Echocardiographic Screening for Rheumatic Heart Disease in High and Low Risk Australian Children

Prevalence and pattern of rheumatic valvular heart disease in Africa: Systematic review and meta-analysis, 2015-2023, population based studies

BACKGROUND

Rheumatic heart disease is a global health concern with a persistently high incidence in developing countries, including Africa. It has a significant economic, morbidity, and mortality burden, particularly for children and young adults during their most productive years. However, in the last ten years, the extent of its impact in Africa has remained unclear. Limited studies conducted on the continent have reported diverse prevalence rates of rheumatic heart disease. As a result of these, the study aimed to aggregate and synthesize findings from population-based studies to offer a comprehensive and updated overview of rheumatic heart disease prevalence and pattern at the African level.

METHODS

The studies were identified through a comprehensive literature search of the electronic databases, including PubMed, Google Scholar, Web searches, and manual searches. The descriptive information for the study is presented in the table, and the quantitative results are presented in forest plots. The Cochrane Q test and I2 test statistic were used to test heterogeneity across studies. The pooled estimate of the prevalence of rheumatic heart disease was computed by a random effects model.

RESULTS

Out of 22 population-based studies analyzed using random-effects, the pooled magnitude of rheumatic heart disease was found to be 18.41/1000 (95% CI: 14.08-22.73/1000). This comprised definite cases of rheumatic heart disease at a prevalence rate of 8.91/1000 (95% CI: 6.50-11.33/1000) and borderline cases at a prevalence rate of 10.69/1000 (95% CI: 7.74-13.65/1000). The combined prevalence of rheumatic heart disease in males was almost equivalent to that in females. Mitral valve regurgitation was the predominant valve affected by rheumatic heart disease, accounting for approximately 73%.

CONCLUSION

This study analysis found the prevalence of rheumatic heart disease in Africa is high. Because of this, policies and interventions should give attention to prioritize continuous population based active surveillance for early detection of cases to the reduction of rheumatic heart disease sequel, especially in the children and adolescent population.

The Echocardiographic Diagnosis of Rheumatic Heart Disease: A Review of the Performance of the World Heart Federation Criteria 2012-2023

Background

The World Heart Federation (WHF) published the first evidence-based guidelines on the echocardiographic diagnosis of rheumatic heart disease (RHD) in 2012. These guidelines have since been applied internationally in research and clinical practice. Substantial research has assessed the utility of the 2012 WHF criteria, including its applicability in low-resource settings. This article summarises the evidence regarding the performance of the guidelines.

Methods

A scoping review assessing the performance of the guidelines was performed. Cochrane, Embase, Medline, PubMed Lilacs, Sielo, and Portal BVS databases were searched for studies on the performance of the guidelines between January 2012-March 2023, and 4047 manuscripts met the search criteria, of which 34 were included. This included papers assessing the specificity, inter-rater reliability, application using hand-carried ultrasound, and modification of the criteria for simplicity. The review followed the PRISMA Extension for Scoping Reviews guideline.

Results

The WHF 2012 criteria were 100% specific for definite RHD when applied in low-prevalence populations. The criteria demonstrated substantial and moderate inter-rater reliability for detecting definite and borderline RHD, respectively. The inter-rater reliability for morphological features was lower than for valvular regurgitation. When applied to hand-carried ultrasound performed by an expert, modified versions of the criteria demonstrated a sensitivity and specificity range of 79-90% and 87-93% respectively for detecting any RHD, performing best for definite RHD. The sensitivity and the specificity were reduced when performed in task-sharing but remains moderately accurate.

Conclusion

The WHF 2012 criteria provide clear guidance for the echocardiographic diagnosis of RHD that is reproducible and applicable to a range of echocardiographic technology. Furthermore, the criteria are highly specific and particularly accurate for detecting definite RHD. There are limitations in applying all aspects of the criteria in specific settings, including task-sharing. This summary of evidence can inform the updated version of the WHF guidelines to ensure improved applicability in all RHD endemic regions.

Epidemiological study of pediatric rheumatic heart disease: An analysis from the Global Burden of Disease Study 2019

BACKGROUND

Rheumatic heart disease (RHD) is the most common acquired heart disease among children in developing countries. However, there is a lack of systematic studies on the epidemiology of pediatric RHD. This study aimed to report the burden of pediatric RHD at global, regional, and national levels between 1990 and 2019, which may provide some reference for policymakers.

METHODS

The numbers and age-standardized rates (ASRs) of incidence, prevalence, mortality, and disability-adjusted life years (DALYs) for childhood RHD from 1990 to 2019 were analyzed based on data obtained from the Global Burden of Disease Study 2019 (GBD 2019). In addition, Joinpoint regression analysis was used to assess temporal trends in the burden of childhood RHD.

RESULTS

Globally, the number of incidence and prevalence cases of RHD in children increased by 41.89% and 40.88%, respectively, from 1990 to 2019. Age-standardized incidence rate (ASIR) and age-standardized prevalence rate (ASPR) increased with an average annual percentage change (AAPC) of 0.75% and 0.66%, respectively. In contrast, the age-standardized DALY rate and age-standardized mortality rate (ASMR) decreased significantly since 1990 by an AAPC of -3.47% and - 2.65%, respectively. Girls had a significantly higher burden of RHD than boys during the study period. At the age level, the RHD burden was significantly highest in the age group of 10-14 years. Moreover, the ASRs of incidence, prevalence, mortality, and DALYs were negatively associated with sociodemographic index (SDI). Nationally, Fiji had the most significant increase in incidence and prevalence, and Philippines had the most remarkable rise in DALYs and mortality rates.

CONCLUSION

From 1990 to 2019, although the incidence and prevalence of childhood RHD increased globally, DALYs and mortality rates markedly reduced. Countries with lower levels of sociodemographic development shoulder a higher burden of childhood RHD. Children aged 10-14 years are critical populations for whom targeted measures are needed to reduce the RHD burden, while attention to girls cannot be neglected.

Application of Transthoracic Echocardiography for Cardiac Safety Evaluation in the Clinical Development Process of Vaccines Against Streptococcus pyogenes

Superficial infections with Streptococcus pyogenes (Strep A), pharyngitis and impetigo can induce acute rheumatic fever, an autoimmune sequela manifesting mostly with arthritis and rheumatic carditis. Valvular heart damage can persist or advance following repeated episodes of acute rheumatic fever, causing rheumatic heart disease. Acute rheumatic fever and rheumatic heart disease disproportionately affect children and young adults in developing countries and disadvantaged communities in developed countries. People living with rheumatic heart disease are at risk of experiencing potentially fatal complications such as heart failure, bacterial endocarditis or stroke. Transthoracic echocardiography plays a central role in diagnosing both rheumatic carditis and rheumatic heart disease. Despite the obvious medical need, no licensed Strep A vaccines are currently available, as their clinical development process faces several challenges, including concerns for cardiac safety. However, the development of Strep A vaccines has been recently relaunched by many vaccine developers. In this context, a reliable and consistent safety evaluation of Strep A vaccine candidates, including the use of transthoracic echocardiography for detecting cardiac adverse events, could greatly contribute to developing a safe and efficacious product in the near future. Here, we propose a framework for the consistent use of transthoracic echocardiography to proactively detect cardiac safety events in clinical trials of Strep A vaccine candidates.

The role of echocardiographic screening in reducing the burden of rheumatic heart disease in Latin America

The objectives of this article are to reflect on the rationale behind the use of echocardiographic screening for rheumatic heart disease and to provide key recommendations about steps needed to implement and improve echocardiographic screening programs in Latin America. Rheumatic heart disease remains a public health problem affecting mainly low-income and lower-middle-income countries and populations. Latin America is an area with economic inequalities, and the epidemiology of rheumatic heart disease remains largely unknown. Echocardiographic screening is useful for updating the epidemiology and providing early diagnosis of the disease. We discuss different approaches used in successful echocardiographic screening programs worldwide and in Latin America. We then identify the key elements needed to establish successful echocardiographic screening programs in Latin America, including increased awareness and involvement from multiple sectors (e.g. the community, health care professionals, scientific organizations and public health entities), identification of areas in need, development of a plan and structure that include different screening approaches, and how to ensure appropriate follow up for those who screen positive.

Detection and management of latent rheumatic heart disease: a narrative review

Rheumatic heart disease (RHD) is a public health concern in many developing nations around the world. Early detection of latent or subclinical RHD can help in reversing mild lesions, retarding disease progression, reducing morbidity and mortality, and improving the quality of life of patients. Echocardiography is the gold-standard method for screening and confirming latent RHD cases. The rates and determinants of progression of latent RHD cases as assessed by echocardiography have been found to be variable through studies. Even though latent RHD has a slow rate of progression, the rate of progression of its subtype, 'definite' RHD, is substantial. A brief training of nonexpert operators on the use of handheld echocardiography with a simplified protocol is an important strategy to scale up the screening program to detect latent cases. Newer advancements in screening, such as deep-learning digital stethoscopes and telehealth services, have provided an opportunity to expand screening programs even in resource-constrained settings. Newer studies have established the efficacy and safety profile of secondary antibiotic prophylaxis in latent RHD. The concerned authorities in endemic regions of the world should work on improving the availability and accessibility of antibiotic prophylaxis.

Morpho-mechanistic screening criteria for the echocardiographic detection of rheumatic heart disease

INTRODUCTION

Screening echocardiography, guided by the current World Heart Federation (WHF) criteria, has important limitations that impede the establishment of large-scale rheumatic heart disease (RHD) control programmes in endemic regions. The criteria misclassify a significant number of normal cases as borderline RHD. Prior attempts to simplify them are limited by incorporation bias due to the lack of an externally validated, accurate diagnostic test for RHD. We set out to assess novel screening criteria designed to avoid incorporation bias and to compare this against the performance of the current WHF criteria.

METHODS

The performance of the WHF and the morpho-mechanistic (MM) RHD screening criteria (a novel set of screening criteria that evaluate leaflet morphology, motion and mechanism of regurgitation) as well as a simplified RHD MM 'rule-out' test (based on identifying a predefined sign of anterior mitral valve leaflet restriction for the mitral valve and any aortic regurgitation for the aortic valve) were assessed in two contrasting cohorts: first, a low-risk RHD cohort consisting of children with a very low-risk RHD profile. and second, a composite reference standard (CRS) RHD-positive cohort that was created using a composite of two criteria to ensure a cohort with the highest possible likelihood of RHD. Subjects included in this group required (1) proven, prior acute rheumatic fever and (2) current evidence of predefined valvular regurgitation on echocardiography.

RESULTS

In the low-risk RHD cohort (n=364), the screening specificities for detecting RHD of the MM and WHF criteria were 99.7% and 95.9%, respectively (p=0.0002). The MM rule-out test excluded 359/364 cases (98.6%). In the CRS RHD-positive cohort (n=65), the screening sensitivities for the detection of definite RHD by MM and WHF criteria were 92.4% and 89.2%, respectively (p=0.2231). The MM RHD rule-out test did not exclude any cases from the CRS RHD-positive cohort.

CONCLUSION

Our proposed MM approach showed an equal sensitivity to the WHF criteria but with significantly improved specificity. The MM RHD rule-out test excluded RHD-negative cases while identifying all cases within the CRS RHD-positive cohort. This holds promise for the development of a two-step RHD screening algorithm to enable task shifting in RHD endemic regions.

Rheumatic Heart Disease: JACC Focus Seminar 2/4

It is a sad reality that although eminently preventable, and despite possessing such knowledge for >70 years, rheumatic heart disease (RHD) remains the most common cause of cardiovascular morbidity and early mortality in young people worldwide. A disease of the poor, RHD is one of the most neglected diseases. Several challenges are unique to the acute rheumatic fever/RHD continuum and contribute to its persistence, including its sequestration among the poorest, its protracted natural history, the erratic availability of penicillin, and the lack of a concerted effort in endemic regions. However, there is cause for optimism following a resurgence in scientific interest over the last 15 years. This review presents the latest advancements in epidemiology, diagnosis, and management. It also discusses pressing research questions on disease pathophysiology, the barriers to implementation of effective management strategies, and pragmatic policy solutions required for translation of current knowledge into meaningful action.

Echocardiographic Screening for Rheumatic Heart Disease in a Ugandan Orphanage: Feasibility and Outcomes

Background: Rheumatic heart disease (RHD) is a major cause of cardiovascular disease in developing nations, leading to more than 230,000 deaths annually. Most patients seek medical care only when long-term structural and hemodynamic complications have already occurred. Echocardiographic screenings ensure the early detection of asymptomatic subjects who could benefit from prophylaxis, monitoring and intervention, when appropriate. The aim of this study is to assess the feasibility of a screening program and the prevalence of RHD in a Ugandan orphanage. Methods: We performed an RHD-focused echocardiogram on all the children (5–14 years old) living in a north Ugandan orphanage. Exams were performed with a portable machine (GE Vivid-I). All the time intervals were recorded (minutes). Results: A total of 163 asymptomatic children were screened over 8 days (medium age 9.1; 46% male; 17% affected by severe motor impairment). The feasibility rate was 99.4%. An average of 20.4 exams were performed per day, with an average of 15.5 images collected per subject. Pathological mitral regurgitation (MR) was found in 5.5% of subjects, while at least two morphological features of RHD were found in 4.3%, leading to 1 “definite RHD” (0.6%) case and 13 “borderline RHD” cases (8.1%). Six congenital heart defects were also noted (3.7%): four atrial septal defects, one coronary artery fistula and one Patent Ductus Arteriosus. Conclusions: We demonstrated the feasibility of an echocardiographic screening for RHD in an orphanage in Uganda. A few factors, such as good clinical and hygienic care, the availability of antibiotics and closeness to a big hospital, may account for the low prevalence of the disease in our population.

Prevalence of Structural Heart Diseases Detected by Handheld Echocardiographic Device in School-Age Children in Iran: The SHED LIGHT Study

Background:

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Potential for Use of Portable Ultrasound Devices in Rural and Remote Settings in Australia and Other Developed Countries: A Systematic Review

Introduction

Objective

Methods

Results

Conclusion

Screening for subclinical rheumatic heart disease: addressing borderline disease in a real-world setting

Aims

The World Heart Federation (WHF) criteria identify a large borderline rheumatic heart disease (RHD) category that has hampered the implementation of population-based screening. Inter-scallop separations (ISS) of the posterior mitral valve leaflet, a recently described normal variant of the mitral valve, appears to be an important cause of mild mitral regurgitation (MR) leading to misclassification of cases as WHF ‘borderline RHD’. This study aims to report the findings of the Echo in Africa project, a large-scale RHD screening project in South Africa and determine what proportion of borderline cases would be re-classified as normal if there were a systematic identification of ISS-related MR.

Methods and results

A prospective cross-sectional study of underserved secondary schools in the Western Cape was conducted. Participants underwent a screening study with a handheld (HH) ultrasound device. Children with an abnormal HH study were re-evaluated with a portable laptop echocardiography machine. A mechanistic evaluation was applied in cases with isolated WHF ‘pathological’ MR (WHF ‘borderline RHD’). A total of 5255 participants (mean age 15± years) were screened. A total of 3439 (65.8%) were female. Forty-nine cases of WHF ‘definite RHD’ [9.1 cases/1000 (95% confidence interval, CI, 6.8–12.1 cases/1000)] and 104 cases of WHF ‘borderline RHD’ [19.5 cases/1000 (95% CI, 16.0–23.7 cases/1000)] were identified. Inter-scallop separations-related MR was the underlying mechanism of MR in 48/68 cases classified as WHF ‘borderline RHD’ with isolated WHF ‘pathological’ MR (70.5%).

Conclusion

In a real-world, large-scale screening project, the adoption of a mechanistic evaluation based on the systematic identification of ISS-related MR markedly reduced the number of WHF ‘screen-positive’ cases misclassified as WHF ‘borderline RHD’. Implementing strategies that reduce this misclassification could reduce the cost- and labour burden on large-scale RHD screening programmes.

Prevalence and risk factors for Subclinical Rheumatic Heart Disease among primary school children in Dar es Salaam, Tanzania: a community based cross-sectional study

BACKGROUND

Rheumatic heart disease (RHD) is the most common acquired heart disease occurring in children and adolescents. RHD is associated with significant morbidity and mortality particularly in low and middle- income countries (LMICs) where the burden is estimated to be higher compared to high income countries. Subclinical RHD is the presence of valvular lesion diagnosed by echocardiography in a person with no clinical manifestation of RHD. This study aimed at determining the prevalence, types and factors associated with subclinical RHD among primary school children in Dar Es Salaam, Tanzania.

METHODS

A descriptive community-based cross-sectional study was conducted in primary school children from February to May 2019. A standardized structured questionnaire was used to collect demographic characteristics, history of upper respiratory tract infections (URTIs), anthropometric measurements, and chest auscultation findings. Moreover echocardiographic screening was done to all children recruited into the study. World Heart Federation echocardiographic classification was used to define the types and prevalence of subclinical RHD.

RESULTS

A total of 949 primary school children were enrolled with females being predominant (57.1%). The prevalence of subclinical RHD was 34 per 1000. All the participants had mitral valve disease only whereby 17 had definite disease and 15 had a borderline disease. The associated factors for subclinical RHD were older age of more than 9 years (OR 10.8, 95% CI 1.4-82.2, P = 0.02) having three or more episodes of URTI in previous six months (OR 21, 95% CI 9.6-46, P = 0.00) and poor hygiene (OR 3, 95% CI 1.3-6.8, P = 0.009).

CONCLUSION

Subclinical RHD as detected by echocardiographic screening is prevalent in primary school children, uniformly affects the mitral valve, and is associated with potentially modifiable risk factors. Children with a history of more than three episodes of URTI in six months represents a high-risk population that should be targeted for RHD screening.

The Spectrum, Severity and Outcomes of Rheumatic Mitral Valve Disease in Pregnant Women in Australia and New Zealand

BACKGROUND

Rheumatic heart disease (RHD) poses significant perinatal risks. We aimed to describe the spectrum, severity and outcomes of rheumatic mitral valve disease in pregnancy in Australia and New Zealand.

METHODS

A prospective, population-based cohort study of pregnant women with RHD recruited 2013-14 through the hospital-based Australasian Maternity Outcomes Surveillance System. Outcome measures included maternal and perinatal morbidity and mortality. Univariable and multivariable logistic regression analyses were undertaken to test for predictors of adverse maternal and perinatal outcomes.

RESULTS

Of 274 pregnant women identified with RHD, 124 (45.3%) had mitral stenosis (MS) and 150 (54.7%) had isolated mitral regurgitation (MR). One woman with mild MS/moderate MR died. There were six (2.2%) stillbirths and two (0.7%) neonatal deaths. Babies born to women with MS were twice as likely to be small-for-gestational-age (22.7% vs 11.4%, p=0.013). In women with MS, use of cardiac medication (AOR 7.42) and having severe stenosis (AOR 16.35) were independently associated with adverse cardiac outcomes, while NYHA class >1 (AOR 3.94) was an independent predictor of adverse perinatal events. In women with isolated MR, use of cardiac medications (AOR 7.03) and use of anticoagulants (AOR 6.05) were independently associated with adverse cardiac outcomes.

CONCLUSIONS

Careful monitoring and specialist care for women with RHD in pregnancy is required, particularly for women with severe MS, those on cardiac medication, and those on anticoagulation, as these are associated with increased risk of adverse maternal cardiac outcomes. In the context of pregnancy, contraception and preconception planning are important for young women diagnosed with RHD.

Early diagnosis of acute rheumatic fever and rheumatic heart disease as part of a secondary prevention strategy: Narrative review

Acute rheumatic fever (ARF) and its sequela rheumatic heart disease (RHD) remain significant causes of morbidity and mortality. In New Zealand, ARF almost exclusively affects Indigenous Māori and Pacific children. This narrative review aims to present secondary interventions to improve early and accurate diagnosis of ARF and RHD, in order to minimise disease progression in New Zealand. Medline, EMBASE and Scopus databases were searched as well as other electronic publications. Included were 56 publications from 1980 onwards. Diagnosing ARF and RHD as early as possible is central to reducing disease progression. Recent identification of specific ARF biomarkers offer the opportunity to aid initial diagnosis and portable echocardiography has the potential to detect undiagnosed RHD in high-risk areas. However, further research into the benefits and risks to children with subclinical RHD is necessary, as well as an economic evaluation.

The variable spectrum of anterior mitral valve leaflet restriction in rheumatic heart disease screening

INTRODUCTION

The World Heart Federation (WHF) screening criteria do not incorporate a strict, reproducible definition of anterior mitral valve leaflet (AMVL) restriction. Using a novel definition, we have identified two distinct AMVL restriction configurations. The first, called "distal tip" AMVL restriction is associated with additional morphological features of rheumatic heart disease (RHD), while the second, "gradual bowing" AMVL restriction is not. This "arch-like" leaflet configuration involves the base to tip of the medial MV in isolation. We hypothesize that this configuration is a normal variant.

METHODOLOGY

The prevalence and associated leaflet configurations of AMVL restriction were assessed in schoolchildren with an established "very low" (VLP), "high" (HP), and "very high" prevalence (VHP) of RHD.

RESULTS

936 studies were evaluated (HP 577 cases; VLP 359 cases). Sixty-five cases of "gradual bowing" AMVL restriction were identified in the HP cohort (11.3%, 95% CI 8.9-14.1) and 35 cases (9.7%, 95% CI 7-13.2) in the VLP cohort (P = .47). In the second analyses, an enriched cohort of 43 studies with proven definite RHD were evaluated. "Distal tip" AMVL restriction was identified in all 43 VHP cases (100%) and affected the central portion of the AMVL in all cases.

CONCLUSION

"Gradual bowing" AMVL restriction appears to be a normal, benign variant of the MV, not associated with RHD risk nor with any other morphological features of RHD. Conversely, "Distal tip" AMVL restriction was present in all cases in the VHP cohort with no cases exhibiting a straight, nonrestricted central portion of the AMVL. This novel finding requires further investigation as a potential RHD rule-out test of the MV.

Raising awareness for rheumatic mitral valve disease

Rheumatic heart disease (RHD) is a major burden in low- to mid-income countries, where each year it accounts for over a million premature deaths associated with severe valve disease. Life-saving valve replacement procedures are not available to the majority of affected RHD patients, contributing to an increased risk of death in young adults and creating a devastating impact. In December 2017, a group of representatives of major cardiothoracic societies and industry, discussed the plight of the millions of patients who suffer from RHD. A comprehensive solution based on this global partnership was outlined in "The Cape Town Declaration on Access to Cardiac Surgery in the Developing World". The key challenge in controlling RHD is related to identification and removal of barriers to the translation of existing knowledge into policy, programs, and practice to provide high-quality care for patients with RHD. This review provides an overview on RHD by emphasizing the disease medical and economic burdens worldwide, risk factors, recent advance for early disease detection, and overall preventive strategies.

Interscallop separations of the posterior mitral valve leaflet: a solution to the 'borderline RHD' conundrum?

Objective

The World Heart Federation (WHF) criteria incorporate a Doppler-based system to differentiate between ‘physiological’ and ‘pathological’ mitral regurgitation (MR)—a sole criterion sufficient for the diagnosis of WHF ‘borderline’ rheumatic heart disease (RHD). We have identified that interscallop separations (ISS) of the posterior mitral valve (MV) leaflet, can give rise to pathological MR in an otherwise-normal MV. We aimed to establish and compare the prevalence of ISS-related MR among South African children at high and low risk for RHD.

Methods

A prospective cross-sectional echocardiographic study of 759 school children (aged 13–18) was performed. Cases with MR≥1.5 cm underwent a second comprehensive study to determine the prevalence of RHD according to the WHF guideline and establish the underlying mechanism of MR.

Results

Of 400 high-risk children, two met criteria for ‘definite RHD’ (5 per 1000 (95% CI 1.4 to 18.0); p=0.5) and 11 for ‘borderline RHD’ (27.5 per 1000 (95% CI 15.4 to 48.6)). Of 359 low-risk children, 14 met criteria for borderline RHD (39 per 1000 (95% CI 23.4 to 64.4)). Comprehensive echocardiography identified an underlying ISS as the mechanism of isolated pathological MR in 10 (83.3%) high-risk children and 11 low-risk children (78.5%; p>0.99).

Conclusions

ISS are a ubiquitous finding among South African schoolchildren from all risk profiles and are regularly identified as the underlying mechanism of WHF pathological MR in borderline RHD cases. A detailed MV assessment with an emphasis on ascertaining the underlying mechanism of dysfunction could reduce the reported numbers of screened cases misclassified as borderline RHD.

Prevalence of rheumatic heart disease in North-Central Nigeria: a school-based cross-sectional pilot study

OBJECTIVES

To present epidemiological data on rheumatic heart disease (RHD), the most common acquired heart disease in children and young adults in low- and middle-income countries, for North-Central Nigeria.

METHODS

In this pilot study, we conducted clinical and echocardiography screening on a cross section of randomly selected secondary schoolchildren in Jos, North-Central Nigeria, from March to September 2016. For outcome classification into borderline or definite RHD, we performed a confirmatory echocardiography using the World Heart Federation criteria for those suspected to have RHD from the screening.

RESULTS

A total of 417 secondary schoolchildren were screened, of whom 247 (59.2%) were female. The median age was 14 years (IQR: 13-15). Clinical screening detected 8/417 children, whereas screening echocardiography detected 42/417 suspected cases of RHD. Definitive echocardiography confirmed 9/417 with RHD corresponding to a prevalence of 21.6 per 1000 (95% CI, 6.7-36.5). All but one of the confirmed RHD cases (8/9) were borderline RHD corresponding to a prevalence of 19.2 per 1000 (95% CI, 8.3-37.5) for borderline RHD and 2.4 per 1000 (95% CI, 0.1-13.3) for definite RHD. RHD was more common in boys and cardiac auscultation missed over 50% of the cases.

CONCLUSIONS

This study showed a high prevalence of RHD among secondary schoolchildren in North-Central Nigeria with a vast predominance of asymptomatic borderline lesions. Larger school-based echocardiography screening using portable or handheld echocardiography aimed at early detection of subclinical RHD should be adopted.

Longitudinal Variation in Presence and Severity of Cardiac Valve Regurgitation in Healthy Children

BACKGROUND

The goal of this study was to document the frequency and longitudinal variation in the presence and severity of echocardiographically documented valvular regurgitation (VR) in healthy children free of evidence of heart disease. We hypothesized that significant variation is common, and our specific aim was to determine change in prevalence and severity of VR in children free of heart disease.

METHODS

The presence of VR was documented on each of the four valves, and the severity of regurgitation was assessed as the body surface area (BSA)-adjusted width of the vena contracta on each of two sequential echocardiograms in healthy children free of clinical and echocardiographic evidence of heart disease.

RESULTS

We included 200 children ages 10.0 ± 4.5 years, BSA = 1.2 ± 0.43 m², at the first exam and 12.8 ± 4.9 years, BSA = 1.42 ± 0.44 m², at the second exam. Frequency of VR was similar on the two exams (tricuspid = 61.5% vs 57.0%, pulmonary = 55.5 vs 57.5%, mitral = 14.5% vs 16.0%, aortic = 3.0 vs 3.5%). The frequency of new appearance was similar to the frequency of resolution of VR for all four valves. For instances where the severity of VR was classified as trace versus mild, the frequency of change from mild to trace between the two exams was similar to the frequency of change from trace to mild.

CONCLUSIONS

In healthy children with no evidence of heart disease, there is substantial temporal variation in the presence and severity of tricuspid and pulmonary VR. The prevalence of mitral and aortic VR is lower in healthy children, but temporal variation is also noted for these valves. The finding of new-onset echocardiographic trace or mild VR cannot be assumed to represent incident valve pathology.

Echocardiographic screening to determine progression of latent rheumatic heart disease in endemic areas: A systematic review and meta-analysis

BACKGROUND

The World Health Organisation previously recommended routine screening in school-aged children in countries with a high prevalence of rheumatic heart disease (RHD); however, it is unclear if screening-detected (latent) valve disease will inevitably evolve to a pathological lesion. Understanding the natural history of latent RHD is essential prior to recommendation of screening in endemic areas. Studies documenting the progression of latent RHD have had contrasting conclusions about the pathogenicity of latent valvular lesions. This review provides estimates of rates of progression of latent RHD.

METHODS AND FINDINGS

In this systematic review and meta-analysis, we searched EMBASE, MEDLINE, Global Index Medicus, Africa Wide, Cochrane Database of Systematic Reviews and Global Health Database for studies published before April 30, 2019. Study data were extracted from all studies which reported follow-up data on progression of latent valve lesions. Studies with control cohorts were used to calculate comparative prevalence ratios. This study is registered with PROSPERO, number CRD42019119427. We identified 12 studies reporting follow-up data on latent RHD for 950 people in 9 countries. The estimated pooled prevalence rate for progression per year of latent RHD was 5%/year (95% CI 2-8). Eight studies reported on the progression of borderline latent RHD with an estimated pooled prevalence of 2%/year (95% CI 0-4). Three studies included control groups. There was a significant increase in the risk of progression of valvular disease in the latent group compared with controls (RR = 3.57 (95%CI = 1.65-7.70, P = 0.001). The overall risk of bias was low. Given most studies included penicillin administration we were unable to document the natural history of latent RHD. Furthermore, we were unable to perform a sensitivity analysis to determine the effect of administering penicillin prophylaxis on progression of valve disease given prescription of penicillin was not standardised.

CONCLUSION

Latent RHD has a slow rate of progression but it is significantly higher compared to controls, with definite latent RHD having a higher rate of progression compared with borderline latent disease. There are a massive number of individuals at risk for RHD in the developing world as well as logistical challenges of screening and delivering penicillin prophylaxis. The low rate of progression from untargeted screening may be an important consideration in resource-constrained environments.

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.

The End Rheumatic Heart Disease in Australia Study of Epidemiology (ERASE) Project: data sources, case ascertainment and cohort profile

PURPOSE

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist as public health issues in developing countries and among disadvantaged communities in high-income countries, with rates in Aboriginal and Torres Strait Islander peoples in Australia among the highest recorded globally. A robust evidence base is critical to support policy recommendations for eliminating RHD, but available data are fragmented and incomplete. The End RHD in Australia: Study of Epidemiology (ERASE) Project aims to provide a comprehensive database of ARF and RHD cases in Australia as a basis for improved monitoring and to assess prevention and treatment strategies. The objective of this paper is to describe the process for case ascertainment and profile of the study cohort.

PATIENTS AND METHODS

The ERASE database has been built using linked administrative data from RHD registers, inpatient hospitalizations, and death registry data from 2001 to 2017 (mid-year). Additional linked datasets are available. The longitudinal nature of the data is harnessed to estimate onset and assess the progression of the disease. To accommodate systematic limitations in diagnostic coding for RHD, hospital-only identified RHD has been determined using a purposefully developed prediction model.

RESULTS

Of 132,053 patients for whom data were received, 42,064 are considered true cases of ARF or RHD in the study period. The patient population under 60 years in the compiled dataset is more than double the number of patients identified in ARF/RHD registers (12,907 versus 5049). Non-registered patients were more likely to be older, non-Indigenous, and at a later disease stage.

CONCLUSION

The ERASE Project has created an unprecedented linked administrative database on ARF and RHD in Australia. These data provide a critical baseline for efforts to end ARF/RHD in Australia. The methodological work conducted to compile this database resulted in significant improvements in the robustness of epidemiological estimates and entails valuable lessons for ARF/RHD research globally.

Echocardiographic screening for rheumatic heart disease in Turkish schoolchildren

BACKGROUND

The aim of this study is to investigate the prevalence of subclinical rheumatic heart disease in schoolchildren aged 5-18 by using portable echocardiography in Ankara, Turkey.

METHODS

The portable echocardiography screening was performed by a paediatric cardiologist for all of the cases. The mean age of 2550 healthy students was 11.09 ± 2.91 years (1339 females, 1211 males) in three private and three public schools. Echocardiographic studies were assessed according to 2012 World Heart Federation criteria for rheumatic heart disease.

RESULTS

After reviewing the echocardiographic images, 73 students were reevaluated by an advanced echocardiography device in the university hospital. Evidence of definite subclinical rheumatic heart disease was found in 39 students (15/1000) and borderline rheumatic heart disease in 20 students (8/1000). No children had any clinical symptoms. The mean age of children diagnosed with rheumatic heart disease and borderline rheumatic heart disease is 12.4 and 11.4 years, respectively. The risk of rheumatic heart disease was found to be increased sevenfold in girls between 14 and 18 years. We surprisingly observed that the prevalence of definite rheumatic heart disease in private schools located in high-income areas of Ankara was higher than that in public schools.

CONCLUSIONS

This is the first and largest single-centred echocardiographic screening study for subclinical rheumatic heart disease in Turkish schoolchildren. The frequency of rheumatic heart disease has been found to be 15/1000. This finding is similar to those of recent echocardiographic screening studies performed in middle and high-risk populations. We conclude that to decrease the burden of rheumatic heart disease, echocardiographic screening studies are necessary, and long-term follow-up of children with echocardiographically diagnosed subclinical rheumatic heart disease is needed.

Determining the impact of Benzathine penicillin G prophylaxis in children with latent rheumatic heart disease (GOAL trial): Study protocol for a randomized controlled trial

Rheumatic heart disease (RHD) remains a high prevalence condition in low- and middle-income countries. Most individuals with RHD present late, missing the opportunity to benefit from secondary antibiotic prophylaxis. Echocardiographic screening can detect latent RHD, but the impact of secondary prophylaxis in screen-detected individuals is not known.

METHODS/DESIGN

This trial aims to determine if secondary prophylaxis with every-4-week injectable Benzathine penicillin G (BPG) improves outcomes for children diagnosed with latent RHD. This is a randomized controlled trial in consenting children, aged 5 to 17 years in Northern Uganda, confirmed to have borderline RHD or mild definite RHD on echocardiography, according to the 2012 World Heart Federation criteria. Qualifying children will be randomized to every-4-week injectable intramuscular BPG or no medical intervention and followed for a period of 2 years. Ongoing intervention adherence and retention in the trial will be supported through the establishment of peer support groups for participants in the intervention and control arms. A blinded echocardiography adjudication panel consisting of four independent experts will determine the echocardiographic classification at enrollment and trajectory through consensus review. The primary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic progression of latent RHD compared to those in the control arm. The secondary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic regression of latent RHD compared to those in the control arm. A sample size of 916 participants will provide 90% power to detect a 50% relative risk reduction assuming a 15% progression in the control group. The planned study duration is from 2018-2021.

DISCUSSION

Policy decisions on the role of echocardiographic screening for RHD have stalled because of the lack of evidence of the benefit of secondary prophylaxis. The results of our study will immediately inform the standard of care for children diagnosed with latent RHD and will shape, over 2-3 years, practical and scalable programs that could substantially decrease the burden of RHD in our lifetime.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03346525. Date Registered: November 17, 2017.

Effect of anaemia on the diagnosis of rheumatic heart disease using World Heart Federation criteria

BACKGROUND

There is overlap between pathological mitral regurgitation seen in borderline rheumatic heart disease using World Heart Federation echocardiography criteria and physiologic regurgitation found in normal children. One possible contributing factor is higher rates of anaemia in endemic countries.

OBJECTIVE

To investigate the contribution of anaemia as a potential confounder in the diagnosis of rheumatic heart disease detected in echocardiographic screening.

METHOD/DESIGN

A novel Server 2012 data warehouse tool was used to incorporate haematology and echocardiography databases. The study included a convenience sample of patients from 5 to 18 years old without structural or functional heart disease that had a haemoglobin value within 1 month prior to an echocardiogram. Echocardiogram images were reviewed to determine presence or absence of World Heart Federation criteria for rheumatic heart disease. The rate of rheumatic heart disease among anaemic and non-anaemic children according to gender- and age-based norms groups was compared.

RESULTS

Of the 935 patients who met the study inclusion criteria, 406 were classified as anaemic. There was no difference in the rate of echocardiograms meeting criteria for borderline rheumatic heart disease in anaemic (2.0%, 95% CI 0.6-3.3%) and non-anaemic children (1.3%, 95% CI 0.3-2.3%). However, there was a statistically significant increase in rates of mitral regurgitation of unclear significance among anaemic versus non-anaemic patients (8.6 versus 3.6%; p = 0.0012).

CONCLUSION

Anaemia does not increase the likelihood of meeting echocardiographic criteria for borderline rheumatic heart disease. Future studies should evaluate for the correlation between anaemia and mitral regurgitation in endemic settings.

Single Parasternal-Long-Axis-View-Sweep Screening Echocardiographic Protocol to Detect Rheumatic Heart Disease: A Prospective Study of Diagnostic Accuracy

BACKGROUND

Echocardiographic screening in school-aged children can detect rheumatic heart disease (RHD) prior to the manifestation of symptoms of heart failure. The challenge is making this practical and affordable on a global scale. This study aims to evaluate the diagnostic utility of an ultra-abbreviated echocardiographic screening protocol involving a single parasternal-long-axis-view-sweep of the heart (SPLASH) in two dimensional (2D) and colour Doppler imaging (index test).

METHODS

This prospective study of diagnostic accuracy compared the diagnostic utility of the index screening test with a comprehensive reference test (standard echocardiographic screening protocols) as per World Heart Federation (WHF) echocardiographic criteria. School students in Timor-Leste aged 5-20 years were enrolled. Both index and reference test images were acquired by cardiologists on Vivid I or Q machines (GE Healthcare, Marlborough, MA, USA).

RESULTS

A total of 1,365 participants were screened; median age was 11 years. The estimated prevalence of definite and borderline RHD was 35.2 per 1,000. Congenital heart disease was identified in 11 children (0.8%) with two needing cardiac surgery. Abnormal SPLASH views were found in 109/1365 (7.99%). No cases of RHD or significant congenital heart disease were missed. Sensitivity and specificity of the abbreviated protocol for detecting RHD were 1.0 and 0.95 respectively.

CONCLUSIONS

A simplified echocardiography screening protocol using SPLASH is highly sensitive and specific and could significantly improve the efficiency of RHD screening. It has the potential to expedite training of health workers whilst protecting the modesty of students.

Echocardiographic screening of 4107 Nigerian school children for rheumatic heart disease

OBJECTIVE

Echocardiographic screening for Rheumatic Heart Disease (RHD) in Africa has revealed prevalence rates in the range of 0.5-7.4%. There are no recent large population-based studies in Nigeria. The objective of the study was to determine the prevalence of RHD in a large sample of Nigerian school children.

METHODS

Using portable transthoracic echocardiography and auscultation, school children aged 5 years to 16 years in Lagos, Nigeria were screened for RHD. Diagnosis was based on the 2012 World Heart Federation echocardiographic criteria.

RESULTS

The 4107 children screened had mean age of 11.3 years (SD = 2.6) and 2206 (53.7%) were females. There were 38 children with abnormal echocardiograms, of which 11 (0.27%) showed RHD including two cases of definite RHD giving a prevalence of 2.7/1000 [2.9/1000 in the peri-urban, 2.4/1000 in the urban area). Echocardiography detected RHD 10 times better than auscultation [echocardiography 11 (0.27%) vs. auscultation 1 (0.02%); P = 0.003]. The remaining 27 children with abnormal echocardiograms had congenital heart defects (CHD) giving a prevalence of 6.6/1000 for CHD, a yield higher than for RHD.

CONCLUSION

Prevalence of RHD among school children in Lagos, South West Nigeria is low compared to other African countries, possibly due to better access to medical care and antibiotic treatment for infections. Our data provides evidence that RHD prevalence may vary substantially within sub-Saharan Africa, necessitating targeted population-based sampling to better understand disease burden and distribution. Further work is needed to compare within- and between-country RHD prevalence as a basis for programme planning and control efforts.

Decreased Prevalence of Rheumatic Heart Disease Confirmed Among HIV-positive Youth

BACKGROUND

There is geographical overlap between areas endemic for rheumatic heart disease (RHD) and those endemic for HIV. A recent pilot study demonstrated that children living with HIV might be at less risk for RHD development; however, the sample size was too small to make definitive conclusions. Our objective was to determine the prevalence of RHD among HIV-positive children in Uganda.

METHODS

We conducted a prospective, cross-sectional study of HIV-positive children (5-15 years of age) receiving care at the Baylor Uganda HIV Clinic, Kampala, Uganda. A focused echocardiogram and chart review was performed. A sample size of 988 children was needed to provide 80% power to detect a difference in population prevalence between HIV-positive children and the general population, 2.97% [95% confidence interval (CI): 2.70-3.24%], based on previous reports.

RESULTS

Screening echocardiography of 993 HIV-positive children found 15 individuals (1.5%; 95% CI: 0.88%-2.54%) with RHD. Of these 15, 2 were classified as definite RHD and 13 as borderline RHD. The majority of children had isolated mitral valve disease (93%). Children found to have RHD were older than those without RHD, 12 versus 10 years of age (P = 0.004). When separated based on geographic location, the prevalence of RHD among HIV-positive children from Kampala was 1.28% (95% CI: 0.63%-2.51%) compared with 2.1% (95% CI: 0.89%-4.89%) in those from outside Kampala.

CONCLUSIONS

Children living with HIV have a lower prevalence of RHD than the general pediatric population. Further studies are needed to explore this protective association.

Rheumatic heart disease in the modern era: recent developments and current challenges

Rheumatic heart disease (RHD) remains a major cause of preventable death and disability in children and young adults. Despite significant advances in medical technology and increased understanding of disease mechanisms, RHD continues to be a serious public health problem throughout the world, especially in low- and middle-income countries. Echocardiographic screening has played a key role in improving the accuracy of diagnosing RHD and has highlighted the disease burden. Most affected patients present with severe valve disease and limited access to life-saving cardiac surgery or percutaneous valve intervention, contributing to increased mortality and other complications. Although understanding of disease pathogenesis has advanced in recent years, key questions remain to be addressed. Preventing or providing early treatment for streptococcal infections is the most important step in reducing the burden of this disease.

The World Heart Federation criteria raise the threshold of diagnosis for mild rheumatic heart disease: Three reviewers are better than one

BACKGROUND

The World Heart Federation (WHF) criteria, published in 2012, provided an evidence-based guideline for the minimal diagnosis of echocardiographically-detected RHD. Primary aim of the study was to determine whether use of the WHF criteria altered the threshold for the diagnosis of echocardiographically-detected RHD compared with the previous WHO/NIH criteria. A secondary aim was to explore the utility of a three reviewer reporting system compared to a single or two reviewer reporting structure.

METHODS

144 de-identified echocardiograms (RHD, congenital valvar abnormality, physiological valvar regurgitation) were independently reported using the WHF criteria by two reviewers blinded to the previous WHO/NIH diagnosis. If there was discordance between the two reviewers, a third cardiologist independently performed a tie-breaker review.

RESULTS

There was a 21% reduction of cases classified as RHD using the WHF criteria compared to the modified WHO/NIH criteria (68 cases compared to 86, p = 0.04). There was a 60% consensus across the different diagnostic categories with 2 reviewers, 89% majority agreement with 3 reviewers. 11% required an open label discussion. There was moderate agreement between 2 reviewers for any RHD, kappa 0.57 (CI 0.44-0.70), with no significant difference in agreement between the different categories.

CONCLUSION

The WHF criteria have raised the threshold for the diagnosis of RHD compared to the WHO/NIH criteria. However, inter-reporter variability of the WHF criteria is high. A three reviewer system is likely more accurate than a single or two reporter system for the diagnosis of mild RHD. This has resource implications for echocardiographic screening programmes.

Two-year evolution of latent rheumatic heart disease in Malawi

BACKGROUND

In asymptomatic children, screening echocardiography has been used to attempt to diagnose rheumatic heart disease (RHD) at an early stage (latent RHD). World Heart Federation guidelines have standardized categorization of "definite," "borderline," or no RHD by echo findings. The progression of RHD diagnosed through echo screening is not known. In 2014, we screened 1450 schoolchildren in Malawi.

OBJECTIVE

Our objective was to evaluate 2-year RHD evolution among those diagnosed through screening.

METHODS

Two-year follow-up echocardiograms of those diagnosed with latent RHD were read by a primary, secondary, then third reader if there was disagreement. Progression or regression of both definite and borderline groups were tabulated. Penicillin adherence, age, gender, number in home, and household income were compared between those with definite RHD who regressed to borderline and those that stayed definite. We utilized the local system used to track HIV defaulters in order to bring participants back into care. Comparisons were made using Fisher's exact and Wilcoxon rank-sum tests.

RESULTS

Of the 39 with borderline RHD, 1 was lost to follow-up (2.6%), 1 progressed to definite (2.6%), 19 remained borderline (48.7%), 17 (43.6%) regressed to normal, and 1 was reclassified as mitral valve prolapse (2.6%). Of the 11 with definite RHD, 6 (54.5%) remained definite, 4 regressed to borderline (36.4%), and 1 regressed to normal (9.1%). Two of 11 with definite RHD had penicillin adherence above 80% for the 2-year follow-up period. There were no differences in adherence, gender, age, household income, or number in household between those with definite RHD that regressed to borderline and those who did not (P > .19).

CONCLUSIONS

Borderlines had a very low progression rate to definite RHD. A strength of our study was a high retention rate (98%). Longer follow-up is needed to determine expected disease evolution.

Inter-rater and intra-rater reliability and agreement of echocardiographic diagnosis of rheumatic heart disease using the World Heart Federation evidence-based criteria

OBJECTIVE

Different definitions have been used for screening for rheumatic heart disease (RHD). This led to the development of the 2012 evidence-based World Heart Federation (WHF) echocardiographic criteria. The objective of this study is to determine the intra-rater and inter-rater reliability and agreement in differentiating no RHD from mild RHD using the WHF echocardiographic criteria.

METHODS

A standard set of 200 echocardiograms was collated from prior population-based surveys and uploaded for blinded web-based reporting. Fifteen international cardiologists reported on and categorised each echocardiogram as no RHD, borderline or definite RHD. Intra-rater and inter-rater reliability was calculated using Cohen's and Fleiss' free-marginal multirater kappa (κ) statistics, respectively. Agreement assessment was expressed as percentages. Subanalyses assessed reproducibility and agreement parameters in detecting individual components of WHF criteria.

RESULTS

Sample size from a statistical standpoint was 3000, based on repeated reporting of the 200 studies. The inter-rater and intra-rater reliability of diagnosing definite RHD was substantial with a kappa of 0.65 and 0.69, respectively. The diagnosis of pathological mitral and aortic regurgitation was reliable and almost perfect, kappa of 0.79 and 0.86, respectively. Agreement for morphological changes of RHD was variable ranging from 0.54 to 0.93 κ.

CONCLUSIONS

The WHF echocardiographic criteria enable reproducible categorisation of echocardiograms as definite RHD versus no or borderline RHD and hence it would be a suitable tool for screening and monitoring disease progression. The study highlights the strengths and limitations of the WHF echo criteria and provides a platform for future revisions.

Secondary prophylaxis to control rheumatic heart disease in developing countries: Put into a cage if can't be killed

A significant socioeconomic inequality is the main barrier to achieve primordial prevention of rheumatic heart disease (RHD) in the developing countries. An effective vaccine with affordable cost against Streptococcus yet to be identified. The subclinical nature of rheumatic fever (RF) is the main hurdle for effective primary prevention of RHD. When RF and RHD are recognized at the earliest, treated adequately and SP with penicillin is strictly followed, then this disease can be kept under control though cannot be eradicated.

Outcomes of Redo Valve Surgery in Indigenous Australians

BACKGROUND

Rheumatic heart disease often leads to valve surgery at a young age in our Indigenous population. Anticoagulation can be problematic and therefore repeat surgery to replace degenerated bioprosthetic valves is common. We sought to examine outcomes following redo valve surgery in this population.

METHODS

Data from our institutional database was reviewed from 1992 to 2017. During this period, 82 redo valve surgeries were performed in 73 patients identifying as Aboriginal and Torres Strait Islander. We compared this study group to Indigenous patients undergoing primary valve surgery (n=389) and non-Indigenous patients undergoing redo valve surgery (n=154).

RESULTS

Redo patients had a median age of 29.5 years (IQR 24, 44), 59% were female, and they had significant comorbidities. The 30-day mortality in this cohort was 6% (EuroSCORE II 3.57), and they had significant morbidity. The median time to repeat surgery in those who had previous mitral valve surgery was 6.3 years, with no difference between mitral valve repair or replacement at the index procedure. Compared to non-Indigenous patients undergoing redo valve surgery, the Indigenous patients were significantly younger with higher left ventricular function but a greater proportion of pulmonary hypertension. There were no significant differences in short-term outcomes. Compared to Indigenous patients undergoing primary valve surgery, the Indigenous redo patients were significantly younger with more co-morbidities. There was no difference in 30-day mortality, but the redo patients did have significantly greater resource utilisation (increased hospital and intensive care unit (ICU) lengths of stay, ventilation and blood transfusion) and poorer long-term survival.

CONCLUSIONS

Indigenous patients presenting for redo valve surgery represent a complex and comorbid group of patients, with outcomes worse than expected in a young population, albeit comparable within study groups. Time from original surgery was short at 6 years, and thus a strategy must be in place in terms of planning future surgeries in this cohort of predominantly young rheumatic heart disease patients.

Acute rheumatic fever

Acute rheumatic fever is caused by an autoimmune response to throat infection with Streptococcus pyogenes. Cardiac involvement during acute rheumatic fever can result in rheumatic heart disease, which can cause heart failure and premature mortality. Poverty and household overcrowding are associated with an increased prevalence of acute rheumatic fever and rheumatic heart disease, both of which remain a public health problem in many low-income countries. Control efforts are hampered by the scarcity of accurate data on disease burden, and effective approaches to diagnosis, prevention, and treatment. The diagnosis of acute rheumatic fever is entirely clinical, without any laboratory gold standard, and no treatments have been shown to reduce progression to rheumatic heart disease. Prevention mainly relies on the prompt recognition and treatment of streptococcal pharyngitis, and avoidance of recurrent infection using long-term antibiotics. But evidence for the effectiveness of either approach is not strong. High-quality research is urgently needed to guide efforts to reduce acute rheumatic fever incidence and prevent progression to rheumatic heart disease.

Comparison Between Different Strategies of Rheumatic Heart Disease Echocardiographic Screening in Brazil: Data From the PROVAR (Rheumatic Valve Disease Screening Program) Study

Background

Considering the limited accuracy of clinical examination for early diagnosis of rheumatic heart disease (RHD), echocardiography has emerged as an important epidemiological tool. The ideal setting for screening is yet to be defined. We aimed to evaluate the prevalence and pattern of latent RHD in schoolchildren (aged 5–18 years) and to compare effectiveness of screening between public schools, private schools, and primary care centers in Minas Gerais, Brazil.

Methods and Results

The PROVAR (Rheumatic Valve Disease Screening Program) study uses nonexperts and portable and handheld devices for RHD echocardiographic screening, with remote interpretation by telemedicine, according to the 2012 World Heart Federation criteria. Compliance with study consent and prevalence were compared between different screening settings, and variables associated with RHD were analyzed. In 26 months, 12 048 students were screened in 52 public schools (n=10 901), 2 private schools (n=589), and 3 primary care centers (n=558). Median age was 12.9 years, and 55.4% were girls. Overall RHD prevalence was 4.0% borderline (n=486) and 0.5% definite (n=63), with statistically similar rates between public schools (4.6%), private schools (3.5%), and primary care centers (4.8%) (P=0.24). The percentage of informed consents signed was higher in primary care centers (84.4%) and private schools (66.9%) compared with public schools (38.7%) (P<0.001). Prevalence was higher in children ≥12 years (5.3% versus 3.1%; P<0.001) and girls (4.9% versus 4.0%; P=0.02). Only age (odds ratio, 1.12; 95% confidence interval, 1.09–1.17; P<0.001) was independently associated with RHD.

Conclusions

RHD screening in primary care centers seems to achieve higher coverage rates. Prevalence among schoolchildren is significantly high, with rates higher than expected in private schools of high‐income areas. These data are important for the formulation of public policies to confront RHD.

Heart disease in East Timor: cross-sectional analysis of 474 patients attending Timor-Leste's first cardiology service

BACKGROUND

East Timor is a developing country and is a close neighbour of Australia. The prevalence of cardiac disease is unknown.

AIMS

To describe the prevalence and patterns of cardiac disease in patients attending the first cardiology service of Timor-Leste.

METHODS

A cross-sectional retrospective analysis was performed of demographic and clinical data of 474 unique patients referred to outpatient cardiology clinics conducted in East Timor from 2003 to 2016.

RESULTS

Mean age was 29.9 ± 18.5 years, with females significantly younger than males (28.8 ± 16.9 vs 32.3 ± 20.6 years). Congenital cardiac disease patients were the youngest (15.5 ± 13.9 years) and cardiomyopathy patients the oldest (46.7 ± 17.8 years). Of patients with rheumatic heart disease, the majority had mitral stenosis (59.4%) and multi-valvular involvement (61.6%). Of note, 28.3% of patients with rheumatic heart disease presented with severe mitral stenosis. Amongst congenital heart disease patients, the most common diagnosis was atrial or ventricular septal defects (61% combined). A total of 19.2% of patients either required immediate referral for intervention or palliation for their cardiac disease. Patients referred to Australia for treatment were significantly younger (19.7 ± 11.7 years) than all other outcome groups.

CONCLUSION

Amongst young East Timorese, rheumatic heart disease and unrepaired congenital cardiac defects impose a significant burden. One-fifth of patients present to clinics with severe disease requiring urgent referral for surgery or palliation.

Latent Rheumatic Heart Disease: Identifying the Children at Highest Risk of Unfavorable Outcome

BACKGROUND

Screening echocardiography has emerged as a potentially powerful tool for early diagnosis of rheumatic heart disease (RHD). The utility of screening echocardiography hinges on the rate of RHD progression and the ability of penicillin prophylaxis to improve outcome. We report the longitudinal outcomes of a cohort of children with latent RHD and identify risk factors for unfavorable outcomes.

METHODS

This was a prospective natural history study conducted under the Ugandan RHD registry. Children with latent RHD and ≥1 year of follow-up were included. All echocardiograms were re-reviewed by experts (2012 World Heart Federation criteria) for inclusion and evidence of change. Bi- and multivariable logistic regression, Kaplan-Meier analysis, and Cox proportional hazards models, as well, were developed to search for risk factors for unfavorable outcome and compare progression-free survival between those treated and not treated with penicillin. Propensity and other matching methods with sensitivity analysis were implemented for the evaluation of the penicillin effect.

RESULTS

Blinded review confirmed 227 cases of latent RHD: 164 borderline and 63 definite (42 mild, 21 moderate/severe). Median age at diagnosis was 12 years and median follow-up was 2.3 years (interquartile range, 2.0-2.9). Penicillin prophylaxis was prescribed in 49.3% with overall adherence of 84.7%. Of children with moderate-to-severe definite RHD, 47.6% had echocardiographic progression (including 2 deaths), and 9.5% had echocardiographic regression. Children with mild definite and borderline RHD showed 26% and 9.8% echocardiographic progression and 45.2% and 46.3% echocardiographic improvement, respectively. Of those with mild definite RHD or borderline RHD, more advanced disease category, younger age, and morphological mitral valve features were risk factors for an unfavorable outcome.

CONCLUSIONS

Latent RHD is a heterogeneous diagnosis with variable disease outcomes. Children with moderate to severe latent RHD have poor outcomes. Children with both borderline and mild definite RHD are at substantial risk of progression. Although long-term outcome remains unclear, the initial change in latent RHD may be evident during the first 1 to 2 years following diagnosis. Natural history data are inherently limited, and a randomized clinical trial is needed to definitively determine the impact of penicillin prophylaxis on the trajectory of latent RHD.

Bmi1 and BRG1 drive myocardial repair by regulating cardiac stem cell function in acute rheumatic heart disease

Rheumatic heart disease (RHD) occurs due to the accumulation of complications associated with rheumatic fever, and it results in high morbidity and mortality. The majority of cases of RHD are diagnosed in the chronic stages, when treatment options are limited. A small reservoir of cardiac stem cells is responsible for maintaining cardiac homeostasis and repairing tissue damage. Understanding the role of cardiac stem cells and the various proteins responsible for their functions in different pathological stages of RHD is an important area of investigation. Polycomb complex protein BMI-1 (Bmi1) and transcription activator BRG1 (BRG1) are associated with the maintenance of stemness in various types of stem cells. The present study investigated the role served by Bmi1 and BRG1 in cardiac stem cells during various pathological stages of RHD through immunohistochemistry and western blotting. A rat model of RHD was established via immunization with the Group A Streptococcus M5 protein. The rat was demonstrated to develop acute RHD 2 months after the final immunization, characterized by cardiac inflammation and tissue damage. Chronic RHD was identified 4 months after the final immunization, revealed by cardiac tissue compression and shrinkage. Expression of the cardiac stem cell marker mast/stem cell growth factor receptor kit was identified to be elevated during acute RHD, but downregulated in the chronic stages of RHD. A similar pattern of expression was revealed for Bmi1 and BRG1, indicating that they serve a role in regulating cardiac stem cell proliferation during acute RHD. These results suggest that cardiac stem cells serve a supportive role in the acute, but not chronic, stages of RHD via expression of Bmi1 and BRG1.