Excess Deaths Associated with Rheumatic Heart Disease, Australia, 2013-2017

During 2013-2017, the mortality rate ratio for rheumatic heart disease among Indigenous versus non-Indigenous persons in Australia was 15.9, reflecting health inequity. Using excess mortality methods, we found that deaths associated with rheumatic heart disease among Indigenous Australians were probably substantially undercounted, affecting accuracy of calculations based solely on Australian Bureau of Statistics data.

Trends in Rheumatic Heart Disease-Related Mortality in the United States from 1999 to 2020

There is a lack of mortality data on rheumatic heart disease (RHD) in the United States (US). In light of this, a retrospective analysis was conducted to investigate the temporal, sex-based, racial, and regional trends in RHD-related mortality in the US, ranging from 1999 to 2020. The Center for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC-WONDER) dataset was analyzed, where crude and age-adjusted mortality rates (AAMR) were identified, along with annual percentage changes (APCs) determined by Joinpoint regression. Through the period of 1999 to 2020, there were 141,137 RHD-related deaths reported, with a marginal decline from 4.05/100,000 in 1999 to 3.12/100,000 in 2020. However, the recent rise in AAMR from 2017 to 2020 has created a source of concern (APC: 6.62 [95% CI, 3.19-8.72]). Similar trends were observed in the Black or African American race from 2017 to 2020 (APC: 10.58 [95% CI, 6.29-17.80]). Moreover, the highest percentage change from 2018 to 2020 was observed in residents of large metropolitan areas (APC: 7.6 [95% CI, 2.8-10.5]). A prominent disparity was observed among states, with values ranging from 1.74/100,000 in Louisiana to 5.27/100,000 in Vermont. States within the top 90th percentile of RHD-related deaths included Alaska, Minnesota, Washington, Wyoming, and Vermont. In conclusion, it is imperative to delve deeper into the evidently rising trends of RHD-related mortality and outline the possible sources of social determinants within US healthcare in order to provide equal and quality medical care throughout the nation.

Rheumatic heart disease mortality in Indigenous and non-Indigenous Australians between 2010 and 2017

OBJECTIVES

To generate contemporary age-specific mortality rates for Indigenous and non-Indigenous Australians aged <65 years who died from rheumatic heart disease (RHD) between 2013 and 2017, and to ascertain the underlying causes of death (COD) of a prevalent RHD cohort aged <65 years who died during the same period.

METHODS

For this retrospective, cross-sectional epidemiological study, Australian RHD deaths for 2013-2017 were investigated by first, mortality rates generated using Australian Bureau of Statistics death registrations where RHD was a coded COD, and second COD analyses of death records for a prevalent RHD cohort identified from RHD register and hospitalisations. All analyses were undertaken by Indigenous status and age group (0-24, 25-44, 45-64 years).

RESULTS

Age-specific RHD mortality rates per 100 000 were 0.32, 2.63 and 7.41 among Indigenous 0-24, 25-44 and 45-64 year olds, respectively, and the age-standardised mortality ratio (Indigenous vs non-Indigenous 0-64 year olds) was 14.0. Within the prevalent cohort who died (n=726), RHD was the underlying COD in 15.0% of all deaths, increasing to 24.6% when RHD was included as associated COD. However, other cardiovascular and non-cardiovascular conditions were the underlying COD in 34% and 43% respectively.

CONCLUSION

Premature mortality in people with RHD aged <65 years has approximately halved in Australia since 1997-2005, most notably among younger Indigenous people. Mortality rates based solely on underlying COD potentially underestimates true RHD mortality burden. Further strategies are required to reduce the high Indigenous to non-Indigenous mortality rate disparity, in addition to optimising major comorbidities that contribute to non-RHD mortality.

Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis

Purpose

Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy.

Methods

Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I² statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529).

Findings

The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54–5.33), and perinatal death (6 studies, RR 3.23, 1.92–5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02–4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02–5.95).

Interpretation

RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.

The temporospatial epidemiology of rheumatic heart disease in Far North Queensland, tropical Australia 1997-2017; impact of socioeconomic status on disease burden, severity and access to care

Background

The incidence of rheumatic heart disease (RHD) among Indigenous Australians remains one of the highest in the world. Many studies have highlighted the relationship between the social determinants of health and RHD, but few have used registry data to link socioeconomic disadvantage to the delivery of patient care and long-term outcomes.

Methods

A retrospective study of individuals living with RHD in Far North Queensland (FNQ), Australia between 1997 and 2017. Patients were identified using the Queensland state RHD register. The Socio-Economic Indexes for Areas (SEIFA) Score–a measure of socioeconomic disadvantage–was correlated with RHD prevalence, disease severity and measures of RHD care.

Results

Of the 686 individuals, 622 (90.7%) were Indigenous Australians. RHD incidence increased in the region from 4.7/100,000/year in 1997 to 49.4/100,000/year in 2017 (p<0.001). In 2017, the prevalence of RHD was 12/1000 in the Indigenous population and 2/1000 in the non-Indigenous population (p<0.001). There was an inverse correlation between an area’s SEIFA score and its RHD prevalence (rho = -0.77, p = 0.005).

249 (36.2%) individuals in the cohort had 593 RHD-related hospitalisations; the number of RHD-related hospitalisations increased during the study period (p<0.001). In 2017, 293 (42.7%) patients met criteria for secondary prophylaxis, but only 73 (24.9%) had good adherence. Overall, 119/686 (17.3%) required valve surgery; the number of individuals having surgery increased over the study period (p = 0.02).

During the study 39/686 (5.7%) died. Non-Indigenous patients were more likely to die than Indigenous patients (9/64 (14%) versus 30/622 (5%), p = 0.002), but Indigenous patients died at a younger age (median (IQR): 52 (35–67) versus 73 (62–77) p = 0.013). RHD-related deaths occurred at a younger age in Indigenous individuals than non-Indigenous individuals (median (IQR) age: 29 (12–58) versus 77 (64–78), p = 0.007).

Conclusions

The incidence of RHD, RHD-related hospitalisations and RHD-related surgery continues to rise in FNQ. Whilst this is partly explained by increased disease recognition and improved delivery of care, the burden of RHD remains unacceptably high and is disproportionately borne by the socioeconomically disadvantaged Indigenous population.

Rheumatic heart disease (RHD), a disease of poverty and disadvantage, is almost completely preventable. It is now extremely rare in wealthy countries, but in Far North Queensland in tropical Australia, the incidence of RHD, RHD-related hospitalisations and RHD-related surgery is continuing to rise, with the burden of disease borne almost entirely by the region’s Indigenous population. While the increasing incidence of RHD and its complications may be partly explained by improvements in local service delivery, the disease remains inextricably linked to socioeconomic disadvantage. In this study, not only were patients living in socioeconomically disadvantaged areas more likely to have RHD, but they were also paradoxically less likely to receive valve surgery. The current local model of care—which is centralised, medical and emphasises disease monitoring and secondary prophylaxis—appears to be having a limited impact on morbidity. Strategies must evolve—in partnership with Indigenous communities—to have a greater focus on disease prevention by addressing the personal, community and environmental factors that increase the risk of the disease. This is likely to not only reduce the incidence of RHD, but will also tend to reduce the burden of the many other diseases that result from socioeconomic disadvantage and that disproportionately affect Indigenous Australians.

Outcomes and Care Quality Metrics for Women of Reproductive Age Living With Rheumatic Heart Disease in Uganda

Background Rheumatic heart disease disproportionately affects women of reproductive age, as it increases the risk of cardiovascular complications and death during pregnancy and childbirth. In sub-Saharan Africa, clinical outcomes and adherence to guideline-based therapies are not well characterized for this population. Methods and Results In a retrospective cohort study of the Uganda rheumatic heart disease registry between June 2009 and May 2018, we used multivariable regression and Cox proportional hazards models to compare comorbidities, mortality, anticoagulation use, and treatment cascade metrics among women versus men aged 15 to 44 with clinical rheumatic heart disease. We included 575 women and 252 men with a median age of 27 years. Twenty percent had New York Heart Association Class III-IV heart failure. Among patients who had an indication for anticoagulation, women were less likely than men to receive a prescription of warfarin (66% versus 81%; adjusted odds ratio, 0.37; 95% CI, 0.14-0.96). Retention in care (defined as a clinic visit within the preceding year) was poor among both sexes in this age group (27% for men, 24% for women), but penicillin adherence rates were high among those retained (89% for men, 92% for women). Mortality was higher in men than women (26% versus 19% over a median follow-up of 2.7 years; adjusted hazard ratio, 1.66; 95% CI, 1.18-2.33). Conclusions Compared with men, women of reproductive age with rheumatic heart disease in Uganda have lower rates of appropriate anticoagulant prescription but also lower mortality rates. Retention in care is poor among both men and women in this age range, representing a key target for improvement.

Prevalence, clinical characteristics and outcomes of valvular atrial fibrillation in a cohort of African patients with acute heart failure: insights from the THESUS-HF registry

INTRODUCTION

Rheumatic heart disease (RHD) is the commonest cause of valvular heart disease and a common cause of heart failure in sub-Saharan Africa (SSA). Atrial fibrillation (AF) complicates RHD, precipitates and worsens heart failure and cause unfavourable outcomes. We set out to describe the prevalence, clinical characteristics and outcomes of valvular atrial fibrillation in a cohort of African patients with acute heart failure (AHF).

METHODS

The sub-Saharan Africa Survey of Heart Failure (THESUS-HF) was a prospective, observational survey of AHF in nine countries. We collected demographic data, medical history and signs and symptoms of HF. Electrocardiograms (ECGs) were done in a standard fashion. AF was defined as either a history of AF or AF on the admission ECG. Using Cox regression models, we examined the associations of AF with all-cause death over 180 days and a composite endpoint of all-cause death or readmission over 60 days.

RESULTS

There were 1 006 patients in the registry. The mean age was 52.3 years and 50.8% were women. AF was present in 209 (20.8%) cases. Those with AF were older (57.1 vs 51.1 years), more likely to be female (57.4 vs 49.1%), had significantly lower systolic (125 vs 132 mmHg) and diastolic (81 vs 85 mmHg) blood pressure (BP), and higher heart rates (109 vs 102 bpm). Ninety-two (44%) AF patients had valvular heart disease. The presence of AF was not associated with the primary endpoints, but having valvular AF predicted death within 180 days.

CONCLUSIONS

AF was present in one-fifth of African patients with AHF. Almost half of the AF patients had valvular disease (RHD) and were significantly younger and at risk of dying within six months. It is important to identify these high-risk patients and prioritise their management, especially in SSA where resources are limited.

Predictive performance of six mortality risk scores and the development of a novel model in a prospective cohort of patients undergoing valve surgery secondary to rheumatic fever

BACKGROUND

Mortality prediction after cardiac procedures is an essential tool in clinical decision making. Although rheumatic cardiac disease remains a major cause of heart surgery in the world no previous study validated risk scores in a sample exclusively with this condition.

OBJECTIVES

Develop a novel predictive model focused on mortality prediction among patients undergoing cardiac surgery secondary to rheumatic valve conditions.

METHODS

We conducted prospective consecutive all-comers patients with rheumatic heart disease (RHD) referred for surgical treatment of valve disease between May 2010 and July of 2015. Risk scores for hospital mortality were calculated using the 2000 Bernstein-Parsonnet, EuroSCORE II, InsCor, AmblerSCORE, GuaragnaSCORE, and the New York SCORE. In addition, we developed the rheumatic heart valve surgery score (RheSCORE).

RESULTS

A total of 2,919 RHD patients underwent heart valve surgery. After evaluating 13 different models, the top performing areas under the curve were achieved using Random Forest (0.982) and Neural Network (0.952). Most influential predictors across all models included left atrium size, high creatinine values, a tricuspid procedure, reoperation and pulmonary hypertension. Areas under the curve for previously developed scores were all below the performance for the RheSCORE model: 2000 Bernstein-Parsonnet (0.876), EuroSCORE II (0.857), InsCor (0.835), Ambler (0.831), Guaragna (0.816) and the New York score (0.834). A web application is presented where researchers and providers can calculate predicted mortality based on the RheSCORE.

CONCLUSIONS

The RheSCORE model outperformed pre-existing scores in a sample of patients with rheumatic cardiac disease.

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.

Global, Regional, and National Burden of Rheumatic Heart Disease, 1990-2015

BACKGROUND

Rheumatic heart disease remains an important preventable cause of cardiovascular death and disability, particularly in low-income and middle-income countries. We estimated global, regional, and national trends in the prevalence of and mortality due to rheumatic heart disease as part of the 2015 Global Burden of Disease study.

METHODS

We systematically reviewed data on fatal and nonfatal rheumatic heart disease for the period from 1990 through 2015. Two Global Burden of Disease analytic tools, the Cause of Death Ensemble model and DisMod-MR 2.1, were used to produce estimates of mortality and prevalence, including estimates of uncertainty.

RESULTS

We estimated that there were 319,400 (95% uncertainty interval, 297,300 to 337,300) deaths due to rheumatic heart disease in 2015. Global age-standardized mortality due to rheumatic heart disease decreased by 47.8% (95% uncertainty interval, 44.7 to 50.9) from 1990 to 2015, but large differences were observed across regions. In 2015, the highest age-standardized mortality due to and prevalence of rheumatic heart disease were observed in Oceania, South Asia, and central sub-Saharan Africa. We estimated that in 2015 there were 33.4 million (95% uncertainty interval, 29.7 million to 43.1 million) cases of rheumatic heart disease and 10.5 million (95% uncertainty interval, 9.6 million to 11.5 million) disability-adjusted life-years due to rheumatic heart disease globally.

CONCLUSIONS

We estimated the global disease prevalence of and mortality due to rheumatic heart disease over a 25-year period. The health-related burden of rheumatic heart disease has declined worldwide, but high rates of disease persist in some of the poorest regions in the world. (Funded by the Bill and Melinda Gates Foundation and the Medtronic Foundation.).

Minimally invasive mitral valve replacement is a safe and effective surgery for patients with rheumatic valve disease: A retrospective study

The aim of the study was to evaluate the treatment of minimally invasive mitral valve replacement (MIMVR) through a right minithoracotomy for patients with rheumatic mitral valve disease.From February 2009 to December 2016, 360 patients with rheumatic mitral valve disease underwent mitral valve replacement by the same surgeon. Among them, 150 patients accepted MIMVR through a right minithoracotomy, whereas the other 210 accepted a traditional median sternotomy. After matching by patients by age, sex, EuroSCORE, New York Heart Association (NYHA) classification, renal and liver function, and degree of mitral valve disease, we selected 224 patients for analysis in our retrospective study.In the MIMVR group (112 patients), the aortic cross-clamp time (ACC time) (55.25 ± 2.18 minutes) was significantly longer than that in the control group (112 patients; 36.05 ± 1.40 minutes) (P < .0001). In contrast, the cardiopulmonary bypass time (CPB time) was shorter in the MIMVR group than in the control group (61.13 ± 2.57 vs 78.65 ± 4.05 minutes, respectively, P < .0001). Patients who accepted MIMVR surgery had less drainage 24 hours postoperation (324.10 ± 34.55 vs 492.90 ± 34.05 mL, P < .0001) and had less total drainage (713.46 ± 65.35 vs 990.49 ± 67.88 mL, P < .0001) than those who underwent median sternotomy. Thirty-two percent of patients in the MIMVR group needed a blood transfusion (1.35 ± .28 units of red blood cells, 155.36 ± 33.43 mL plasma), whereas 67.0% of the control group needed a blood transfusion (2.15 ± .24 units of red blood cells, 287.50 ± 33.54 mL plasma) (Ptransfusion < .001, Pcell = .029, Pplasma = .006). In total, 5 deaths occurred during the perioperative period; 3 occurred in the MIMVR group. The average hospital stay was significantly shorter in the MIMVR group than that in the control group (6.56 ± .23 vs 8.53 ± .59 days, P = .003).MIMVR, an effective and safe treatment approach for patients suffering from rheumatic mitral valve disease, is associated with less trauma and a faster recovery. It is a better choice for treating simple rheumatic mitral valve disease.

Trends and Patterns of Geographic Variation in Cardiovascular Mortality Among US Counties, 1980-2014

IMPORTANCE

In the United States, regional variation in cardiovascular mortality is well-known but county-level estimates for all major cardiovascular conditions have not been produced.

OBJECTIVE

To estimate age-standardized mortality rates from cardiovascular diseases by county.

DESIGN AND SETTING

Deidentified death records from the National Center for Health Statistics and population counts from the US Census Bureau, the National Center for Health Statistics, and the Human Mortality Database from 1980 through 2014 were used. Validated small area estimation models were used to estimate county-level mortality rates from all cardiovascular diseases, including ischemic heart disease, cerebrovascular disease, ischemic stroke, hemorrhagic stroke, hypertensive heart disease, cardiomyopathy, atrial fibrillation and flutter, rheumatic heart disease, aortic aneurysm, peripheral arterial disease, endocarditis, and all other cardiovascular diseases combined.

EXPOSURES

The 3110 counties of residence.

MAIN OUTCOMES AND MEASURES

Age-standardized cardiovascular disease mortality rates by county, year, sex, and cause.

RESULTS

From 1980 to 2014, cardiovascular diseases were the leading cause of death in the United States, although the mortality rate declined from 507.4 deaths per 100 000 persons in 1980 to 252.7 deaths per 100 000 persons in 2014, a relative decline of 50.2% (95% uncertainty interval [UI], 49.5%-50.8%). In 2014, cardiovascular diseases accounted for more than 846 000 deaths (95% UI, 827-865 thousand deaths) and 11.7 million years of life lost (95% UI, 11.6-11.9 million years of life lost). The gap in age-standardized cardiovascular disease mortality rates between counties at the 10th and 90th percentile declined 14.6% from 172.1 deaths per 100 000 persons in 1980 to 147.0 deaths per 100 000 persons in 2014 (posterior probability of decline >99.9%). In 2014, the ratio between counties at the 90th and 10th percentile was 2.0 for ischemic heart disease (119.1 vs 235.7 deaths per 100 000 persons) and 1.7 for cerebrovascular disease (40.3 vs 68.1 deaths per 100 000 persons). For other cardiovascular disease causes, the ratio ranged from 1.4 (aortic aneurysm: 3.5 vs 5.1 deaths per 100 000 persons) to 4.2 (hypertensive heart disease: 4.3 vs 17.9 deaths per 100 000 persons). The largest concentration of counties with high cardiovascular disease mortality extended from southeastern Oklahoma along the Mississippi River Valley to eastern Kentucky. Several cardiovascular disease conditions were clustered substantially outside the South, including atrial fibrillation (Northwest), aortic aneurysm (Midwest), and endocarditis (Mountain West and Alaska). The lowest cardiovascular mortality rates were found in the counties surrounding San Francisco, California, central Colorado, northern Nebraska, central Minnesota, northeastern Virginia, and southern Florida.

CONCLUSIONS AND RELEVANCE

Substantial differences exist between county ischemic heart disease and stroke mortality rates. Smaller differences exist for diseases of the myocardium, atrial fibrillation, aortic and peripheral arterial disease, rheumatic heart disease, and endocarditis.

Value of pulmonary artery pressure in predicting in-hospital and one-year mortality after valve replacement surgery in middle-aged and aged patients with rheumatic mitral disease: an observational study

OBJECTIVES

To investigate the role of pulmonary artery pressure (PAP) in predicting in-hospital death after valve replacement surgery in middle-aged and aged patients with rheumatic mitral disease.

DESIGN

An observational study.

SETTING

Guangdong General Hospital, China.

PARTICIPANTS

1639middle-aged and aged patients (mean age 57±6 years) diagnosed with rheumatic mitral disease, undergoing valve replacement surgery and receiving coronary angiography and transthoracic echocardiography before operation, were enrolled.

INTERVENTIONS

All participants underwent valve replacement surgery and received coronary angiography before operation.

PRIMARY AND SECONDARY OUTCOME MEASURES

In-hospital death and 1-year mortality after operation.

METHODS

Included patients were divided into four groups based on the preoperative PAP obtained by echocardiography: group A (PAP≤30 mm Hg); group B (>30 mm Hg<PAP≤50 mm Hg), group C (>50 mm Hg<PAP≤70 mm Hg) and group D (PAP>70 mm Hg). The relationship between PAP and in-hospital death and cumulative rate of 1-year mortality was evaluated.

RESULTS

In-hospital mortality rate increased gradually but significantly as the PAP level increased, with 1.9% in group A (n=268), 2.3% in group B (n=771), 4.7% in group C (n=384) and 10.2% in group D (n=216) (p<0.001). Multivariate analysis showed that PAP>70 mm Hg was an independent predictor of in-hospital death (OR=2.93, 95% CI 1.61 to 5.32, p<0.001). PAP>52.5 mm Hg had a sensitivity of 60.3% and specificity of 67.7% in predicting in-hospital death (area under the curve=0.672, 95% CI 0.602 to 0.743, p<0.001). Kaplan-Meier analysis showed that patients with PAP>52.5 mm Hg had higher 1-year mortality after operation than those without (log-rank=21.51, p<0.001).

CONCLUSIONS

PAP could serve as a predictor of postoperative in-hospital and 1-year mortality after valve replacement surgery in middle-aged and aged patients with rheumatic mitral disease.

Progression of Tricuspid Regurgitation after Mitral Valve Replacement for Rheumatic Heart Disease

BACKGROUND AND AIM OF THE STUDY

Progression of tricuspid regurgitation (TR) may occur after mitral valve replacement (MVR). The study aim was to define the independent predictors for new severe TR after MVR to treat rheumatic heart disease.

METHODS

A total of 413 patients (177 men, 236 women; mean age 40.9 ± 9.2 years) with rheumatic heart disease undergoing MVR without concomitant tricuspid valve repair at the authors' institute between 1995 and 2005, who did not have preoperative severe TR, were followed for at least one year postoperatively. Survival without severe TR was estimated using the Kaplan-Meier method. Independent predictors for new severe TR were identified using multiple Cox regression analysis.

RESULTS

During a median follow up of 13 years there were two late deaths, and 46 patients (11.1%) had new severe TR. Survival without severe TR was 88.0 ± 1.7% at 10 years. Independent predictors for new severe TR were preoperative moderate TR (HR 2.401; p = 0.008) and atrial fibrillation (AF) (HR 2.119; p = 0.018). At the most recent follow up, furosemide was used in 23.9% patients with and 7.3% patients without new severe TR (p = 0.001). Patients with new severe TR had larger right ventricles and higher pulmonary artery pressures on echocardiography.

CONCLUSIONS

Among patients with rheumatic heart disease undergoing MVR without concomitant tricuspid valve repair, independent predictors for new severe TR were preoperative moderate TR and AF. New severe TR was associated with increased furosemide use.

Rheumatic heart disease in Uganda: predictors of morbidity and mortality one year after presentation

BACKGROUND

Rheumatic heart disease (RHD), the long-term consequence of rheumatic fever, accounts for most cardiovascular morbidity and mortality among young adults in developing countries. However, data on contemporary outcomes from resource constrained areas are limited.

METHODS

A prospective cohort study of participants aged 5-60 years with established RHD was conducted in Kampala, Uganda, in which clinical exam, echocardiography, electrocardiography (ECG), and laboratory evaluation were done every 3 months and every 4-week benzathine penicillin prophylaxis was prescribed. Participants were followed up for 12 months and outcomes and predictors of morbidity and mortality were assessed using Kaplan Meier curves and Cox proportional hazards models.

RESULTS

Of 449 subjects, 66.8% (300/449) were females, median age was 30 (interquartile range 20). 73.7% (331/449) had atleast one follow up visit. Among these, 35% (116/331) developed decompensated heart failure and, 63.7% (211/331) developed atrial fibrillation. Heart failure was associated with poor penicillin adherence (OR = 3.3, CI 2-5.4, p = 0.001), and left ventricular end diastolic diameter greater than 55 mm (OR = 3.16, CI 1.73-5.76, p = 0.001). Atrial fibrillation was associated with left atrial diameter >40 mm (OR = 7.5, CI 2.4-9.8, p = 0.001). There were 59 deaths with a 1-year mortality rate of 17.8%. Most deaths occurred within the first three months of presentation. Subjects whose average adherence to benzathine penicillin was <80% had significantly greater mortality (31% vs. 9%, log rank p < 0.001). In multivariate analysis, the risk of death among those with poor penicillin adherence was 3.81 times higher than those with better adherence (HR = 3.81, CI 1.92-7.63, p = 0.001). Other predictors of 1 year mortality included heart failure (HR 8.36, CI 3.28-21.31, p = 0.001) and left ventricular end diastolic diameter greater than 55 mm (HR = 1.93, CI 1.07-3.49, p = 0.02).

CONCLUSION

In this study of RHD in Uganda, morbidity and mortality within 1 year of presentation were higher than in recently published from other low and middle income countries. Suboptimal adherence to benzathine penicillin injections was associated with incident heart failure and mortality over 1 year. Future studies should test interventions to improve adherence among patients with advanced disease who are at the highest risk of mortality.

Epidemiology, health systems and stakeholders in rheumatic heart disease in Africa: a systematic review protocol

INTRODUCTION

Rheumatic heart disease (RHD) is a chronic disease affecting the heart valves, secondary to group A streptococcal infection (GAS) and subsequent acute rheumatic fever (ARF). However, RHD cure and preventative measures are inextricably linked with socioeconomic development, as the disease mainly affects children and young adults living in poverty. In order to address RHD, public health officials and health policymakers require up-to-date knowledge on the epidemiology of GAS, ARF and RHD, as well as the existing enablers and gaps in delivery of evidence-based care for these conditions. We propose to conduct a systematic review to assess the literature comprehensively, synthesising all existing quantitative and qualitative data relating to RHD in Africa.

METHODS AND ANALYSIS

We plan to conduct a comprehensive literature search using a number of databases and reference lists of relevant articles published from January 1995 to December 2015. Two evaluators will independently review and extract data from each article. Additionally, we will assess overall study quality and risk of bias, using the Newcastle-Ottawa Scale and the Critical Appraisal Skills Programme criteria for quantitative and qualitative studies, respectively. We will meta-analyse estimates of prevalence, incidence, case fatality and mortality for each of the conditions separately for each country. Qualitative meta-analysis will be conducted for facilitators and barriers in RHD health access. Lastly, we will create a list of key stakeholders. This protocol is registered in the PROSPERO International Prospective Register of systematic reviews, registration number CRD42016032852.

ETHICS AND DISSEMINATION

The information provided by this review will inform and assist relevant stakeholders in identifying key areas of intervention, and designing and implementing evidence-based programmes and policies at the local and regional level. With slight modifications (ie, to the country terms in the search strategy), this protocol can be used as part of a needs assessment in any endemic country.

Acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by infection with group A Streptococcus. The long-term damage to cardiac valves caused by ARF, which can result from a single severe episode or from multiple recurrent episodes of the illness, is known as rheumatic heart disease (RHD) and is a notable cause of morbidity and mortality in resource-poor settings around the world. Although our understanding of disease pathogenesis has advanced in recent years, this has not led to dramatic improvements in diagnostic approaches, which are still reliant on clinical features using the Jones Criteria, or treatment practices. Indeed, penicillin has been the mainstay of treatment for decades and there is no other treatment that has been proven to alter the likelihood or the severity of RHD after an episode of ARF. Recent advances - including the use of echocardiographic diagnosis in those with ARF and in screening for early detection of RHD, progress in developing group A streptococcal vaccines and an increased focus on the lived experience of those with RHD and the need to improve quality of life - give cause for optimism that progress will be made in coming years against this neglected disease that affects populations around the world, but is a particular issue for those living in poverty.

Changing causes of heart valve disease mortality in New Zealand from 1988 to 2007

AIM

We wished to determine the mortality burden of valvular heart disease (VHD) in New Zealand, and how it changed prior to the introduction of transcatheter aortic valve replacement.

METHOD

Patient-level cause of death data from 1988 to 2007 were used to examine trends in VHD mortality rates over time. Our outcome measure was death, where the primary cause of death was valvular heart disease.

RESULTS

The annual number of VHD deaths increased 2.9% in New Zealand each year (p&lt;0.001). The total VHD mortality rate increased with older age and male sex. There was little, if any, overall change in age- and sex-adjusted total VHD mortality rate over time (annual mortality rate ratio 0.998, p=0.21). The oldest age group, aged 85 years and above, which now contribute most to total VHD mortality, had an increase in mortality rate through the 1990s, which plateaued after the year 2000. The adjusted mortality rate for non-rheumatic aortic valve disease increased (p&lt;0.001), while that for rheumatic heart disease and endocarditis decreased (p&lt;0.001). Assuming VHD mortality rates remain stable, deaths due to VHD are projected to double over the next 25 years.

CONCLUSION

Adjusted VHD mortality rates showed no change over the two decades examined. Without a substantial reduction in mortality rates, the ageing population is likely to lead to an increase in VHD deaths in the future.

Impact of Chronic Rheumatic Valve Diseases on Large Vessels

BACKGROUND AND AIM OF STUDY: Rheumatic valvular heart disease, which remains a common health problem in developing countries, has numerous consequences on the heart chambers and circulation. The study aim was to investigate the effects of chronic rheumatic valve disease on the diameters of the descending aorta (DA) and inferior vena cava (IVC). METHODS: A total of 88 patients with echocardiographically documented rheumatic valvular heart disease and 112 healthy controls were enrolled into the study. All patients underwent detailed echocardiographic examinations, while their height and body weight were recorded and adjusted to their body surface area. RESULTS: The most common involvement was mitral valve disease, followed by aortic valve disease and tricuspid valve disease. The mean diameter of the DA (indexed to BSA) was 1.79 ± 0.49 cm for patients and 1.53 ± 0.41 for controls (p <0.001). The mean diameter of the IVC (indexed to BSA) was 1.69 ± 0.73 for patients and 1.38 ± 0.35 cm for controls (p <0.001). There was a significant positive correlation between mitral valve mean gradient and IVC diameter (p = 0.01, r = 0.18). There were also strong associations between the mitral valve area and the diameters of the DA (p = 0.001, r = -0.239) and IVC (p <0.001, r = -0.246). CONCLUSION: Rheumatic valve disease, especially mitral stenosis, was closely related to remodeling of the great vessels.

Rheumatic Heart Disease-Attributable Mortality at Ages 5-69 Years in Fiji: A Five-Year, National, Population-Based Record-Linkage Cohort Study

Background

Rheumatic heart disease (RHD) is considered a major public health problem in developing countries, although scarce data are available to substantiate this. Here we quantify mortality from RHD in Fiji during 2008–2012 in people aged 5–69 years.

Methods and Findings

Using 1,773,999 records derived from multiple sources of routine clinical and administrative data, we used probabilistic record-linkage to define a cohort of 2,619 persons diagnosed with RHD, observed for all-cause mortality over 11,538 person-years. Using relative survival methods, we estimated there were 378 RHD-attributable deaths, almost half of which occurred before age 40 years. Using census data as the denominator, we calculated there were 9.9 deaths (95% CI 9.8–10.0) and 331 years of life-lost (YLL, 95% CI 330.4–331.5) due to RHD per 100,000 person-years, standardised to the portion of the WHO World Standard Population aged 0–69 years. Valuing life using Fiji’s per-capita gross domestic product, we estimated these deaths cost United States Dollar $6,077,431 annually. Compared to vital registration data for 2011–2012, we calculated there were 1.6-times more RHD-attributable deaths than the number reported, and found our estimate of RHD mortality exceeded all but the five leading reported causes of premature death, based on collapsed underlying cause-of-death diagnoses.

Conclusions

Rheumatic heart disease is a leading cause of premature death as well as an important economic burden in this setting. Age-standardised death rates are more than twice those reported in current global estimates. Linkage of routine data provides an efficient tool to better define the epidemiology of neglected diseases.

Rheumatic heart disease is the result of an abnormal immune response to the bacteria Streptococcus pyogenes. The disease causes permanent scarring of the heart values, which results in heart failure, stroke and early death. It primarily affects the world’s poorest and most disadvantaged populations and despite the availability of cheap and effective prevention strategies receives little attention from policy-makers and funders. One of the major difficulties has been measuring how many people die prematurely from this disease. Simply counting up deaths is highly inaccurate and so an alternate strategy was needed. Focusing on Fiji in the Western Pacific, we pulled together information from several different health databases using a process called record-linkage. We then worked out how much more frequently rheumatic heart disease patients die than you might expect when comparing them to persons of similar age, gender and ethnicity in the general population. From these data we estimate about twice as many patients were dying from the disease than had been previously suggested. Most of these deaths occurred earlier than was thought with substantial knock-on effects for the economy. On balance we think this strategy for measuring mortality is useful and robust, and it will be increasingly possible to employ it elsewhere.

Heart Transplant in Patients with Predominantly Rheumatic Valvular Heart Disease

BACKGROUND AND AIM OF THE STUDY

International records indicate that only 2.6% of patients with heart transplants have valvular heart disease. The study aim was to evaluate the epidemiological and clinical profile of patients with valvular heart disease undergoing heart transplantation.

METHODS

Between 1985 and 2013, a total of 569 heart transplants was performed at the authors' institution. Twenty patients (13 men, seven women; mean age 39.5 +/- 15.2 years) underwent heart transplant due to structural (primary) valvular disease. Analyses were made of the patients' clinical profile, laboratory data, echocardiographic and histopathological data, and mortality and rejection.

RESULTS

Of the patients, 18 (90%) had a rheumatic etiology, with 85% having undergone previous valve surgery (45% had one or more operations), and 95% with a normal functioning valve prosthesis at the time of transplantation. Atrial fibrillation was present in seven patients (35%), while nine (45%) were in NYHA functional class IV and eight (40%) in class III. The indication for cardiac transplantation was refractory heart failure in seven patients (35%) and persistent NYHA class III/IV in ten (50%). The mean left ventricular ejection fraction (LVEF) was 26.6 +/- 7.9%. The one-year mortality was 20%. Histological examination of the recipients' hearts showed five (27.7%) to have reactivated rheumatic myocarditis without prior diagnosis at the time of transplantation. Univariate analysis showed that age, gender, LVEF, rheumatic activity and rejection were not associated with mortality at one year.

CONCLUSION

Among the present patient cohort, rheumatic heart disease was the leading cause of heart transplantation, and a significant proportion of these patients had reactivated myocarditis diagnosed in the histological analyses. Thus, it appears valid to investigate the existence of rheumatic activity, especially in valvular cardiomyopathy with severe systolic dysfunction before transplantation.

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.

Natural history of rheumatic heart disease, a 12 years observational study "penicillin bites the muscle but heals the heart"

BACKGROUND

Rheumatic Heart Disease (RHD) is amajor cause of cardiovascular morbidity and mortality in young individuals, in developing countries. Long term studies regarding natural history of RHD in Pakistan have not been reported in literature. We present our follow up observations on RHD patients at the end of 12 years since our first survey conducted in rural communities in 1994.

METHODS

Our study patients were known cases of RHD, diagnosed in cross sectional survey of rural areas of Rahimyar Khan in 1994. Second survey conducted in 2006, in which these RHD patients were evaluated in detail with history/Physical examination, 12 lead ECG, X-ray chest PA view and Echo/Doppler studies at Sheikh Zayed Medical College Rahimyar Khan.

RESULTS

Out of 57 patients enrolled in 1994, 21 patients (37%) were available for further evaluation. Overall mortality was 23%. Male to female ratio was 1:1.62. Age ranges between 20- 80 years with mean of 43 years. Only 6 patients (29%) were taking rheumatic prophylaxis (RP) and six patients had recurrent RF. Five patients (24%) developed new aortic regurgitation (AR) and 38% increased in grade of severity of lesions on Echo (none of them was on RP). Regression of mild lesions noted in six patients (all of them were on RP). Two patients underwent surgery. 10% developed new atrial fibrillation.

CONCLUSION

Unabated RF/RHD led to a very high mortality. Favourable out come observed with prophylaxis even for short period on mild or moderate RHD. Patients not on RP had severe diseases. This small study is a big blow to our claims of combating RF/RHD in the 21st century.

Mitral valve repair versus replacement in patients with rheumatic heart disease

BACKGROUND AND AIM OF THE STUDY

Rheumatic fever is still the main cause of valve disease in developing countries. The study aim was to investigate the appropriateness of mitral valve repair in adult patients with rheumatic heart disease (RHD).

METHODS

A systematic literature retrieval was performed for all clinical trials comparing the outcomes of mitral valve repair and replacement for RHD in PubMed, EMBASE and the Cochrane Library. Studies were excluded if they lacked a direct comparison of repair versus replacement. The primary outcomes were 30-day and long-term (> 5 years) survival. Secondary outcomes were postoperative complications and reoperation rates. Standard meta-analysis techniques were used.

RESULTS

A total of seven studies was included. When comparing mitral valve repair (MVP) to mitral valve replacement (MVR), the summary odds ratio for 30-day mortality was 0.54 (95% confidence interval (CI) 0.34-0.86; p = 0.009), and the summary hazard ratio (HR) for long-term mortality was 0.62 (95% CI 0.45-0.85; p = 0.003). Other than the benefits of better survival rates, the risk of postoperative complications (cardiac death, bleeding or thromboembolic complications) was also lower in the repair group (HR 0.63; 95% CI 0.47-0.84; p = 0.002). A significantly higher reoperation rate was observed among patients with mitral valve repair (HR 1.85; 95% CI 1.41-2.43; p < 0.01).

CONCLUSION

Mitral valve repair provides better short-term and long-term event-free survival for rheumatic patients. With an acceptable reoperation rate, MVP is also more beneficial by avoiding troublesome lifelong anticoagulation. Thus, whenever possible, MVP should be attempted in patients with RHD.

Is rheumatic mitral valve repair still a feasible alternative?: indications, technique, and results

Rheumatic heart disease is still a major cause of mitral valve dysfunction in developing countries. We present our early results of rheumatic mitral valve repair. From August 2009 through July 2011, 60 patients (24 male and 36 female) with rheumatic disease underwent mitral repair. The mean age was 51.1 ± 13.8 years (range, 16-77 yr). Forty-nine patients were in New York Heart Association functional class III or IV. Repair procedures included chordal and papillary muscle splitting, secondary chordal division, mitral ring annuloplasty (n=58), commissurotomy (n=36), chordal replacement (n=9), posterior leaflet extension (n=4), annular decalcification (n=2), and quadrangular resection (n=2). Secondary procedures included tricuspid ring annuloplasty, left atrial ablation, obliteration of left atrial appendage, aortic valve replacement, and left atrial reduction. The early (30-d) mortality rate was 1.7%. The mean follow-up time was 14.9 ± 5 months (range, 4-26 mo). Follow-up echocardiography revealed trivial or no mitral regurgitation (MR) in 35.5% and mild (1+) MR in 49.1% of patients. Only 1 patient presented with severe (3+) MR. The mean MR grade decreased from 3.2 ± 0.9 to 0.3 ± 0.4 postoperatively (P=0.001). Left ventricular end-diastolic diameter and left atrial diameter significantly decreased postoperatively (P=0.006 and P=0.001, respectively). The mean gradient over the mitral valve decreased significantly from 11 ± 5.9 mmHg to 3.5 ± 1.8 mmHg (P=0.001). Because current techniques of mitral repair can effectively correct valve dysfunction in most patients with rheumatic disease, the number of repair procedures should be increased in developing countries to prevent complications of mechanical valve placement.

Rheumatic mitral repair versus replacement in a threshold country: the impact of commissural fusion

BACKGROUND AND AIM OF THE STUDY

In developing countries rheumatic heart disease is the predominant indication for cardiac surgery. As the disease tends to progress, reoperation rates for mitral valve repairs are high. Against this background, the predictors of failure were assessed and the overall performance of repairs compared with replacements in a 10-year cohort of rheumatic single mitral valve procedures.

METHODS

Between 2000 and 2010, a total of 646 consecutive adult (aged >15 years) patients underwent primary, single mitral valve procedures. All 87 percutaneous balloon valvuloplasties (100%) were rheumatic, compared to 280 of the 345 primary mitral valve replacements (81%) and 69 of the 215 primary mitral valve repairs (32%). As the study aim was to compare the outcome of mitral valve repair versus replacement in rheumatic patients of a threshold country, all 69 repair patients were propensity-matched with 69 of the replacement patients. Based on propensity score analysis, Kaplan-Meier actuarial analysis with log-rank testing was used to evaluate survival and morbidity.

RESULTS

The follow up was 100% complete (n = 138), and ranged from 0.6 to 132 months (mean 53.3 +/- 36.5 months). Actuarial freedom from valve-related mortality was 96 +/- 3% and 92 +/- 4% at five years, and 96 +/- 3% and 80 +/- 11% at 10 years for repairs and replacements, respectively (p = NS). Actuarial freedom from all valve-related events (deaths, reoperations and morbidity) was 80 +/- 6% and 86 +/- 5% at five years, and 70 +/- 8% and 69 +/- 11% at 10 years (p = NS). Actuarial freedom from all valve-related events was 57 +/- 11% and 96 +/- 3% at five years (p = 0.0008), and 42 +/- 12% and 96 +/- 3% at 10 years (p < 0.001) for those mitral valve repairs with and without commissural fusion, respectively (p = 0.0002 overall).

CONCLUSION

The long-term results for mitral valve replacement in an indigent, rheumatic heart disease population of a developing country were better than generally perceived. Notwithstanding, mitral valve repair has a superior long-term outcome in those patients who do not show commissural fusion at operation.

Rheumatic mitral valve repair: 22-year clinical results

BACKGROUND AND AIM OF THE STUDY

Rheumatic mitral valve disease presents a surgical and a medical challenge to surgeons in the developing and developed world. Comprehensive reproducible repair techniques of the anatomic units in individual patients are required to restore the normal mitral valve anatomy and function.

METHODS

Between April 1986 and December 2009, a total of 2,211 patients underwent mitral valve repair at the authors' institution. Of these patients, 50 (32 women, 18 men) underwent repair at a median age of 45.6 years. Pure mitral stenosis was identified in four cases (8%), pure mitral regurgitation in 37 (74%), and mixed lesions in nine (18%). Posterior leaflet plication, Paneth posterior suture and autologous pericardial strip annuloplasty, chordal transfer and papillary muscle splitting were used to repair a rheumatically diseased mitral valve with leaflet prolapse, annulus dilatation and elongated or restricted chordae and malformed papillary muscle.

RESULTS

Three deaths (6%) occurred in hospital (< or = 30 days), and 14 late deaths occurred between 60 days and 14 years. The overall survival was 94.1 +/- 3.3%, 87.5 +/- 4.8%, 84.7 +/- 5.4%, 66.9 +/- 7.9% and 50.2 +/- 9.3% at 30 days and one, five, 10 and 15 years, respectively. Successful repair was achieved in 39 cases (78%). Actuarial freedom from severe mitral regurgitation and reoperation at one, five and 10 years was 92.7 +/- 4.1%, 77.3 +/- 7.2% and 53.4 +/- 9.6%, respectively, and was 78% for Paneth posterior suture and autologous pericardial strip annuloplasty at five and 10 years. The linearized rate for reoperation in the age groups < 20 years and > 20 years was 4.5%/pt-yr (range: 2.0-10.2%/pt-yr) and 4.3%/pt-yr (range: 2.5-7.2%/pt-yr), respectively.

CONCLUSION

Mitral valve repair in rheumatic disease is feasible, but the results are suboptimal. Pure mitral incompetence may be reparable and long-lasting, whilst mixed lesions may be reparable but fail subsequently. The predictability of repair and long-term functional results was determined by perioperative echocardiographic evaluation and the application of an appropriate repair technique to treat the complex pathology of the mitral valve apparatus.

Pattern of heart failure in a Nigerian teaching hospital

BACKGROUND

Congestive cardiac failure (CCF) has emerged as a major public health problem worldwide and imposes an escalating burden on the health care system.

OBJECTIVE

To determine the causes and mortality rate of CCF in the University of Port Harcourt Teaching Hospital (UPTH), south Nigeria, over a five-year period from January 2001 to December 2005.

METHODS

A retrospective study of CCF cases were identified from the admission and discharge register of the medical wards of UPTH and the case notes were retrieved from the medical records department and analyzed.

RESULTS

There were 423 patients: 242 males and 181 females. Their ages ranged from 18 to 100 years with a mean of 54.4 +/- 17.3. The commonest causes of CCF were hypertension (56.3%) and cardiomyopathy (12.3%). Chronic renal failure, rheumatic heart disease, and ischemic heart disease accounted for 7.8%, 4.3%, and 0.2% of CCF, respectively. Peripartum heart disease was rare despite being commonly reported in northern Nigerian females. Eighteen patients died from various complications with a mortality rate of 4.3%.

CONCLUSION

The burden of CCF in the Niger Delta is mainly attributed to hypertension. Efforts should be geared towards hypertension awareness, detection, treatment, and prevention in the region.

[Mitral valve repair for rheumatic valve disease in children in Senegal: a review of 100 cases]

Mitral valve repair is a better therapeutic alternative than valve replacement for rheumatic valve disease in children. Repair procedures are especially well suited to developing countries where heart prostheses and life-long anti-coagulation therapy are largely unaffordable. The purpose of this study was to evaluate medium-term outcome of mitral valve repair in children in Senegal. A retrospective review was conducted in a cohort of 100 patients who underwent mitral valve repair for rheumatic mitral lesions over the 8-year period from 1999 to 2007. Mean age was 12 +/- 5 years (range, 7 to 17 years). The most common symptom of valve disease was dysypnea (stage IV in 26 cases and stage III in 74). Valve lesions were complex with anterior leaflet prolapse in 62 cases, posterior leaflet restriction in 35, commissural fusion in 30, and fusion of chordaes in 54. Repair procedures consisted of transfer and shortening of chordaes in 73 cases in association with commissurotomy in 22 cases and cleft closure in 17. Ring annuloplasty was performed in 84 patients. Hospital mortality was 2%. Postoperative morbidity was characterized by residual mitral regurgitation in four cases. Mean follow-up was 5 years. No late deaths were observed. Outcome was satisfactory in 84 patients with low-grade mitral regurgitation (grade I-II). Reduction of left ventricle diameter was statistically significant during systole and diastole, i.e., from 29.5 +/- 6.2 mm to 33.1 +/- 5.3 mm (p<0.05) and from 47.1 +/- 8.6 mm to 50.5 +/- 9.4 mm (p<0.05) respectively. Improvement in cardiac function was not significant, i.e., from 63.3 +/- 4.8% to 62 +/- 6.4% (p = 0.99). Mitral valve repair was successful in stabilizing myocardial function and remodeling the left ventricle. Outcome is dependent on careful patient selection and evaluation of lesions. Middle-term outcome is encouraging.

Combined mitral and aortic valve replacement for rheumatic heart disease: fifteen-year follow up and long-term results

BACKGROUND AND AIM OF THE STUDY

Rheumatic heart disease is the most common cause of multivalvular disease in developing countries. Unless aggressive and timely intervention in the form of valve replacement is pursued, the condition progresses rapidly to disability and death. Combined mitral-aortic valve replacement represents a major technical challenge, and carries high early and late mortality rates.

METHODS

The course of 382 consecutive hospital survivors of combined mitral-aortic valve replacement, operated on between January 1992 and December 2006, was reviewed. The valve of choice for the mitral position was the Starr-Edwards (98%), while Medtronic-Hall and St. Jude Medical valves were favored for the aortic position (81%).

RESULTS

The mean postoperative follow up was 64.8 +/- 53.9 months, with a total cumulative follow up of 1,792 patient-years (pt-yr); the follow up was 87% complete (n=332). Late death occurred in 29 patients (8.7%). Long-term survival at five, 10 and 15 years was 92%, 78% and 45%, respectively, with a mean survival of 153 months. The linearized rates of thromboembolism, anticoagulation-related hemorrhage and prosthetic valve endocarditis were 1.06, 2.41 and 0.334% per pt-yr, respectively.

CONCLUSION

Among the rheumatic population, double valve replacement offers excellent symptomatic improvement and favorable late survival. Hemodynamic superiority and thromboresistance are the normal selection criteria for these prostheses, although the surgeon's experience, and the ease of insertion, availability and cost of the valve also play important roles. A strict adherence to optimal anticoagulation levels optimizes protection against thromboembolism and anticoagulation-related hemorrhage, and helps to provide the patient with a good quality life.

Prevention and control of rheumatic fever and rheumatic heart disease: the Cuban experience (1986-1996-2002)

BACKGROUND

Rheumatic fever (RF) and rheumatic heart disease (RHD) are still major medical and public health problems mainly in developing countries. Pilot studies conducted during the last five decades in developed and developing countries indicated that the prevention and control of RF/RHD is possible. During the 1970s and 1980s, epidemiological studies were carried out in selected areas of Cuba in order to determine the prevalence and characteristics of RF/RHD, and to test several long-term strategies for prevention of the diseases.

METHODS

Between 1986 and 1996 we carried out a comprehensive 10-year prevention programme in the Cuban province of Pinar del Rio and evaluated its efficacy five years later. The project included primary and secondary prevention of RF/RHD, training of personnel, health education, dissemination of information, community involvement and epidemiological surveillance. Permanent local and provincial RF/RHD registers were established at all hospitals, policlinics and family physicians in the province. Educational activities and training workshops were organised at provincial, local and health facility level. Thousands of pamphlets and hundreds of posters were distributed, and special programmes were broadcast on the public media to advertise the project.

RESULTS

There was a progressive decline in the occurrence and severity of acute RF and RHD, with a marked decrease in the prevalence of RHD in school children from 2.27 patients per 1,000 children in 1986 to 0.24 per 1,000 in 1996. A marked and progressive decline was also seen in the incidence and severity of acute RF in five- to 25-year-olds, from 18.6 patients per 100,000 in 1986 to 2.5 per 100,000 in 1996. There was an even more marked reduction in recurrent attacks of RF from 6.4 to 0.4 patients per 100,000, as well as in the number and severity of patients requiring hospitalisation and surgical care. Regular compliance with secondary prophylaxis increased progressively and the direct costs related to treatment of RF/RHD decreased with time. The implementation of the programme did not incur much additional cost for healthcare. Five years after the project ended, most of the measures initiated at the start of the programme were still in place and occurrence of RF/RHD was low.

Rheumatic mitral valve surgery in the fifth decade: our experience

AIM

Rheumatic mitral patients reach their fifth decade of life more often now than in the past. The purpose of this study is to provide insight into improving morbidity and mortality in these patients.

METHODS

This retrospective study included 105 patients aged 50 years or more. Seventy-five underwent mechanical valve replacement and 30 received a bioprosthetic valve. Data were collected from medical records and outpatient department (OPD) registers. Follow-up included transthoracic 2D echocardiography, supported by clinical parameters, and X-ray findings.

RESULTS

Mean age was 58.52+/-2.4 years. Follow-up period ranged from one to eleven years (mean 6.8+/-0.9 years). Immediate perioperative mortality included five patients (4.76%) and long term mortality included three patients (3%). 35 patients previously underwent closed and open commissurotomy and balloon valvotomy. Multivariate analysis showed age, repeat surgery, atrial fibrillation, tricuspid valve disease, and preoperative functional status to be incremental risk factors. Freedom from repeat operation at 3 and 6 years was 90% and 85% in group I (<60 years), respectively. Actuarial survival at 4 and 6 years of follow up was 94.24% and 88.52%, respectively.

CONCLUSION

With improving life expectancy and early interventions, the number of < or = 50-year old rheumatic valvular disease patients is increasing. The present study showed a marked improvement for this subset of patients, although age still remains the main risk factor along with atrial fibrillation, repeat surgery, stroke and tricuspid valve disease.

Experience with cardiac valve operations in Cape York Peninsula and the Torres Strait Islands, Australia

OBJECTIVE

To describe the outcome of valve surgery, for rheumatic heart disease (RHD) and non-RHD, in residents of Cape York Peninsula and the Torres Strait Islands referred to the Cairns Base Hospital specialist outreach service.

DESIGN AND PARTICIPANTS

Retrospective review of medical records on all patients residing in the outreach area who had surgery for valvular heart disease between 1 January 1992 and 31 December 2004.

MAIN OUTCOME MEASURES

Operation type and perioperative characteristics; 5- and 10-year survival rates; reoperation rates; complications.

RESULTS

Forty-seven patients met the selection criteria; the median age was 40 years (range, 4-76 years); and 39 patients were Indigenous. RHD was the predominant cause of valve dysfunction (30/47 patients). Thirty-seven patients had valve replacements, six had valve repair and four had balloon valvotomy as the initial procedure. There were three bleeding complications, two episodes of operated valve endocarditis, and six embolic complications. There were nine valve-related deaths (six in the first 5 years). At 5 years, all seven patients who had had valve repair or balloon valvotomy were alive. Seven of the 47 patients required reoperation. Survival analysis showed freedom from valve-related deaths to be 83% (95% CI, 66%-92%) at 5 years and 61% (95% CI, 33%-80%) at 10 years. Freedom from reoperation at 5 years was 88% (95% CI, 71%-95%). Among the 30 patients with RHD, freedom from valve-related death was 80% (95% CI, 60%-92%) at 5 years and 52% (95% CI, 21%-75%) at 10 years. In patients with RHD, freedom from reoperation at 5 years was 87% (95% CI, 65%-96%).

CONCLUSION

Valvular heart disease results in substantial morbidity and mortality, despite intervention. Efforts need to focus on prevention of rheumatic fever and closer follow-up.

Primary triple valve surgery for advanced rheumatic heart disease in Mainland China: a single-center experience with 871 clinical cases

BACKGROUND

Triple valve surgery (TVS) is still of choice for advanced rheumatic heart disease (RHD), which has been associated with reported poor early and late outcomes. We describe the short- and long-term results after TVS in last two decades in Mainland China.

METHODS

From January 1985 to January 2005, a total of 871 patients (217 men, 654 women), with mean age of 42+/-11 years, underwent primary TVS for isolated advanced RHD. All patients received replacement procedures in mitral and aortic position (845 mechanical, 26 bioprosthetic), and 840 patients received repair procedures and the other 31 received replacement procedures in tricuspid position (9 mechanical, 22 bioprosthetic). Preoperative, perioperative, and postoperative data were retrospectively analyzed and risk factors affecting early and late survival were evaluated.

RESULTS

The 30-day hospital mortality was 8% (n=71). Presence of ascites, New York Heart Association (NYHA) class IV and lower left ventricular ejection fraction (LVEF) were identified as independent risk factors for hospital mortality. Overall long-term survival rate was 71%+/-3% at 5 years, and 59%+/-5% at 10 years. The cardiac survival rate was 75%+/-3% at 5 years and 63%+/-4% at 10 years. The event-free survival rate at 5 years and 10 years was 61%+/-6% and 41%+/-13%, respectively. Multivariate analysis revealed advanced age, NYHA class IV and lower LVEF were associated with increased late mortality. The freedom from thromboembolism and anticoagulation-related hemorrhage at 10 years was 90%+/-4% and 81%+/-5%, respectively. Of the 508 patients still alive, 376 (74%) were in NYHA class I and II.

CONCLUSIONS

Primary TVS for advanced RHD appears to offer satisfactory short- and long-term results with excellent symptomatic improvement. Cardiac-related late mortality following TVS may be improved by early surgical treatment before NYHA class IV or deterioration of LVEF occurs.

Serial radionuclide angiographic assessment of left ventricular ejection fraction and regional wall motion after mitral valve replacement in patients with rheumatic disease

BACKGROUND

This study was designed to prospectively investigate the effects of total or partial chordal-sparing and chordal-nonsparing mitral valve replacement (MVR) procedures on regional and global ventricular function in a rheumatic population using sequential multiple-gated acquisition scan.

METHODS

One hundred five consecutive patients undergoing different techniques of chordal preservation procedures during MVR are included in this prospective study. Fifteen patients had complete excision of the chordopapillary apparatus (group 1), 34 had total chordal preservation (group 2), and 56 had preservation of the posterior chordopapillary apparatus (group 3). Radionuclide-derived left ventricular ejection fraction (LVEF) and regional wall motion (RWM) studies on 99 survivors were performed preoperatively, at discharge, at 1 year, and at 2 years.

RESULTS

At discharge, there was a decline in LVEF in all the 3 groups. Statistically significant improvement in ejection fraction occurred in the chordal preservation groups (2 and 3) (P < .05) as compared with the nonchordal group immediately and late postoperatively. Only the total chordal group (2) demonstrated complete recovery of LVEF by 2 years postoperatively. Significant and persistent RWM abnormalities were noted in both the nonchordal and posterior chordal groups.

CONCLUSIONS

We conclude that complete retention of the chordopapillary apparatus during MVR provides superior results compared with nonchordal and partial chordal preservation in terms of preservation of LVEF and reduced incidence of abnormal postoperative RWM.

Determinants of Hospital Mortality after Repeat Mitral Valve Surgery for Rheumatic Mitral Valve Disease

OBJECTIVE

The aim of this study is to detect the risk factors for hospital mortality in patients who underwent reoperative mitral valve replacement.

METHODS

Rheumatic mitral valve patients who underwent primary mitral valve replacement (386 cases) and repeat mitral valve replacement (94 cases) were analysed retrospectively. The incremental effects of the reoperative procedure on hospital mortality were studied by comparing primary and reoperative procedures and analyzing a series of possible predisposing factors.

RESULTS

Operative mortality for repeat procedures was found significantly higher than the first operations (respectively 12.8% versus 4.3%, p=0.022). Risc factors affecting the hospital mortality in reoperation group were determined as advanced age, diameter of left atrium, prolonged bypass time and development of postoperative low output state. The indication for surgery also had a significant role in patients' outcome. Mortality found significantly higher in cases operated due to endocarditis or mitral mechanical valve thrombosis compared to other reoperation groups.

CONCLUSION

Patients over age of 70 years, with a left atrial diameter over 60 mm, reoperated due to endocarditis and mechanical valve thrombosis, should be reevaluated for risk assessment while giving the decision of optimal operation timing. Especially patients with left ventricular hypertrophy and decreased myocardial reservoirs, efficient myocardial protection during the operation had an important role.

[Rheumatic fever and rheumatic heart disease]

Rheumatic heart disease, the sequel of acute rheumatic fever, is a very common cause of cardiovascular mortality and morbidity all over the world, and is the predominant indication for cardiac surgery in the industrialized countries. Diagnosis of rheumatic chronic carditis may sometimes be difficult because valvular regurgitation may not always be detected by routine clinical auscultation. A recent report from the World Health Organization Expert Committee recognizes the usefulness of echocardiography Doppler in providing supporting evidence for diagnosis of rheumatic carditis in the presence of equivocally pathological murmur, and recommends that patients with subclinical carditis should be managed as rheumatic heart disease until proven otherwise, because the disease still represents a major health problem. The aim of this review is to give an update on the disease by underlining changes made by the World Health Organization on disease diagnosis and patient management.

Ross procedure in rheumatic aortic valve disease☆

OBJECTIVE

To assess the results of aortic valve replacement with the pulmonary autograft in patients with rheumatic heart disease.

METHODS

From October 1993 through September 2003, 81 rheumatic patients with aortic valve disease, mean age 29.5+/-11.9 years (11-56 years) underwent, the Ross procedure with root replacement technique. Forty patients were 30 years of age or below (young rheumatics). Associated procedures included mitral valve repair (n=19), open mitral commissurotomy (n=15), tricuspid valve repair (n=2), and homograft mitral valve replacement (n=2).

RESULTS

Early mortality was 7.4% (six patients). Mean follow-up was 92.3+/-40.9 months (7-132 months, median 109 months). Sixty of the 73 patients whose follow-up was available (82%) had no significant aortic regurgitation. Re-operation was required in seven (8.4%) patients for autograft dysfunction with failed mitral valve repair (n=3), autograft dysfunction alone (n=2) and failed mitral valve repair alone (n=2). No re-operations were required for the pulmonary homograft. There were six (7.5%) late deaths. Actuarial survival and re-operation-free survival at 109 months were 84.5+/-4.1% and 90.5+/-3.7%, respectively. Freedom from significant aortic stenosis or regurgitation was 78.4+/-5.2% and event-free survival was 64.6+/-5.8%. When compared to rheumatics above 30 years of age, the relative risk of autograft dysfunction was high in the young rheumatics.

CONCLUSION

The Ross procedure is not suitable for young patients with rheumatic heart disease. However, it provides acceptable mid-term results in carefully selected older (>30 years) patients with isolated rheumatic aortic valve disease.

[Effect of surgical treatment of tricuspid regurgitation late after valve replacement of left heart]

OBJECTIVE

To investigate the appropriate methodology and outcome of surgical treatment of tricuspid regurgitation late after valve replacement of left heart.

METHODS

Eighteen patients with tricuspid insufficiency, with the diagnosis conformed by echocardiogram and in New York Heart Association (NYHA) class III to IV, were treated surgically 3 to 14 years after left heart valve replacement, including 13 mitral valve replacements and 5 double valve replacements, from January 1995 to May 2004. DeVega was used in 5 patients. The ages at the time of tricuspid surgery ranged from 35 to 65 years (median 50 years). The patients were followed up for 36.7 months (12-114 months).

RESULTS

There was no death from hemorrhage because of re-open. Tricuspid repair was performed in 8 patients, tricuspid replacement was done in 10 patients, 5 bioprostheses and 5 mechanical valves were implanted. The hospital mortality was 16.7%. Among the survivors, the three-year survival rate was 78.8%. Twelve patients showed improvement of symptoms, while there was no improvement in 3 patients who needed medical therapy.

CONCLUSION

The pathophysiology of tricuspid regurgitation is associated with delayed left heart operation, implement of tricuspid repair in the first operation or progressive right ventricular failure. The surgical intervention should be earlier before the onset of severe right ventricular failure Tricuspid valve repair is the procedure of choice, while tricuspid valve replacement is also acceptable.

Intermediate-term results of percutaneous transvenous mitral commissurotomy in children less than 12 years of age

The objectives of this study were to review the efficacy of percutaneous transvenous mitral commissurotomy (PTMC) in young children less than 12 years of age and to provide intermediate-term follow-up data. There is a paucity of information regarding the long-term efficacy of PTMC done in children less than 12 years of age. The data of 100 consecutive children less than 12 years of age (mean, 11.1 +/- 1.2 years) who underwent PTMC using Inoue balloon were analyzed retrospectively. Serial clinical and echocardiographic follow-up information of more than 6 months was available in 94 patients. The procedure was successful in 94 patients. The mean calculated mitral valve area (MVA) increased from 0.72 0.14 to 1.7 0.35 cm(2) (P 0.0001). Echocardiographic restenosis (MVA < or = 1 cm(2) or > 50% gain loss) occurred in 14 of 94 patients (16%) over a mean follow-up of 34.4 25.9 (range, 2-115) months. The improvement in New York Heart Association (NYHA) functional class was maintained in most patients (from a mean of 2.87 0.5 pre-PTMC to 1.42 0.6 at follow-up). Seven out of 14 patients with restenosis underwent a re-PTMC. The actuarial rate of good functional status (survival, no repeat interventions, and NYHA class 1 or 2) at 100 months was 75.4% 8.7%. PTMC provides excellent intermediate-term palliation even in young children with rheumatic mitral stenosis.

Long term follow up of rheumatic fever and predictors of severe rheumatic valvar disease in Brazilian children and adolescents

OBJECTIVES

To investigate the progress of rheumatic fever (RF) and the predictors of severe chronic valvar disease.

DESIGN

Patients prospectively followed up since their first attack of acute RF (ARF).

SETTING

Universidade Federal de Minas Gerais, Brazil.

PATIENTS

258 children and adolescents who met the revised Jones criteria for RF. The follow up period ranged from 2-15 years.

MAIN OUTCOME MEASURES

The presence and severity of mitral or aortic valvar disease were determined by both clinical and Doppler echocardiographic examinations. The variables associated with severe chronic valvar disease were initially identified by the Kaplan-Meier method and, later, by multivariate analysis.

RESULTS

Doppler echocardiography of 258 patients studied showed that 186 (72.1%) developed chronic valvar disease and 41 (15.9%) progressed to severe chronic mitral or aortic lesions. Of 146 patients who developed carditis, 49 (33.6%) had a normal clinical examination in the chronic phase but only nine (6.2%) had normal Doppler echocardiographic findings--that is, 40 (27.4%) patients progressed to chronic subclinical valvar disease. Moderate or severe carditis, recurrences of ARF, and mother's low educational level were risk factors in predicting severe chronic valvar diseases.

CONCLUSION

The increased risk of progressing to severe chronic valvar disease was associated with moderate or severe carditis, recurrences of ARF, and mother's low educational level. Hence, in a country such as Brazil, the options available for disease control are mainly primary and secondary prophylaxis.

Maternal and perinatal outcome of pregnancies complicated by cardiac disease

OBJECTIVE

The aim of this study was to assess the maternal and perinatal outcome of pregnancies complicated by cardiac disease in a tertiary care center in Egypt.

METHODS

During a 1-year period, a total of 86 pregnant women with cardiac disease were admitted. Maternal and perinatal morbidity and mortality were calculated and compared with a control group.

RESULTS

Seventy-seven (89.5%) patients were due to rheumatic affection, and 60 patients were classified as NYHA classes I-II. There was one case of maternal mortality (1.16%), and 10 other cases developed life-threatening complications. Two perinatal mortalities (2.32%) occurred in this series. Birth weight of babies born to mothers with functional classes III and IV were significantly lower than those of functional classes I-II and control group.

CONCLUSION

Rheumatic heart disease with pregnancy is still predominant in Egypt. Maternal and perinatal morbidity and mortality are strongly correlated to maternal cardiac functional classification.

Mitral valve repair with aortic valve replacement in rheumatic heart disease

From 1992 to 2001, 609 patients with rheumatic heart disease underwent aortic valve replacement with either mitral valve repair (n = 201) or mitral valve replacement (n = 408). Follow-up extended to 10 years. Thirty-day mortality was 1.4% for mitral valve repair and 0.7% for mitral valve replacement (p = 0.4). Survival at 9 years was 96.5 +/- 1.4% after mitral valve repair and 89.7 +/- 7.8% after mitral valve replacement (p = 0.73). Freedom from major bleeding at 9 years was 94.8 +/- 2.4% after mitral valve repair and 81 +/- 7.2% after mitral valve replacement (p = 0.03). Freedom from other valve-related complications and from mitral valve re-operation was similar for the two groups. This study showed that in patients with rheumatic heart disease the results of mitral valve repair with aortic valve replacement were comparable to those of double valve replacement. Major bleeding was less frequent after mitral valve repair with aortic valve replacement. Therefore, whenever feasible, mitral valve repair should be attempted in patients with rheumatic heart disease who need concomitant aortic valve replacement.

[The causes of death of patients with rheumatic diseases in Moscow]

The study was held in order to analyze the main causes of death in cases of rheumatic diseases (RD) in Moscow. The authors studied the pathology records of autopsies performed in 1999-2002 in two pathology departments of Moscow clinics. Cases with RD were selected. The study found 165 cases of RD, which constituted 2% of all autopsies performed in these departments. There were 99 cases (60%) of rheumatic heart disease (RHD), 4 cases (2.4%) of rheumatic fever (RF) relapse, 28 cases (17%) of rheumatoid arthritis (RA), 8 cases (4.8%) of systemic lupus erythematosus (SLE), 3 cases (1.8%) of scleroderma systematica (SS), 2 cases (1.2%) of ankylosing spondylitis (AS), 2 cases (1.2%) of systemic vasculitis (SPV), 11 cases (7.3%) of osteoarthrosis, 3 cases (1.8%) of gout, 1 case (0.6%) of polymyositis. The death of patients with RHD had been caused by hemodynamic decompensation (HD) in 54% of the cases, acute cardiovascular collapse (ACC) in 14% of the cases, 6% of the patients had died from thromboembolism (TE) and 26%--from other conditions (intoxication, uremia, brain and lung edema etc). The death of patients with RF was caused by TE in 2 cases, by HD in 1 case and by ACC in 1 case. Secondary amyloidosis resulting in chronic renal failure and uremia occurred in 5 out of 28 cases of RA, HD--in 3, ACC--in 7, TE--in 1, infectious complications--in 5, other complications--in 7 cases. Patients with SLE died from various conditions: uremia in 2 cases, acute adrenal failure in 1 case, infectious complications in 2, ACC--in 2, brain edema--in 1 case. The complications of SS were uremia and intoxication. ACC was the cause of death in cases of gout and SS. The majority of RD cases were patients with RHD. The main cause of death in RD was cardiovascular disorders.