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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017
AFRICA
249
(ASOT) was performed in all patients as an indication of recent
streptococcal infection.
12
Disease severity was defined according to the task force on
the management of valvular heart disease of the European
Society of Cardiology and the ESC committee for practice
guidelines.
13
The newly revised clinical criteria for the diagnosis
of ARF/RHD by the World Health Federation 2012
11
can be
seen in Table 1.
Results
A total of 56 patients with ARF and RHD were seen and/or
admitted at the Paediatric Cardiology Unit from January 2008 to
August 2015. Ninety-three per cent (
n
=
52) of patients presented
for the first time with RHD (all were new patients). The majority
(
n
=
37) of patients in our cohort were from the OR Tambo
district of the former Transkei region of the Eastern Cape.
The average age at presentation is given in Table 2. Ninety-
three per cent of patients (
n
=
52) were between the age of five
and 15 years, and the remainder were below the age of five years
(
n
=
4), with the youngest patient three years old.
In terms of clinical disease presentation, most patients (
n
=
52) presented with chronic RHD. Out of this group, two
presented with acute-on-chronic RHD in that, in addition to
having echocardiographic evidence of chronic RHD, they had
a raised ASOT, fever and raised levels of inflammatory markers
(C-reactive protein and erythrocyte sedimentation rate). These
patients were aged eight and nine years old. All the patients
younger than five years old had ARF diagnosed by the revised
Jones criteria.
11,12
Six patients presented with a combination of RHD and
congenital heart disease (three atrial septal defects, two patent
ductus arteriosus and one ventricular septal defect). The most
commonly involved valve was the mitral valve, followed by the
aortic valve (Table 2). Of the total cohort, only four patients
presented with isolated aortic valve disease.
All patients had assessment of left ventricular function pre-
and post-operatively. Twelve of 23 (52%) patients had dilated
left ventricular end-diastolic diameter (LVEDD > 50 mm)
pre-operatively. Of those, nine out of 12 (75%) had improved
to normal left ventricular end-diastolic diameter (LVEDD < 50
mm) post-operatively (
p
< 0.05). Six of 23 (26%) patients had
left ventricular systolic dysfunction (ejection fraction < 55%)
pre-operatively.
The mean follow-up time for patients after surgery was
six months. Over the study period 23/56 (41%) patients were
operated on for chronic rheumatic valve disease. Twelve patients
had mitral valve repair, five mitral valve replacement, three
aortic valve repair and three double valve (mitral and aortic
valve) replacement. The average age at surgery was 11 years. No
patients had surgical valvotomy or balloon valvuloplasty. Four
patients required re-operation with mitral valve replacement
following failed mitral valve repair.
A single patient with atrial flutter post operatively, who was
treated with amiodarone, had good control of the arrhythmias.
Only one patient died in this cohort, and the cause of death was
non-cardiac related (suicide).
Discussion
A total of 56 patients were reviewed in this study from 2008 to
2015. Of note, the majority of patients in our cohort (
n
=
37; 66%)
were from the OR Tambo district, Eastern Cape. These patients
started attending the cardiology clinic at Dora Nginza Hospital
from 2012, and were included in the study from 2012 onwards.
Our results suggest that RHD continues to be a scourge in
children from the OR Tambo district, whereas the disease burden
seems to be declining elsewhere in South Africa.
3,9
A study done
by Cilliers
3
in the Chris Hani/Baragwanath Hospital from 1993 to
2010 showed a decline in the number of cases of RF/RHD from
64 in 1993 to three in 2010. This decline in numbers is thought
to be due to improved access to medical care in South Africa
since 1994. Although we did not have a reference study in our
population, we do see more patients than was reported by Cilliers.
Smit
et al
.
9
also reported a decline in the prevalence of RHD
in the preliminary results of the Wheels-of-Hope outreach
programme, with a prevalence rate of 4.9/1 000 leaners in grades
10 to 12 in central South Africa. This was postulated to be due
to improved rural and socio-economic development in South
Africa since 1994.
The majority (93%) of patients in our study were within the
expected age range of patients affected by this disease.
1
However
there were patients younger than five years of age (
n
=
4) in our
cohort. This is in line with the report by Tani
et al
.
14
on children
younger than five years who presented with ARF and were
diagnosed using the revised Jones criteria.
11
In our study, the
Table 1. Newly revised clinical criteria for the diagnosis of
ARF/RHD by the World Health Federation 2012
11
Criteria
Symptoms
Major criteria for the diagnosis of ARF
Low-risk population Carditis (clinical and or subclinical), arthritis (polyar-
thritis only), chorea, erythema marginatum, subcuta-
neous nodules
Moderate- and high-
risk population
Carditis (clinical or subclinical), arthritis (includ-
ing mono-arthritis, polyarthritis or polyarthralgia),
chorea, erythema marginatum, subcutaneous nodules
Minor criteria for the diagnosis of ARF
Low-risk population Polyarthralgia, fever (≥ 38.5°C), ESR ≥ 60 mm/h and/
or CRP ≥ 3.0 mg/dl, prolonged PR interval on electro-
cardiogram
Moderate- and high-
risk population
Mono-arthralgia, fever (≥ 38°C), ESR ≥ 30 mm/h and/
or CRP ≥ 3.0 mg/dl, prolonged PR interval on electro-
cardiogram
Criteria for diagnosis of ARF: two major criteria required, or one major crite-
rion with two minor criteria
Echocardiographic diagnosis of RHD
Pathological mitral
regurgitation
Defined as jet length > 2 cm in at least one view,
velocity > 3 m/s for one complete envelope and a pan-
systolic jet in at least one envelope
Pathological aortic
regurgitation
Defined as a jet length ≥ 1 cm in at least one view,
velocity > 3 m/s in early diastole and pan-diastolic jet
in at least one envelope
ESR, erythrocyte sedimentation rate; CRP, C-reactive protein
Table 2. Extent of the valvular disease
Extent of the disease
Number (
n
=
56)
Average age at
diagnosis (years)
Isolated MV regurgitation
31
10
MV regurgitation with MV stenosis
7
11
MV regurgitation with AV regurgitation
14
10
AV regurgitation
3
10
AV regurgitation with AV stenosis
1
11
MV, mitral valve; AV, aortic valve.