclinical RHD.

METHODS AND ANALYSIS

We aim to recruit 1700 children from a group of schools serving the underprivileged over a 12-month period in Karachi (Pakistan). All consenting students within the age of 5-15 years with no underlying congenital heart disease will be eligible for the study. We will gather information regarding sociodemographics, anthropometric data, history of symptoms or diagnosis of rheumatic fever, phonocardiogram (PCG) and electrocardiography (ECG) data obtained from DAS. Handheld echocardiogram will be performed on each study participant to assess the presence of a mitral regurgitation (MR) jet (>1.5 cm), or the presence of aortic regurgitation (AR) in any view. If any of these findings are present, a confirmatory standard echocardiogram using the World Heart Federation (WHF) will be performed to confirm the diagnosis of subclinical RHD. The auscultatory data from digital stethoscope will be used to train the deep neural network for the automatic identification of patients with subclinical RHD. The proposed neural network will be trained in a supervised manner using labels from standard echocardiogram of the participants. Once trained, the neural network will be able to automatically classify the DAS data in one of the three major categories-patient with definite RHD, patient with borderline RHD and normal subject. The significance of the results will be confirmed by standard statistical methods for hypothesis testing.

ETHICS AND DISSEMINATION

Ethics approval has been taken from the Aga Khan University, Pakistan. Findings will be disseminated through scientific publications and to collaborators.

ARTICLE FOCUS

This study focuses on determining the frequency of subclinical RHD in school-going children in Karachi, Pakistan and developing a DL algorithm to screen for this condition using a digital stethoscope.

Ethnically Disparate Disease Progression and Outcomes among Acute Rheumatic Fever Patients in New Zealand, 1989-2015

We investigated outcomes for patients born after 1983 and hospitalized with initial acute rheumatic fever (ARF) in New Zealand during 1989-2012. We linked ARF progression outcome data (recurrent hospitalization for ARF, hospitalization for rheumatic heart disease [RHD], and death from circulatory causes) for 1989-2015. Retrospective analysis identified initial RHD patients <40 years of age who were hospitalized during 2010-2015 and previously hospitalized for ARF. Most (86.4%) of the 2,182 initial ARF patients did not experience disease progression by the end of 2015. Progression probability after 26.8 years of theoretical follow-up was 24.0%; probability of death, 1.0%. Progression was more rapid and ≈2 times more likely for indigenous Māori or Pacific Islander patients. Of 435 initial RHD patients, 82.2% had not been previously hospitalized for ARF. This young cohort demonstrated low mortality rates but considerable illness, especially among underserved populations. A national patient register could help monitor, prevent, and reduce ARF progression.

The role of causal knowledge in stigma considerations in African genomics research: Views of South African Xhosa people

INTRODUCTION

Advances in genomics research have raised several ethical concerns. One concern is the potential impact of genomics research on stigma experienced by people affected by a disease. Studies have found that the type of illness as well as disease causal beliefs impact on the relation between genetic attribution and stigma. This study explored the potential impact of genetic attribution of disease on stigma among Xhosa people with Rheumatic Heart Disease (RHD).

METHODS

Study participants were 46 Xhosa people with RHD living in the Western Cape Province of South Africa. Using video vignettes in 7 focus group discussions we explored whether and how genetic attribution may impact on disease-stigma. Vignettes introduced participants to non-genetic and genetic causal explanations and were followed-up with a series of open-ended questions eliciting their perceptions of non-genetic disease causes as well as genetic causation and its impact on internalised stigma.

RESULTS

This study found that Xhosa people with RHD have a general understanding of genetics and genetic attribution for disease. Additionally, and not withstanding their genetic knowledge, these participants hold multiple disease causal beliefs including genetic, infectious disease, psychosocial, behavioural and cultural explanations. While there was evidence of internalised stigma experiences among participants, these appeared not to be related to a genetic attribution to the disease.

DISCUSSION

The findings of this study provide clues as to why it is unlikely that a genetic conceptualisation of disease impacts internalised stigma experiences of Xhosa people. The causal explanations provided by participants reflect their cultural understandings and their context, namely, living in low-income and poverty-stricken environments. Divergence in these findings from much of the evidence from high-income countries emphasises that context matters when considering the impact of genetic attribution on stigma and caution against generalising findings from one part of the globe to another.

Pattern of Cardiac Diseases and Co-Existing Morbidities Among Newly Registered Cardiac Patients in an Adult Cardiac Referral Clinic of Hawassa University Comprehensive Specialized Hospital, Southern-Ethiopia

Background

Currently, cardiovascular diseases (CVDs) are rising in the world and require great concern because the consequences are not only morbidity and mortality, but also a high economic burden. However, the pattern of CVDs in Ethiopia is not well known. Therefore, this study aimed to describe CVD and co-existing morbidities among newly registered cardiac patients in Hawassa University Comprehensive Specialized Hospital.

Methods

A retrospective cross-sectional study was conducted from January 1 to December 31, 2016 among newly registered cardiac patients in an adult cardiac referral clinic. Records and cardiac referral clinic logbooks were used to collect relevant information using structured checklists.

Results

Of the total 310 records of cardiac patients, 236 were explored and included in the study, while the records of 74 patients were absent in the cards room when tracing and/or incomplete to assess cardiac pattern. Rheumatic heart disease (RHD) was the leading cardiac problem and diagnosed in 70 (29.7%) cases followed by non-ischemic cardiomyopathy (55, 23.3%), ischemic heart disease (41, 17.4%), hypertensive heart disease (29, 12.3%), and cor pulmonale (14, 5.9%). The mean age of RHD patients was 28.7 (±13.1) years. Eighty-two (35%) females and 23 (19.8%) males had RHD, while 69 (29.2%) females and 23 (19.8%) males had non-ischemic cardiomyopathy. The overall rate of mitral stenosis, mitral regurgitation, and aortic regurgitation among patients with RHD were 39 (55.7%), 48 (68.6%), and 26 (37.1%), respectively. Moreover, the overall coexisted morbidity was 81 (34.3%), with a high rate of hypertension alone at 44 (18.6%) followed by hypertension with diabetes at 11 (4.7%).

Conclusion

This study indicated that more than one-third of cardiac patients had at least one of the co-existing morbidities like hypertension, diabetes mellitus, asthma and other diseases. Therefore, careful diagnosis and management of cardiac patients plays an important role to minimize comorbidity-linked complications. Moreover, population-based studies are recommended for better representing and generalization.

How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018)

Rheumatic heart disease (RHD) as a chronic sequela of repeated episodes of acute rheumatic fever (ARF), remains a cause of cardiac morbidity in Egypt although it is given full attention through a national RHD prevention and control program. The present report reviews our experience with subjects presenting with ARF or its sequelae in a single RHD centre and describes the disease pattern over the last decade. A cross-sectional study was conducted in El-Mahalla RHD centre between 2006 and 2018. A total of 17014 individual were enrolled and evaluated. Diagnosis ARF was based on the 2015 revised Jones criteria and RHD was ruled in by echocardiography. The majority of the screened subjects were female (63.2%), in the age group 5-15 years (64.6%), rural residents (61.2%), had primary education (43.0%), and of low socioeconomic standard (50.2%). The total percentage of cases presenting with ARF sequelae was 29.3% [carditis/RHD (10.8%), rheumatic arthritis (Rh.A) (14.9%), and Sydenham's chorea (0.05%)]. Noticeably, 72% were free of any cardiac insult, of which 37.7% were victims of misdiagnoses made elsewhere by untrained practitioners who prescribed for them long term injectable long-acting penicillin [Benzathine Penicillin G (BPG)] without need. About 54% of the study cohort reported the occurrence of recurrent attacks of tonsillitis of which 65.2% underwent tonsillectomy. Among those who experienced tonsillectomy and/or received BPG in the past, 14.5% and 22.3% respectively had eventually developed RHD. Screening of family members of some RHD cases who needed cardiac surgery revealed 20.7% with undiagnosed ARF sequalae [RHD (56.0%) and Rh.A (52.2%)]. Upon the follow-up of RHD cases, 1.2% had improved, 98.4% were stable and 0.4% had their heart condition deteriorated. Misdiagnosis of ARF or its sequelae and poor compliance with BPG use may affect efforts being exerted to curtail the disease. Updating national guidelines, capacity building, and reliance on appropriate investigations should be emphasized. Since the genetic basis of RHD is literally confirmed, a family history of RHD warrants screening of all family members for early detection of the disease.

An Overview of First 100 Cardiac Surgery Cases at a Newly Developed Satellite Center in Sukkur, Pakistan

Introduction

The aim of this research is to evaluate the in-hospital and early outcomes of the first 100 adult cardiac surgeries performed at a newly developed satellite center in Sukkur, Pakistan.

Methods

This is an audit of the first 100 adult cardiac surgeries performed at a newly developed satellite center of the National Institute of Cardiovascular Diseases (NICVD) at Sukkur, Pakistan, from March 2018 to November 2018 with 12 months of post-operative follow-up. Patients were offered off-pump coronary artery bypass (OPCAB), on-pump coronary artery bypass (ONCAB), mitral valve replacement (MVR), aortic valve replacement (AVR), minimally invasive cardiac surgery (MICS), and congenital adult congenital heart disease (ACHD) procedures by expert faculty of NICVD with a minimum of five years of post-fellowship experience.

Results

The mean age was 47.11 ± 14.6 years, with a male predominance of 77%. Hypertension and smoking were the most common risk factors that were observed in 32% and 33%, respectively, followed by diabetes and dyslipidemia with a frequency of 20% and 9%, respectively. The mean EuroSCORE (European System for Cardiac Operative Risk Evaluation) II for this patient cohort was 1.165 ± 0.50, with a maximum score of 2.3 in one patient. Out of 100 procedures, 51 were ONCAB, 19 were OPCAB, 16 were MVR, three were AVR, nine were ACHD, and two were MICS. Survival status post-operative as well as after one year was 100%. The frequency of post-operative bleeding was 7%, mean post-operative mechanical ventilation time was 213 ± 273 hours, and in-hospital stay was 5.41 ± 0.165 days. Lost to follow-up at one year was 4% (four). During the follow-up assessment, 39.5% of the patients had complained of mild-to-moderate intensity retrosternal pain and 4.2% had superficial surgical site infection of the sternal wound. A significant improvement in functional class was observed in 38.5% of patients, whereas 4.2% (four) had a significant drop in functional class post-operatively.

Conclusion

Providing tertiary care and early cardiac surgical facility to the people of Sukkur at their doorstep, in a newly developed satellite center, has resulted in improved outcomes, early quality treatment facility, and avoidance of long travel time.

Ten-year trends in the incidence, treatment and outcomes of patients with mitral stenosis in Korea

Objective

Mitral stenosis increases the risk of atrial fibrillation (AF) and stroke. Large data underlying the trend in incidence, treatment and outcomes of mitral stenosis are lacking.

Methods

Based on the Health Insurance Review and Assessment Service database in Republic of Korea, patients who were diagnosed with mitral stenosis between 2007 and 2016 were enrolled. Trends in the incidence rate and changing patterns of treatment and outcome for stroke and systemic embolism and intracranial haemorrhage (ICH) were analysed.

Results

A total of 42 075 patients (mean age 60.7±13.5 years, 13 303 (31.6%) male) were included in the present study. The number included 27 824 (66.1%) patients with mitral stenosis and comorbid AF. The age-standardised annual incidence rate per 100 000 of mitral stenosis in Korea decreased remarkably from 10.3 to 3.6 over 10 years. The use of anticoagulation therapy increased consistently. The annual incidence of stroke and systemic embolism showed signs of plateau, while the incidence of ICH increased.

Conclusions

The overall incidence rate of mitral stenosis in Korean population has decreased remarkably. As increasing the use of vitamin K antagonist, the annual incidence rate of ICH was increased but the rate of stroke incidence reached a plateau. Alternative effective anticoagulation strategy should be investigated.

Prevalence and progression of rheumatic heart disease: a global systematic review and meta-analysis of population-based echocardiographic studies

This systematic review and meta-analysis aimed to provide a contemporaneous estimate of the global burden of rheumatic heart disease (RHD) from echocardiographic population-based studies. We searched multiple databases between January 01, 1996 and October 17, 2017. Random-effect meta-analysis was used to pool data. We included 82 studies (1,090,792 participant) reporting data on the prevalence of RHD and 9 studies on the evolution of RHD lesions. The pooled prevalence of RHD was 26.1‰ (95%CI 19.2-33.1) and 11.3‰ (95%CI 7.2-16.2) for studies which used the World Heart Federation (WHF) and World Health Organization (WHO) criteria, respectively. The prevalence of RHD varied inversely with the level of a country's income, was lower with the WHO criteria compared to the WHF criteria, and was lowest in South East Asia. Definite RHD progressed in 7.5% (95% CI 1.5-17.6) of the cases, while 60.7% (95% CI 42.4-77.5) of cases remained stable over the course of follow-up. The proportion of cases borderline RHD who progressed to definite RHD was 11.3% (95% CI 6.9-16.5). The prevalence of RHD across WHO regions remains high. The highest prevalence of RHD was noted among studies which used the WHF diagnostic criteria. Definite RHD tends to progress or remain stable over time.

Risk Factors for Acute Rheumatic Fever: Literature Review and Protocol for a Case-Control Study in New Zealand

Acute rheumatic fever (ARF) and its sequela, rheumatic heart disease (RHD), have largely disappeared from high-income countries. However, in New Zealand (NZ), rates remain unacceptably high in indigenous Māori and Pacific populations. The goal of this study is to identify potentially modifiable risk factors for ARF to support effective disease prevention policies and programmes. A case-control design is used. Cases are those meeting the standard NZ case-definition for ARF, recruited within four weeks of hospitalisation for a first episode of ARF, aged less than 20 years, and residing in the North Island of NZ. This study aims to recruit at least 120 cases and 360 controls matched by age, ethnicity, gender, deprivation, district, and time period. For data collection, a comprehensive pre-tested questionnaire focussed on exposures during the four weeks prior to illness or interview will be used. Linked data include previous hospitalisations, dental records, and school characteristics. Specimen collection includes a throat swab (Group A Streptococcus), a nasal swab (Staphylococcus aureus), blood (vitamin D, ferritin, DNA for genetic testing, immune-profiling), and head hair (nicotine). A major strength of this study is its comprehensive focus covering organism, host and environmental factors. Having closely matched controls enables the examination of a wide range of specific environmental risk factors.

Initial Experience of Minimally Invasive Concomitant Aortic and Mitral Valve Replacement/Repair at a Tertiary Care Cardiac Centre of a Developing Country

Introduction

Minimally invasive double valve replacement (DVR) surgery through a small transverse anterior thoracotomy is an alternate technique to sternotomy for concomitant aortic and mitral valve (AVR, MVR) surgery. The aim of this study was to evaluate the in-hospital and early outcomes of direct vision minimal invasive double valve surgery (DVMI-DVR) at a tertiary care cardiac center of a developing country.

Methods

This study was conducted at the National Institute of Cardiovascular Diseases Karachi, Pakistan from January 2018 to September 2018. Nineteen consecutive patients undergoing DVMI-DVR for aortic and mitral disease without any prior cardiac surgery were included in this study. For all procedures, access was obtained through small transverse anterior thoracotomy incision with wedge resection (Chaudhry’s Wedge) of sternum opposite to the third and fourth costosternal joints. Patients were observed during their hospital stay and the following variables were observed the length of hospital stay (LOHS), ventilator support, intensive care unit (ICU) stay, pain score, and mortality. The pain score was assessed using the visual analog scale (VAS).

Results

The male/female ratio was 11:8 with a mean age of 35 ± 12 years with mean EuroSCORE of 6.6 ± 3.5%. The mean total bypass time was 129.8 ± 23.83 min (range: 98-181 minutes). The mean mechanical ventilation time was 3.16 ± 1.12 hours (range: 2-6 hours). The mean intensive care unit (ICU) stay was 41.84 ± 8.36 hours. The mean post-operative LOHS was 5.63 ± 1.12 days (range: 4-8 days). We had zero frequency of wound infection and surgical mortality. The mean pain score was 4.32 (on a predefined pain scale of one to nine with a high value indicating severe pain).

Conclusion

Minimally invasive DVR surgery is a safe and reproducible technique with comparable outcomes such as postoperative pain score (4.32 ± 2.05), ventilation time (3.16 ± 1.12 hours), ICU stay (41.84 ± 8.36 hours), and hospital stay (5.63 ± 1.12 days). In terms of mortality, operative times, ICU stay, and hospital stay, the minimally invasive DVR is at least comparable to those achieved with median sternotomy. Further prospective randomized studies are needed to validate our findings.

The effect of oral progesterone for the treatment of abnormal uterine bleeding in women taking warfarin following prosthetic valve replacement

Objectives:

To evaluate the effect of oral progesterone for the treatment of abnormal uterine bleeding in patients taking warfarin after prosthetic valve replacement.

Methods:

A total of 85 women of reproductive age, who were on warfarin due to prosthetic valve replacement were enrolled in the study. After detailed evaluation, their menstrual bleeding was quantified using Pictorial Bleeding Evaluation Chart. The patients were then prescribed an oral progesterone (Norethisterone) 5mg three times daily. The first follow up was done after one-month then at 3-months and at six months. The improvement in PBAC score was recorded at each visit. Data was entered and analyzed using SPSS (version 23.0). The mean ± Standard Deviation were calculated for quantitative variables while qualitative variables were presented in frequency table. The normality of data was checked using Kolmogorov-Smirnov test. Due lack of normal distribution of data in various groups, the Wilcoxon Sign Rank test was used to test the significance before and after treatment. The p-value of <0.05 was taken as statistically significant.

Results:

The mean age of the patients was 30.13±7.69 years. The mean PBAC score was 162.8 ± 24.86 before initiation of treatment while at the end of the treatment it was 105.48 ± 8.38. Forty-six (54.1%) patients had continuous per vaginal bleeding, 33 (38.8%) had menorrhagia, 4 (4.7%) had inter-menstrual bleeding and 2 (2.4%) had menorrhagia along with polymenorrhea. The mean dose of warfarin taken by the patients was 5.85 ± 2.69 mg. The median parity of the patients was 2. The Wilcoxon Sign Rank test showed p-value of <0.00001 for comparison of the pre-treatment PCBA values with those of one, three and six-months after the treatment. The Friedman’s test also had a p-value of <0.00001. This confirmed that the post treatment bleeding was significantly less than pretreatment bleeding.

Conclusion:

The warfarin induced abnormal uterine bleeding can be controlled effectively and safely with low dose of oral progesterone.

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

Background

To assess the prevalence patterns of isolated/mixed rheumatic valvular lesions and associated risk factors among rheumatic heart disease (RHD) patients undergoing surgical valve replacement.

Methods

An 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.

Results

Age (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 (τ_c = -0.188, p-value = 0.033) and positively with aortic stenosis (AS) severity (τ_c = 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.

Conclusions

MR 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.

Time to tackle rheumatic heart disease: Data needed to drive global policy dialogues

Rheumatic heart disease (RHD) is an avoidable disease of poverty that persists predominantly in low resource settings and among Indigenous and other high-risk populations in some high-income nations. Following a period of relative global policy inertia on RHD, recent years have seen a resurgence of research, policy and civil society activity to tackle RHD; this has culminated in growing momentum at the highest levels of global health diplomacy to definitively address this disease of disadvantage. RHD is inextricably entangled with the global development agenda, and effective RHD action requires concerted efforts both within and beyond the health policy sphere. This report provides an update on the contemporary global and regional policy landscapes relevant to RHD, and highlights the fundamental importance of good data to inform these policy dialogues, monitor systems responses and ensure that no one is left behind.

The role of social determinants of health in the risk and prevention of group A streptococcal infection, acute rheumatic fever and rheumatic heart disease: A systematic review

Background

Rheumatic heart disease (RHD) poses a major disease burden among disadvantaged populations globally. It results from acute rheumatic fever (ARF), a complication of Group A Streptococcal (GAS) infection. These conditions are acknowledged as diseases of poverty, however the role of specific social and environmental factors in GAS infection and progression to ARF/RHD is not well understood. The aim of this systematic review was to determine the association between social determinants of health and GAS infection, ARF and RHD, and the effect of interventions targeting these.

Methodology

We conducted a systematic literature review using PubMed, the Cochrane Library and Embase. Observational and experimental studies that measured: crowding, dwelling characteristics, education, employment, income, nutrition, or socioeconomic status and the relationship with GAS infection, ARF or RHD were included. Findings for each factor were assessed against the Bradford Hill criteria for evidence of causation. Study quality was assessed using a standardised tool.

Principle findings

1,164 publications were identified. 90 met inclusion criteria, comprising 91 individual studies. 49 (50.5%) were poor quality in relation to the specific study question. The proportion of studies reporting significant associations between socioeconomic determinants and risk of GAS infection was 57.1%, and with ARF/RHD was 50%. Crowding was the most assessed factor (14 studies with GAS infection, 36 studies with ARF/RHD) followed by socioeconomic status (6 and 36 respectively). The majority of studies assessing crowding, dwelling characteristics, education and employment status of parents or cases, and nutrition, reported a positive association with risk of GAS infection, ARF or RHD. Crowding and socioeconomic status satisfactorily met the criteria of a causal association. There was substantial heterogeneity across all key study aspects.

Conclusion

The extensive literature examining the role of social determinants in GAS infection, ARF and RHD risk lacks quality. Most were observational, not interventional. Crowding as a cause of GAS infection and ARF/RHD presents a practical target for prevention actions.

Rates of rheumatic heart disease (RHD) are high in disadvantaged populations globally. It results from acute rheumatic fever (ARF), a complication of Group A Streptococcal (GAS) infection. These are described as diseases of poverty, but exactly what components of poverty promote them has been unclear. The aim of this review was to find what specific social and environmental factors are associated with GAS infection, ARF and RHD, and if actions targeting these can reduce disease rates. We did a search of published literature and found 90 relevant articles. Many supported an association between GAS infection, ARF or RHD and crowding, dwelling characteristics, low education level and employment status, poor nutrition and low social class. There was enough evidence to show that crowding and socioeconomic disadvantage increase the risk of GAS infection and ARF/RHD. However, most studies were of fair to poor quality in their ability to answer the research question, and there was little interventional research. This may relate to challenges inherent in intervening to change social determinants of health, but may also suggest lesser research attention to health issues affecting disadvantaged populations. The association between crowding and disease risk strongly supports initiatives to reduce crowding. This should become a key target for ARF and RHD prevention.

GWAS implicated risk variants in different genes contribute additively to increase the risk of coronary artery disease (CAD) in the Pakistani subjects

Background

Coronary artery disease (CAD) remains the single most important cause of mortality worldwide. Many candidate and GWAS genetic variants have been identified in the recent years. In the current study, we selected six SNPs from various genes that have originally been identified in GWAS studies and examined the association of SNPs individually and as a genetic risk score (GRS) with CAD and blood lipid levels in the Pakistani subjects.

Methods

Six hundred twenty-four (404 cases and 219 controls) subjects were genotyped for variants rs10757274 in CDKN2A gene, rs17465637 in MIA3 gene, rs7025486 in DAB2IP gene, rs17228212 in SMAD3 gene, rs981887 in MRAS gene and rs1746048 in CXCL12 gene, by TaqMan and KASPar allele discrimination techniques. Serum lipid parameters were measured using commercially available kits. Statistical analyses were done using SPSS version 22.

Results

Individually, the single SNPs were not associated with CAD (p < 0.05). However, the combined GRS of 6 SNPs was significantly higher in cases than controls (4.89 ± 0.11 vs 4.58 ± 0.08, p = 0.024). Among blood lipids, GRS showed significant positive association with serum triglycerides levels (p = 0.022).

Conclusion

The GRS was quantitatively associated with CAD risk and showed association with serum triglycerides levels, suggesting that the mechanism of these variants is likely to be in part at least through creating an atherogenic lipid profile in subjects carrying high numbers of risk alleles.

Electronic supplementary material

The online version of this article (10.1186/s12944-018-0736-2) contains supplementary material, which is available to authorized users.

Echocardiographic Assessment of Mitral Stenosis Orifice Area: A Comparison of a Novel Three-Dimensional Method Versus Conventional Techniques

BACKGROUND

A comprehensive evaluation of mitral stenosis (MS) severity commonly utilizes two-dimensional (2D) echocardiography techniques. However, the complex three-dimensional (3D) structure of the mitral valve (MV) poses challenges to accurate measurements of its orifice area by 2D imaging modalities. We aimed to assess MS severity by comparing measurements of the MV orifice area using conventional echocardiography methods to 3D orifice area (3DOA), a novel echocardiographic technique which minimizes geometric assumptions.

METHODS

Routine 2D and 3D intraoperative transesophageal echocardiographic images from 26 adult cardiac surgery patients with at least moderate rheumatic MS were retrospectively reviewed. Measurements of the MV orifice area obtained by pressure half-time (PHT), proximal isovelocity surface area (PISA), continuity equation, and 3D planimetry were compared to those acquired using 3DOA.

RESULTS

MV areas derived by PHT, PISA, continuity equation, 3D planimetry, and 3DOA (mean value ± standard deviation) were 1.12 ± 0.27, 1.03 ± 0.27, 1.16 ± 0.35, 0.97 ± 0.25, and 0.76 ± 0.21 cm, respectively. Areas obtained from the 3DOA method were significantly smaller than areas derived from PHT (mean difference 0.35 cm, P < .0001), PISA (mean difference: 0.28 cm, P = .0002), continuity equation (mean difference: 0.43 cm, P = .0015), and 3D planimetry (mean difference: 0.19 cm, P < .0001). MV 3DOAs also identified a significantly greater percentage of patients with severe MS (88%) compared to PHT (31%, P = .006), PISA (42%, P = .01), and continuity equation (39%, P = .017) but not in comparison to 3D planimetry (62%, P = .165).

CONCLUSIONS

Novel measures of the stenotic MV 3DOA in patients with rheumatic heart disease are significantly smaller than calculated values obtained by conventional methods and may be consistent with a higher incidence of severe MS compared to 2D techniques. Further investigation is warranted to determine the clinical relevance of 3D echocardiographic techniques used to measure MV area.

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

BACKGROUND AND AIMS

Rheumatic 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 METHODS

This is a hospital based descriptive cross-sectional study during June 2014 to April 2016 over a period of 22 months at College of Medical Sciences-Bharatpur including 235 patients with clinical and/or echocardiographic evidence of definite rheumatic heart disease.

RESULTS

The age of the patients ranged from 7 to 76 years with mean age 39.82 ± 4.2 years with female preponderance (F:M = 2.1:1) (p < 0.01). Majority of the rheumatic heart disease patients belonged to 30-44 years (28.78%) followed by 15-29 years (25.75%) and 45-59 years (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.

CONCLUSION

RHD is a leading cause of heart failure among young populations with requirement of prolonged duration of medical treatment and many of them requiring surgery.

Acute rheumatic fever and exposure to poor housing conditions in New Zealand: A descriptive study

AIM

Acute rheumatic fever (ARF) is an important public health problem in low- and middle-income countries and in certain populations in high-income countries. Indigenous Australians, and New Zealand Māori and Pacific people, have incidence rates among the highest in the world. We aimed to investigate ARF cases' housing conditions and sore throat treatment to identify opportunities for improving ARF prevention in New Zealand.

METHODS

Recently diagnosed cases and their care givers were interviewed. Information was obtained about the cases' demographics, housing circumstances and conditions, and sore throat treatment preceding ARF.

RESULTS

We interviewed 55 cases. Most (75%) lived in rental housing and reported multiple measures of deprivation. Common exposures were household crowding (58%), bed-sharing (49%), dampness and mould (76%), cold (82%) and co-habiting with smokers (71%). Experiencing sore throat in the weeks before ARF was recalled by 62%, with 29% seeing a doctor or nurse and 13% of the total sample receiving antibiotics.

CONCLUSIONS

The environmental conditions reported could contribute to high group A Streptococcus transmission and susceptibility to infection, thus increasing ARF risk. Sore throat treatment has important limitations as an intervention, particularly as 38% of participants did not recall sore throat preceding the diagnosis. The results support the need to improve rental housing. Interventions promoting minimum enforceable standards in social housing and private rental sectors (such as a housing warrant of fitness) could support these changes. A rigorous investigation, such as a case control study, is needed to explore risk factors further.

Antibiotic susceptibility in Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes in Pakistan: a review of results from the Survey of Antibiotic Resistance (SOAR) 2002-15

OBJECTIVES

To investigate changes in the antibiotic susceptibility of Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes from the Survey of Antibiotic Resistance (SOAR) in community-acquired respiratory tract infections (CA-RTIs) between 2002 and 2015 in Pakistan.

METHODS

This is a review based on previously published studies from 2002-03, 2004-06 and 2007-09 and also new data from 2014-15. Susceptibility was determined by Etest(®) or disc diffusion according to CLSI and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 706 isolates from CA-RTIs comprising 381 S. pneumoniae, 230 H. influenzae and 95 S. pyogenes were collected between 2002 and 2015 and tested against a range of antibiotics. Antibiotic resistance in S. pneumoniae rose steeply from 2002 to 2009, with isolates non-susceptible to penicillin and macrolides increasing from 10% to 34.1% and from 13%-14% to 29.7%, respectively. Susceptibility to amoxicillin/clavulanic acid (and by inference amoxicillin) remained between 99.4% and 100% from 2002 to 2015. Over the years, the prevalence of susceptibility to cefuroxime was 98%-100% among S. pneumoniae. Resistance in S. pneumoniae to some older antibiotics between 2007 and 2009 was high (86.8% for trimethoprim/sulfamethoxazole and 57.2% for tetracycline). Between 2002 and 2015, ampicillin resistance (β-lactamase-positive strains) among H. influenzae has remained low (between 2.6% and 3.2%) and almost unchanged over the years (H. influenzae was not tested during 2004-06). For S. pyogenes isolates, macrolide resistance reached 22%; however, susceptibility to penicillin, amoxicillin/clavulanic acid and cefuroxime remained stable at 100%.

CONCLUSIONS

In S. pneumoniae from Pakistan, there has been a clear reduction in susceptibility to key antibiotics since 2002, but not to amoxicillin/clavulanic acid (amoxicillin) or cefuroxime. However, susceptibility in H. influenzae has remained stable. Local antibiotic susceptibility/resistance data are essential to support informed prescribing for CA-RTIs and other infections.

The value of urotensin II in patients with left-sided rheumatic valvular regurgitation

Aims

Rheumatic valve diseases are most common etiological valve diseases in developing countries. Urotensin II is cardiovascular autacoid/hormone and may be associated with patients of heart valve diseases. The present study was to measure plasma urotensin II concentrations in patients with left-sided rheumatic valve diseases such as mitral regurgitation (MR) and aortic regurgitation (AR), and to examine its correlation with severity of valve impairment, function (New York Heart association, NYHA) class and pulmonary artery pressure (PAP).

Methods and results

Sixty patients with moderate to severe rheumatic left-sided valve regurgitation and 20 healthy controls were selected after performing the echocardiography. Plasma urotensin II level was measured in all subjects. The patients with MR and AR were significantly increased of left ventricular end diastolic dimension (LVEDD), left ventricular end systolic dimension (LVESD), left atrial diameter, PAP, but decreased of EF% versus the controls. Urotensin II level was highly significant in patients with MR (1.83 ± 0.92 ng/ml, P < 0.001) and AR (0.79 ± 0.3 ng/ml, P < 0.05) versus the controls (0.48 ± 0.13 ng/ml). Also, there was significant correlation between Urotensin II level and LVEDD (MR, r = 0.318, P = 0.03; AR, r = 0.805, P < 0.001), LVESD (MR, r = −0.271, P = 0.115; AR, r = 0.614, P = 0.001), and PAP (MR, r = 0.706, P < 0.001; AR, r = 0.129, P = 0.538).

Conclusion

Urotensin II was elevated in patients with rheumatic left-sided valvular regurgitation, and positively correlated with increased LVEDD (in both MR and AR), LVESD (only AR) and pulmonary artery pressure (only MR). Therefore, urotensin II level may be used as diagnostic biomarker in patients with rheumatic valvular diseases for assessment of the severity in parallel with echocardiography.

Prosthetic Valve Replacement in Adolescents with Rheumatic Heart Disease

To assess long-term survival and anticoagulant-related complications after mechanical valve replacement in adolescents with rheumatic heart disease, 88 patients aged ≤ 18 years were prospectively followed up for 10 years (404.2 patient-years). There were 58 (65.9%) boys and 30 (34.1%) girls, with a mean age of 15.4 ± 2.1 years. Mitral regurgitation was detected in 39 (44.3%) patients, and both mitral and aortic regurgitation in 15 (17%). Ball valves were inserted in 52 (59.1%) patients, bileaflet valves in 31 (35.2%), and single-disc valves in 5 (5.7%). There were 4 (4.5%) hospital deaths and 11 late deaths. Patient survival at 30 days, 3 months, 1, 5, and 10 years was 95.5%, 93.2%, 87.5%, 82.9%, and 82.9%, respectively. Mechanical valve thrombosis occurred in 4 patients; it was fatal in 3 of them. Three patients died from stroke. Severe hemorrhage required hospital admission in 4 (4.5%) patients. Mechanical valve replacement in adolescents, with careful follow-up and anticoagulation, has acceptable long-term results.

Anticoagulation in Pregnancy with Mechanical Heart Valves: 10-Year Experience

Anticoagulation in pregnancy was evaluated in 33 women with a mechanical heart valve prosthesis who had 53 pregnancies between 1994 and 2006. Their mean age at valve operation was 24.4 ± 5.4 years, and 22 (67%) had isolated mitral valve disease. Of these patients, 22 had a single pregnancy, 5 had 2 pregnancies, 3 had 3, and 3 had 4. In 43 pregnancies, the patients took warfarin throughout; in the other 10, heparin was used in the first trimester followed by warfarin until the last 15 days. Mean international normalized ratio and warfarin levels before, during, and after pregnancy were similar. Complications occurred in 3 (6%) women who had thrombosed valves: 2 (20%) in the heparin group and 1 (2%) who had warfarin only. Live births resulted from 37 (70%) pregnancies. There were significantly more abortions in the heparin group (6; 60%) than the warfarin group (8; 19%). Hemorrhage requiring transfusion occurred in 2 (5%) patients in the warfarin group. All live births resulted in healthy babies. It was concluded that anticoagulation with warfarin is safe during pregnancy in women with mechanical heart valves.

Screening for Rheumatic Heart Disease among Peruvian Children: A Two-Stage Sampling Observational Study

BACKGROUND

The objective of the study was to evaluate the implications of different classifications of rheumatic heart disease on estimated prevalence, and to systematically assess the importance of incidental findings from echocardiographic screening among schoolchildren in Peru.

METHODS

We performed a cluster randomized observational survey using portable echocardiography among schoolchildren aged 5 to 16 years from randomly selected public and private schools in Arequipa, Peru. Rheumatic heart disease was defined according to the modified World Health Organization (WHO) criteria and the World Heart Federation (WHF) criteria.

FINDINGS

Among 1395 eligible students from 40 classes and 20 schools, 1023 (73%) participated in the present survey. The median age of the children was 11 years (interquartile range [IQR] 8-13 years) and 50% were girls. Prevalence of possible, probable and definite rheumatic heart disease according to the modified WHO criteria amounted to 19.7/1000 children and ranged from 10.2/1000 among children 5 to 8 years of age to 39.8/1000 among children 13 to 16 years of age; the prevalence of borderline/definite rheumatic heart disease according to the WHF criteria was 3.9/1000 children. 21 children (2.1%) were found to have congenital heart disease, 8 of which were referred for percutaneous or surgical intervention.

CONCLUSIONS

Prevalence of RHD in Peru was considerably lower compared to endemic regions in sub-Saharan Africa, southeast Asia, and Oceania; and paralleled by a comparable number of undetected congenital heart disease. Strategies to address collateral findings from echocardiographic screening are necessary in the setup of active surveillance programs for RHD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02353663.

Epidemiology and Management Cost of Myocardial Infarction in North Punjab, Pakistan

Background:

Coronary heart disease (CHD) is an important cause of morbidity and mortality in Pakistan. The temporal trends in the risk factors for myocardial infarction (MI) and the impact of socioeconomic status on these risk factors remain ambiguous.

Objectives:

The objectives of the present analysis were to investigate the potential association between various risk factors and MI in North Punjab, Pakistan, and to assess the status of the control of the risk factors associated with MI in this population.

Patients and Methods:

The present study included 515 patients admitted to the coronary care units or equivalent cardiology wards of the participating hospitals between 2011 and 2012 in North Punjab, Pakistan. The analysis was focused on identifying the socioeconomic status, lifestyle, family history of MI, and risk factors (i.e. hypertension, diabetes, smoking, and hyperlipidemia). A structured questionnaire was designed to collect data. The lipid profile was recorded from the investigation chart of every patient. For statistical analysis, the Kruskal Wallis, Mann-Whitney U, Wilcoxon, and chi-square tests were used.

Results:

MI was common in the males at the age of 41 - 60 years as compared to the females (P = 0.015). Patients with a positive parental history of CHD experienced MI at a younger age (P = 0.0001) at a body mass index (BMI) ≤ 25 kg/m². Sedentary lifestyle (70%) and smoking (60%) had a male predominance. Hypertension accounted for nearly 37%, hyperlipidemia 26%, and diabetes 19.4% of the rural and urban subjects (P < 0.01). High-density lipoprotein cholesterol decreased (up to 34 mg/dl), while low-density lipoprotein cholesterol and hypertension increased with age. The mean monthly cost of medicines and physicians’ fees per patient was 2381.132 Pakistani Rupees (24.24 USD).

Conclusions:

Higher BMI, positive family history, smoking, hypertension, hyperlipidemia, and diabetes were the strong predictors of MI in North Punjab, Pakistan. Preventive efforts are needed to start early in life and continue throughout the life course.

Gender differences in outcomes following cardiac surgery: implications for managing patients with mitral valve disease

PURPOSE OF REVIEW

This review summarizes the differences in clinical outcomes following cardiac surgery according to gender.

RECENT FINDINGS

Women comprise a large proportion of patients presenting with coronary artery or valvular heart disease. Although it is well known that women have poorer survival following bypass surgery compared with men, more recent data confirm that women also have poorer outcomes after heart valve surgery. Women are also more likely to receive mitral valve replacement instead of repair, when compared with men. These divergent outcomes are because of many factors, including valve disease and clinical presentation, which may result in delayed surgical referral in women.

SUMMARY

Factors that result in poorer outcomes following heart valve surgery, including mitral valve surgery, between men and women remain incompletely understood. These may relate to differences in clinical presentation, valve morphology, and physiology. Further research is needed to clarify differences in heart valve outcomes according to gender.

Triple valve replacement for rheumatic heart disease: short- and mid-term survival in modern era

OBJECTIVES

Triple valve replacement (TVR) is still deemed a complex and challenging choice for rheumatic heart disease (RHD) and carries significant mortality and morbidity. We report the short- and mid-term results after TVR in the last decade.

METHODS

In a historical cohort, ninety consecutive patients, at a mean age of 47 ± 12 years underwent TVR between 2003 and 2013 for RHD. Most of the patients were in the New York Heart Association (NYHA) functional class II or III. Univariate and multivariate analyses were performed to identify the predictors of overall and event-free survival.

RESULTS

The 30-day hospital mortality rate was 6% (n = 5). One-year and 4-year overall survival (cardiac survival) rates were 91.7 and 89.5%, respectively. One-year and 4-year rates of freedom from cardiac events (e.g. cardiac death, cardiac rehospitalization, cardiac reoperation, cerebrovascular events, anticoagulation-related major haemorrhage and significant valvular malfunction) were 83.5 and 69.5%, respectively. Age, diabetes and pump time were the independent predictors of overall survival, and diabetes and hypertension were the independent predictors of event-free survival. One-year and 4-year freedom rates from anticoagulation-related major haemorrhage were 96.6 and 90.7%, respectively. The 1-year and 4-year rates of freedom from a composite of valvular thrombosis, major bleeding events and thromboemboli were 94.1 and 88.5%, respectively. One-year and 4-year freedom rates from cardiac rehospitalization were 94.0 and 88.0%, respectively. One-year and 4-year rates of freedom from cardiac reoperation were 98.8 and 93.9%, respectively. One-year and 4-year rates of freedom from significant prosthetic valve malfunction (e.g. structural valve deterioration, valve thrombosis and paravalvular leakage) were 96.6 and 90.7%, respectively. The 1-year and 4-year rates of freedom from major adverse valve-related events were 86.3 and 78.5%, respectively.

CONCLUSIONS

TVR for RHD appears to confer satisfactory short- and mid-term results with excellent symptomatic improvement. The overall mortality following TVR may be improved by early surgical treatment before the NYHA functional class IV.

Heart valve surgery: EuroSCORE vs. EuroSCORE II vs. Society of Thoracic Surgeons score

BACKGROUND

This is a validation study comparing the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II with the previous additive (AES) and logistic EuroSCORE (LES) and the Society of Thoracic Surgeons' (STS) risk prediction algorithm, for patients undergoing valve replacement with or without bypass in Pakistan.

PATIENTS AND METHODS

Clinical data of 576 patients undergoing valve replacement surgery between 2006 and 2013 were retrospectively collected and individual expected risks of death were calculated by all four risk prediction algorithms. Performance of these risk algorithms was evaluated in terms of discrimination and calibration.

RESULTS

There were 28 deaths (4.8%) among 576 patients, which was lower than the predicted mortality of 5.16%, 6.96% and 4.94% by AES, LES and EuroSCORE II but was higher than 2.13% predicted by STS scoring system. For single and double valve replacement procedures, EuroSCORE II was the best predictor of mortality with highest Hosmer and Lemmeshow test (H-L) p value (0.346 to 0.689) and area under the receiver operating characteristic (ROC) curve (0.637 to 0.898). For valve plus concomitant coronary artery bypass grafting (CABG) patients actual mortality was 1.88%. STS calculator came out to be the best predictor of mortality for this subgroup with H-L p value (0.480 to 0.884) and ROC (0.657 to 0.775).

CONCLUSIONS

For Pakistani population EuroSCORE II is an accurate predictor for individual operative risk in patients undergoing isolated valve surgery, whereas STS performs better in the valve plus CABG group.

Predictors of successful percutaneous transvenous mitral commissurotomy using the Bonhoeffer Multi-Track system in patients with moderate to severe mitral stenosis: Can we see beyond the Wilkins score?

Objective

To know the predictors of a successful outcome of percutaneous transvenous mitral commissurotomy (PTMC) other than described in the Wilkins scoring system.

Methods

Two hundred fifty-eight consecutive patients were enrolled for this observational study in a tertiary care heart center of Pakistan who had a Wilkins score of ≤8. Patients with more than mild mitral regurgitation (MR) or having a clot in the left atrium were excluded. The Bonhoeffer multi-track system was used as a default technique. Successful PTMC was defined as achieving a mitral valve area (MVA) of ≥1.5 cm² with no more than mild MR.

Results

Out of 258 PTMC procedures, 197 were successful. The Bonhoeffer multi-track system was used in ~94% cases. Among unsuccessful procedures, 41 patients did not achieve the required valve area, and 21 patients developed more than mild MR, including those 8 patients who did not achieve the required valve area and had more than mild MR. Bigger mean annulus size (33.5±2.6 versus 32.8±2.1 mm; p=0.02) and pre-procedure MVA (0.93±0.1 versus 0.87±0.1 cm²; p=0.002) had a significant effect on successful PTMC. Lower mean preprocedure systolic right ventricular pressure on echo (65.4±19.4 versus 75.3±18 mm Hg; p=0.000) and on cath (74±21.5 versus 81.5±24.6 mm Hg; p=0.002), lower grade of left ventricular dysfunction (p=0.04), and tricuspid regurgitation on echo (p=0.003) also had positive effects on the outcome.

Conclusion

Bigger preprocedure mitral valve annulus size and mitral valve area, and better left and right ventricular hemodynamics are correlated with successful PTMC.

Predictors of the size of prosthetic aortic valve and in-hospital mortality in aortic valve replacement

Purpose:

We hypothesized that gender, age, aortic root dimension, blood group and Left Ventricular End Diastolic and Systolic Diameters may have a significant correlation with the size of mechanical valve used.

Methods:

We included 48 patients retrospectively who had been operated at a single tertiary hospital. All patients with aortic stenosis or regurgitation were included in the study. Patients who had undergone previous cardiac surgery or concomitant surgical procedures, such as coronary artery bypass grafting, were excluded from the study.

Results:

The median size of the valves used in males (23mm) and females (21mm) were significantly different (P = 0.001). Size of the valve used was significantly associated with Left Ventricular End Systolic Diameter (LVESD) (r = 0.327, P = 0.007) and aortic root dimension (r = 0.526, P < 0.001). Moreover, significantly higher values of LVESD were observed in the expired patients (P = 0.023).

Conclusion:

This study shows that aortic root dimension and gender may be important predictors for the size of the prosthetic aortic valve used in aortic valve replacement. Our study also concludes that LVESD has significant relationship with in-hospital mortality. However, more long term clinical trials should be conducted to confirm these relationships.

Epidemiology of acquired valvular heart disease

Population-based studies including systematic echocardiographic examinations are required to assess the prevalence of valvular heart disease. In industrialized countries, the prevalence of valvular heart disease is estimated at 2.5%. Because of the predominance of degenerative etiologies, the prevalence of valvular disease increases markedly after the age of 65 years, in particular with regard to aortic stenosis and mitral regurgitation, which accounts for 3 in 4 cases of valvular disease. Rheumatic heart disease still represents 22% of valvular heart disease in Europe. The prevalence of secondary mitral regurgitation cannot be assessed reliably but it seems to be a frequent disease. The incidence of infective endocarditis is approximately 30 cases per million individiuals per year. Its stability is associated with marked changes in its presentation. Patients are getting older and staphylococcus is now becoming the microorganism most frequently responsible. Heath care-associated infections are the most likely explanation of changes in the microbiology of infective endocarditis. In developing countries, rheumatic heart disease remains the leading cause of valvular heart disease. Its prevalence is high, between 20 and 30 cases per 1000 subjects when using systematic echocardiographic screening. In conclusion, the temporal and geographical heterogeneity illustrates the effect of socioeconomic status and changes in life expectancy on the frequency and presentation of valvular heart disease. A decreased burden of valvular disease would require the elaboration of preventive strategies in industrialized countries and an improvement in the socioeconomic environment in developing countries.

Pregnancy complicated by heart disease in Nepal

OBJECTIVE

To investigate the prevalence, characteristics and maternal and perinatal outcomes of pregnancies complicated by heart disease.

DESIGN

Prospective single-centre registry.

SETTING

Tertiary care teaching hospital in eastern Nepal.

PATIENTS

Pregnant women presenting to the antenatal clinic and/or labour room between 1 March 2012 and 31 March 2013.

MAIN OUTCOME MEASURES

Prevalence, characteristics, and maternal and perinatal outcomes of pregnancies complicated by heart disease.

RESULTS

Fifty-three out of 9463 pregnancies (0.6%) were complicated by cardiac disease. Proportions of acquired, congenital and arrhythmic heart disease amounted to 89%, 9% and 2%, respectively. Rheumatic heart disease (RHD) was the most frequent cardiac disease complicating pregnancy (n=47). Among 45 women with RHD continuing pregnancy until delivery, 30 (67%) were primigravidae. The predominant valvular pathology was mitral stenosis (62%), followed by mitral regurgitation (21%) and aortic regurgitation (13%). Twenty women (44%) underwent elective or emergency caesarean section. Maternal and fetal/perinatal mortality of pregnancies complicated by RHD amounted to 4% and 16%, respectively. New York Heart Association (NYHA) functional class III or class IV (HR 6.0, 95% CI 1.2 to 29.1, p=0.026), pulmonary hypertension (HR 9.1, 95% CI 1.6 to 51.5, p=0.012) and severe mitral stenosis (HR 7.0, 95% CI 1.4 to 34.4, p=0.017) were identified as predictors of maternal or fetal/perinatal mortality in an univariate analysis.

CONCLUSIONS

Rheumatic mitral stenosis was the most frequent heart disease complicating pregnancy in a consecutive cohort from a teaching hospital in Nepal. Exercise intolerance, pulmonary hypertension and severe mitral stenosis were identified as predictors of maternal or fetal/perinatal mortality.

Rheumatic mitral stenosis in children: more accelerated course in sub-Saharan patients

Background

Mitral stenosis, one of the grave consequences of rheumatic heart disease, was generally considered to take decades to evolve. However, several studies from the developing countries have shown that mitral stenosis follows a different course from that seen in the developed countries. This study reports the prevalence, severity and common complications of mitral stenosis in the first and early second decades of life among children referred to a tertiary center for intervention.

Methods

Medical records of 365 patients aged less than 16 and diagnosed with rheumatic heart disease were reviewed. Mitral stenosis was graded as severe (mitral valve area < 1.0 cm²), moderate (mitral valve area 1.0-1.5 cm²) and mild (mitral valve area > 1.5 cm²).

Results

Mean age at diagnosis was 10.1 ± 2.5 (range 3–15) years. Of the 365 patients, 126 (34.5%) were found to have mitral stenosis by echocardiographic criteria. Among children between 6–10 years, the prevalence of mitral stenosis was 26.5%. Mean mitral valve area (n = 126) was 1.1 ± 0.5 cm² (range 0.4-2.0 cm²). Pure mitral stenosis was present in 35 children. Overall, multi-valvular involvement was present in 330 (90.4%). NYHA functional class was II in 76% and class III or IV in 22%. Only 25% of patients remember having symptoms of acute rheumatic fever. Complications at the time of referral include 16 cases of atrial fibrillation, 8 cases of spontaneous echo contrast in the left atrium, 2 cases of left atrial thrombus, 4 cases of thrombo-embolic events, 2 cases of septic emboli and 3 cases of airway compression by a giant left atrium.

Conclusion

Rheumatic mitral stenosis is common in the first and early second decades of life in Ethiopia. The course appeared to be accelerated resulting in complications and disability early in life. Echocardiography-based screening programs are needed to estimate the prevalence and to provide support for strengthening primary and secondary prevention programs.

Rheumatic heart disease in rural south India: A clinico-observational study

BACKGROUND

Rheumatic heart disease (RHD) is still a public health issue in many countries in the world, and particularly in Southeast Asia. India, for example, contributes 25%-50% of the global burden of RHD. Clinic-based and epidemiological studies on RHD in India have used different methodologies and clinical criteria to estimate RHD burden in India. The present study employs strict clinical criteria, including echocardiography, to estimate RHD prevalence and associated clinical complications in a large unique rural population in southern India covered through a governmental health insurance scheme.

MATERIALS AND METHODS

Total 44,164 eligible patients were screened from 238 primary care health centers in rural southern India between October 2007 and March 2012 using strict clinical criteria and objective ascertainment. A total of 403 patients aged 15 years or above were finally analyzed based on both the inclusion and exclusion criteria. Detailed information on both demographic and clinical characteristics was obtained through personal interviews and clinical examinations. Descriptive analyses were performed, including age standardization.

RESULTS

The age-standardized RHD prevalence rate was 9.7/1000 populations-more common in younger age groups (<44 years) and relatively high among females. Pulmonary hypertension was the most common clinical complication followed by CHF, tricuspid regurgitation, as well as infective endocarditis. More than two-thirds had no past history of RHD or penicillin prophylaxis.

CONCLUSIONS

RHD rates are still high in rural India among populations covered through governmental health insurance scheme. Both primary and secondary preventive measures, including widespread coverage of penicillin prophylaxis, must be considered mainstay tools to both prevent and reduce RHD burden in endemic populations, including rural India.

Screening for rheumatic heart disease: current approaches and controversies

Rheumatic heart disease (RHD) is a leading cause of cardiac disease among children in developing nations, and in indigenous populations of some industrialized countries. In endemic areas, RHD has long been a target of screening programmes that, historically, have relied on cardiac auscultation. The evolution of portable echocardiographic equipment has changed the face of screening for RHD over the past 5 years, with greatly improved sensitivity. However, concerns have been raised about the specificity of echocardiography, and the interpretation of minor abnormalities poses new challenges. The natural history of RHD in children with subclinical abnormalities detected by echocardiographic screening remains unknown, and long-term follow-up studies are needed to evaluate the significance of detecting these changes at an early stage. For a disease to be deemed suitable for screening from a public health perspective, it needs to fulfil a number of criteria. RHD meets some, but not all, of these criteria. If screening programmes are to identify additional cases of RHD, parallel improvements in the systems that deliver secondary prophylaxis are essential.