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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 5, September/October 2014
AFRICA
207
Congenital heart disease
CHD (
n
=
41) was the main cause of HF in children under 16
years (30/50; 60%). Table 2 summarises the type of congenital
defects observed. The main diseases associated with HF in
children were isolated ventricular septal defect (VSD) (
n
=
7/30,
23%), atrio-ventricular septal defects (AVSD) (
n
=
4/30, 13%)
and tetralogy of Fallot (
n
=
4/30, 13%). Other abnormalities
included isolated atrial septal defects (ASD) (
n
=
6/41, 15%) and
persistent ductus arteriosus (PDA) (
n
=
5/41, 12%).
Complex congenital defects were observed in 11 children
(11/30, 37%), including rare diseases such as type II persistent
truncus arteriosus and aortopulmonary window. Uncorrected
CHD was responsible for HF in 11 adults (11/90; 12%), including
two cases (5%) of Eisenmenger syndrome and two cases (5%) of
severe Ebstein anomaly.
Other aetiologies of structural heart disease
We reported eight cases of EMF in HF (6% of all causes of HF
in our series). The echocardiographic findings of biventricular
EMF were similar in all cases, with the exception of the degree of
right ventricular obstruction. In two cases, there was a significant
obliteration of the right inflow tract and the apex (Fig. 4A). In
the other case, the fibrosis involved only the right apex (Fig. 4B).
We also observed a rare case of calcified isolated LV EMF (Fig.
4C).
The proportion of patients with HF associated with
hypertension (
n
=
22/140; 16%) or presumptive IHD (
n
=
14/140;
10%) increased in older patients, with a peak incidence (33/52
among the 90 adults) in the seventh decade (Table 1). Pulmonary
hypertension and right HF not associated with left-sided heart
abnormalities accounted for 5% (7/140 cases) of causes of HF.
Pulmonary embolism (6/7 cases, 86%) was recognised as the
main cause of PH associated with right-sided HF. In four cases,
CT scans or venous Doppler examination of the inferior limbs
also supported the diagnosis.
Patients with an indication for cardiac surgery:
access to treatment, and outcomes
Among 85 patients with HF related to RHD and CHD, all
presented a theoretical indication for cardiac surgery, and 74
Fig. 3.
Three main patterns of rheumatic mitral regurgitation (MR). (A) Symmetrical restriction of leaflets and annular dilatation. (B)
Restricted posterior leaflet and pseudo-prolapse of the anterior leaflet. (C) Restricted posterior leaflet and ruptured chordae
tendineae of the anterior leaflet. LV = left ventricle, LA = left atrium.
A
B
C
Table 1. Clinical and echocardiographic characteristic of 113 patients with heart failure.
Main cause of HF
RHD CHD
Hyperten-
sive CMP IHD EMF
RVD associ-
ated with PH
Miscella-
neous
Total
No of cases (%)
44 (31)
41 (29)
22 (16)
14 (10)
8 (6)
7(5)
4 (3)
140
Age (years) [median (IQR)]
19 (12–52) 4 (1–17)
66 (56–76) 75 (60–85) 18 (14–30) 50 (38–72) 50 (32–66) 40 (14–66)
Females,
n
(%)
36 (82)
21 (58)
13 (59)
5 (36)
3 (37)
3 (43)
2 (50)
83 (59)
LV systolic dysfunction,
n
(%)
13 (29)
7 (17)
16 (73)
13 (93)
2 (25)
2 (28)
4 (100)
57 (41)
LVEF % [median (IQR)]
60 (40–60) 60 (57–60) 37 (20–55) 35 (25–40) 55 (45–60) 55 (48–58) 40 (30–40) 55 (35–60)
LV dilatation*,
n
(%)
30 (68)
10 (24)
12 (54)
8 (57)
1 (12)
0 (0)
3 (75)
64 (46)
LA severe dilatation
§
,
n
(%)
38 (86)
5 (12)
10 (45)
1 (7)
2 (25)
0 (0)
1 (25)
57 (41)
AF,
n
(%)
5 (11)
0 (0)
8 (36)
1 (7)
0 (0)
0 (0)
0 (0)
14 (10)
Moderate to severe MR,
n
(%)
39 (89)
10 (24)
12 (54)
5 (36)
6 (75)
2 (28)
2 (50)
76 (54)
PH,
n
(%)
43 (98)
34 (81)
20 (91)
7 (50)
7 (87)
7 (100)
2 (50)
120 (86)
Moderate to severe RV dysfunction,
n
(%) 27 (61)
20 (49)
12 (54)
3 (21)
8 (100)
6 (86)
1 (25)
77 (55)
RHD
=
rheumatic heart disease, CHD
=
congenital heart disease, CMP
=
cardiomyopathy, IHD
=
ischaemic heart disease, RVD
=
right ventricular
dysfunction, PH
=
pulmonary hypertension, EMF
=
endomyocardial fibrosis, LV
=
left ventricle, EF
=
ejection fraction, LA
=
left atrium, AF
=
atrial fibrillation, MR
=
mitral regurgitation, RV
=
right ventricle.
*Defined as end-diastolic diameter
>
55 mm for adults.
§
Defined as volume
>
40 ml for adults, PH defined as pulmonary artery systolic pressure
>
35 mmHg.