Prevalence of rheumatic valvular heart disease in Rwandan school children: echocardiographic evaluation using the World Heart Federation criteria

BACKGROUND

Rheumatic fever (RF) and rheumatic valvular heart disease (RHD) remain important medical, surgical and public health concerns in many parts of the world, especially in sub-Saharan Africa. However, there are no published data from Rwanda. We performed a RHD prevalence study in a randomly selected sample of Rwandan school children using the 2012 World Heart Federation (WHF) criteria.

METHODS

Echocardiographic assessment of 2 501 Rwandan school children from 10 schools in the Gasabo district near Kigali was carried out. Resulting data were evaluated by four experienced echocardiographers. Statistical analyses were carried out by statisticians.

RESULTS

RHD prevalence was 6.8/1 000 children examined (95% CI: 4.2/1 000-10.9/1 000). Seventeen met WHF criteria for RHD, 13 fulfilled criteria for 'borderline' RHD and four were 'definite' RHD. None of these 17 had been previously identified.

CONCLUSION

These data indicate a significant burden of RHD in Rwanda and support a need for defined public health RF control programmes in children there.

[Evaluation of the cardiovascular function in patients with chronic rheumatic heart disease in the practice of medical and social expertise]

Chronic rheumatic heart disease (HRHD) for a long time occupied a prominent position in the structure of the disability population in Ukraine. Aim of the study is to define clinical signs of cardiovascular function in patients with HRHD for disability evaluation in the practice of medical and social expertise. We examined 180 patients with HRHD aged 40-65 years. There were significant differences in patient groups, which allowed us to formulate clinical and functional diagnostic markers of dysfunction of circulation for the objective assessment of the limitations of their life, the definition of disability groups and the development of rehabilitation programs.

Myocardial dysfunction in rheumatic carditis--does it really exist?

OBJECTIVES

Acute rheumatic fever (ARF) continues to affect millions of children in developing countries. Aim of the present study was to evaluate the role of myocardial dysfunction in the genesis of heart failure in patients with rheumatic carditis. There are limited studies on this subject.

METHODS AND RESULTS

In this prospective study, 108 consecutive patients of ARF were evaluated by echocardiography and assay of cardiac troponin I blood levels. The patients were divided into three groups. Group A (n = 30): patients with no evidence of carditis; Group B (n = 45): patients with first attack of carditis; and group C (n = 33): patients with recurrent attacks of carditis. Left ventricular dimensions tended to be larger in Group B and C patients. Left ventricular ejection fraction did not differ between the groups (Group A: 63 +/- 8.1%, Group B: 58 +/- 7.9%, Group C: 61.2 +/- 9%, p = ns). Heart failure was present in 37.7% patients of Group B, and in 60.6% patients of Group C (p = < 0.05). Ejection fraction was normal in majority of heart failure patients (75.7%). It was reduced in 29.4% of patients in Group B and in 20% of Group C patients with heart failure (p = ns). All patients with low ejection fraction had hemodynamically significant regurgitant valvular lesions. Mean cardiac troponin I values, an index of myocardial damage, did not differ between the three groups (Group A: 0.062 +/- 0.027 ng/ml, Group B: 0.068 +/- 0.019 ng/ml, Group C: 0.071 +/- 0.031 ng/ml, p = ns).

CONCLUSION

The present study did not demonstrate any echocardiographic abnormalities or cardiac troponin I elevation suggesting significant myocardial involvement during acute rheumatic fever. This lends credence to the view that myocardial involvement does not play any significant role in the genesis of heart failure in patients with rheumatic carditis.

Association between transforming growth factor-beta1 gene C-509T and T869C polymorphisms and rheumatic heart disease

BACKGROUND

Scarring and collagen deposition in the valves and destruction of myocytes may result from the combined effects of a smoldering rheumatic process and a constant trauma to the mitral valve or aortic valve by the turbulent flow in rheumatic heart disease (RHD). Transforming growth factor-beta1 (TGF-beta1) may be responsible for the increased valvular fibrosis and calcification in the pathogenesis of RHD. However, the role of TGF-beta1 genetic variant in RHD has not been studied. This case-controlled study was carried out to investigate the possible relationship between the TGF-beta1 gene C-509T and T869C polymorphisms and RHD among the Chinese population in Taiwan.

METHODS

A group of 115 patients with RHD documented by using echocardiography and 100 age- and sex-matched healthy control patients were studied. TGF-beta1 gene C-509T and T869C polymorphisms were identified with polymerase chain reaction-based restriction analysis.

RESULTS

A significant difference was seen in the distribution of genotypes between patients with RHD and control patients for either TGF-beta1 C-509T polymorphism (P <.0001) or T869C polymorphism (P <.0001). The frequency of TGF-beta1 C-509T CC genotype was lower in the RHD group than in the control group (chi2 = 19.05, P <.0001), which suggests that this genotype may confer protective effects against RHD. A significant difference was seen in the distribution of allelic frequency between patients with RHD and control patients for TGF-beta1 T869C polymorphism (P =.04). The odds ratio (OR) for risk of RHD associated with TGF-beta1 T869C T allele was 1.49 (95% CI, 1.02-2.19). Further categorization of patients with RHD into mitral valve disease and combined valve disease subgroups revealed no statistical difference in these gene polymorphisms when compared with the 2 subgroups.

CONCLUSIONS

Patients with RHD have a lower frequency of TGF-beta1 C-509T CC genotype and a higher frequency of T869C T allele, which supports a role for the TGF-beta1 gene C-509T and T869C polymorphisms in determining the risk/protection of RHD in Taiwan Chinese patients.

[Present-day classification and nomenclature of rheumatic fever]

The paper presents a new classification of rheumatic fever, which has been adopted by the Plenary Session of the Association of Rheumatologists of Russia in May 2003. This classification envisages the abandonment of the term "rheumatism" in its former interpretation. The term "acute rheumatic fever" (ARF) appears to be more justified since it makes a physician elucidate its association with Group A streptococcal infection of the throat and prescribe antibiotics for eradication of this infection in its acute period (primary prophylaxis) and for prevention of repeated attacks (secondary prophylaxis). The current interpretation of the clinical syndromes/symptoms and laboratory parameters that enter into diagnostic criteria for ARF is presented. There are 2 types of outcome of the disease. In case of recovery, we are dealing with the complete regression of the clinical symptomatology of ARF, normalized laboratory parameters and no residual changes. Chronic rheumatic diseases of the heart are considered to mean a disease characterized by a cardiac valvular lesion as postinflammatory marginal fibrosis of valvular leaflets or cardiac abnormality (failure and/or stenosis) developed after prior ARF. Emphasis is laid on the significance of evidence of Group A streptococcal infection that precedes the development of the disease. Examples of clinical diagnosis in accordance with the terminology of the International Classification of Diseases, the 10th edition, are given in the paper.

Impact of tissue harmonic imaging on the assessment of rheumatic mitral stenosis

We examined the effect of tissue harmonic imaging on the echocardiographic splitability score and valve area measurement of 40 patients with rheumatic mitral stenosis. Planimetered valve areas were unaffected by the use of harmonic imaging, but valve scores were increased, particularly in patients with scores <10.

Advanced atrioventricular block in a 39-year-old man with acute rheumatic fever

This report describes the development of advanced (2:1 and 3:1) AV block in a 39-year-old man with acute rheumatic fever. AV block progressed from first-degree to type I second-degree and finally to advanced AV block. The latter lasted 5 days. AV block regressed in a stepwise fashion via sustained type I second-degree AV block and eventually first-degree AV block. The PR interval returned to normal several weeks after resolution of second-degree AV block. In view of the resurgence of acute rheumatic fever, the diagnosis of acute rheumatic fever should now be considered in young adults or middle-aged patients presenting with second-degree or third-degree AV block of undetermined etiology.

[Diagnostic criteria of infectious endocarditis]

Accurate diagnostic criteria for infective endocarditis are essential to epidemiological studies. The von Reyn's criteria have been widely used for more than a decade after they were published in 1981. In 1994, the Duke's criteria for the clinical diagnosis of infective endocarditis were published, incorporating echocardiographic findings. They are modeled after the Jones criteria for the identification of cases of rheumatic fever and include 2 major and 6 minor diagnostic criteria. They are about twice as specific as the former von Reyn's criteria, without loss of specificity, and should become a standard reference for diagnosing infective endocarditis.

Role of an operative score in mitral reconstruction in dominantly stenotic lesions

OBJECTIVE

The role of an operative score in selection and results of mitral valve reconstruction in dominantly stenotic mitral lesions was assessed.

METHODS

A total of 136 patients consecutively underwent reconstruction for rheumatic mitral stenosis with or without regurgitation from December 1989 through December 1994. Mitral valve structure was scored for cuspal pliability and thickness, cuspal area loss, chordal length, papillary muscle length, annular dilatation and degree of associated regurgitation and calcification. A score of 0 indicated normal valve while a score of 24 indicated a grossly deformed valve. Age, sex, functional class, cardiac rhythm, mitral valve orifice area, left ventricular and left atrial dimensions, transmitral gradients, pulmonary artery pressures and thoroughness of repair were evaluated.

RESULTS

Mitral valve architecture was disorganised moderately in 50 (37%) and severely in 69 (52%) patients. Extent of thoroughness in different operative techniques correlated with good (n = 30) or adequate (n = 60) outcome. Mean mitral valve orifice area increased from 0.77 +/- 0.2 to 2.56 +/- 0.6 cm2, peak gradient dropped from 20.3 +/- 6.2 to 8.6 +/- 3.5 torr, mean gradient from 13.5 +/- 4.9 to 4.76 +/- 2.2 torr and end-diastolic gradient from 10.1 +/- 5.0 to 3.2 +/- 1.9 torr. Lack of recognition of anatomical details and of all necessary componental measures constituted the learning curve of different operators.

CONCLUSIONS

Recurrent disease, learning curve, inadequate repair and higher operative mitral valve score were the factors for poorer results in the intermediate term follow-up to 64 months. Thoroughness of repair was the most important correlate of outcome and indicative of expertise.

[Echocardiography and Jones criteria in the diagnosis of rheumatic heart diseases: 138 cases reviewed at the Cardiology Institute of Abidjan]

The files of 138 patients suffering from rheumatic heart disease were studied in order to confirm the value of modified Jones' criteria and heart damage and to evaluate the contribution of echocardiography findings. Only files containing complete clinical and laboratory findings were studied. Of the 138 cases reviewed there were 51 cases of carditis (36.6 percent) and 87 cases of heart damage (63.4 percent). Carditis was associated with arthritis in 35.3 percent of cases. Antistreptolysin O levels were elevated in 74.5% percent of cases. Regarding Jones' criteria, the presence of a minor clinical criteria such as fever, polyarthritis, and history of acute rheumatic joint inflammation and laboratory findings such as elevated erythrosedimentation and antistreptolysin O rates were associated with carditis significantly more often than with heart damage. Echocardiography played a determinant role in the diagnosis between rheumatic heart disease in 35.3 percent of cases. Only echocardiography allowed differential diagnosis between rheumatic heart damage and other tropical cardiovascular diseases.

Hemoptysis in rheumatic heart disease

107 Consecutive patients with rheumatic valvular heart disease (41 males, 66 females, average age 24.2 years) being followed at an Ethiopian cardiology referral clinic were examined and questioned about their experience of hemoptysis. 51 Patients (48%) gave a history of hemoptysis; 11 described their usual hemoptysis as frank blood, 40 as blood-streaked sputum. 29 patients had frequent hemoptysis, 13 had several episodes, and 9 only 1 occurrence. Prevalence of hemoptysis did not vary significantly by sex, physical findings, New York Heart Association classification, or valvular lesion, including the presence or absence of mitral stenosis. A majority (64) had been tested for tuberculosis, with 5 having been treated for active disease. Hemoptysis is a common manifestation of rheumatic heart disease, and is usually well tolerated.