Cardiovascular Journal of Africa: Vol 28 No 4 (July/August 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017 AFRICA 215
The changing spectrum of rheumatic mitral regurgitation
in Soweto, South Africa
Ruchika Meel, Ferande Peters, Elena Libhaber, Mohammed Rafique Essop
Abstract
Objectives: To determine the clinical and echocardiograph-
ic characteristics of contemporary patients with rheumat-
ic mitral regurgitation (MR) at Chris Hani Baragwanath
Academic Hospital.
Methods: This prospective, cross-sectional study included 84
patients with isolated moderate or severe rheumatic MR who
underwent clinical and echocardiographic assessment.
Results: Mean age of the patients was 44 ± 15.3 years (84%
females). Acute rheumatic fever was rare. Hypertension
and HIV were present in 52 and 26%, respectively.
Echocardiography showed leaflet thickening and calcifica-
tion, restricted motion and subvalvular disease in 41, 25 and
34%, respectively. Carpentier IIIa leaflet dysfunction occurred
in 80% of patients and leaflet prolapse was seen in only 20%.
These findings contrast with the previous literature, where
patients were younger, they had rheumatic carditis and there
were no co-morbidities. Leaflets were pliable, isolated leaflet
prolapse was common and commissural fusion was absent.
Conclusion: Contemporary patients with rheumatic MR
were older, fewer had rheumatic fever and there were more
co-morbidities. Echocardiographic features had evolved to
greater leaflet thickening, calcification and reduced motion
with minimal prolapse. These findings may have important
implications for surgical management of this disease.
Keywords: rheumatic mitral regurgitation, echocardiography
Submitted 4/6/16, accepted 15/9/17
Cardiovasc J Afr 2017; 28: 215–220
DOI: 10.5830/CVJA-2016-086
The epidemiology of mitral regurgitation (MR) shows striking
regional variation.1,2 In developed countries, degenerative disease
is the major cause of MR and when surgery is indicated, repair
of the valve is the preferred therapy.2 In geographically low-
and middle-income areas, MR is still predominantly due to
rheumatic disease, and when severe, mitral valve replacement is
often required.1
While the demographic profile and echocardiographic
features of degenerative MR have been well documented, there
remains uncertainty regarding rheumatic MR, ranging from
diagnostic echocardiographic criteria to optimal management.1-3
This difficulty is compounded by several factors, including the
declining incidence of acute rheumatic fever (ARF), the rising
incidence of co-morbidities such as human immunodeficiency
virus (HIV) infection, and chronic diseases of lifestyle associated
with increasing urbanisation.4,5
In a landmark study of 700 patients with rheumatic valvular
disease from this institution, published approximately 30 years
ago, Marcus et al. provided detailed echocardiographic and
surgical data.6 The demographic profile and echocardiographic
features of patients with rheumatic MR within that cohort
were characterised by a disease afflicting predominantly young
individuals with a high burden of concomitant acute rheumatic
carditis. We therefore chose to examine our contemporary
patient population with severe rheumatic MR, specifically to
detect the changing demographic and echocardiographic profile
in a hospital serving the large community of Soweto in South
Africa.
Methods
We conducted a prospective cross-sectional study at the Chris
Hani Baragwanath Academic Hospital (CHBAH). Patients
were enrolled between January and October 2014 from the
valvular heart disease clinic. This study forms part of an
ongoing study of rheumatic mitral regurgitation. The study
was approved by the University of the Witwatersrand Ethics
Committee (M140114).
All patients were screened and patients deemed to have
moderate or severe rheumatic MR were referred for possible
inclusion in the study. A total of 91 patients with presumed
rheumatic MR underwent clinical evaluation, resting
electrocardiogram and detailed echocardiographic assessment
according to a predetermined protocol.
The inclusion criteria were patients aged 14 years or older
with echocardiographic features of moderate or severe rheumatic
MR. Patients were excluded if they had significant aortic valve
disease, concurrent mitral stenosis (MS) with a valve area of less
than 2.0 cm2 (as assessed by planimetry), documented ischaemic
heart disease, pre-existing non-valvular cardiomyopathy, prior
cardiac surgery, congenital or pericardial disease, pregnancy,
severe systemic disorders such as renal failure, uncontrolled
hypertension (systolic blood pressure > 140 mmHg and diastolic
blood pressure > 90 mmHg) on medication, or severe anaemia
(haemoglobin < 10 g/dl). Seven patients were excluded due to the
following: anaemia, renal dysfunction, mild MR, and MR of
non-rheumatic aetiology. The final sample included 84 patients.
After obtaining voluntary consent, all patients underwent
a detailed clinical evaluation and 12-lead electrocardiogram,
Department of Cardiology Chris Hani Baragwanath
Academic Hospital, University of the Witwatersrand,
Johannesburg, South Africa
Ruchika Meel, MB ChB, MMed, Cert Card (SA), PhD,
Ferande Peters, MB BCh, FCP, Cert Card (SA), FACC
Elena Libhaber, MSc, PhD
Mohammed Rafique Essop, MB BCh, FCP, FRCP, FACC