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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 2, March/April 2021
AFRICA
65
elevation of pulmonary pressures between the two age groups (
p
> 0.05), the LV diameters and LVEF showed that the older age
group had larger LV chambers (
p
< 0.05) and the younger group
had much higher EF (
p
< 0.05). There was no difference in the
LA diameters between groups (
p
= 0.11).
Comparative analysis of the morphology of the mitral
valve revealed no significant differences in leaflet thickness and
commissural fusion (
p
> 0.05) between the two age groups, but
subvalvular apparatus thickening and calcification were more
frequent in the older group (
p
< 0.05), while chordal rupture was
more common in the younger group (
p
= 0.04) (Table 2).
Human immune virus (HIV) was positive in 33 patients, and
this subset comprised older patients (
p
< 0.05). Echocardiography
revealed no significant difference in terms of the severity of MR
(
p
= 0.94) between HIV-positive and -negative subjects. There
was also no significant difference in the echocardiographic
dimensions of the LV and LA, and the LVEF between the
two groups (
p
> 0.05). Apart from the increase in frequency of
the leaflet prolapse noted in the HIV-positive group (16.6% in
HIV negative vs 38.9 in HIV positive,
p
= 0.00), there were no
other significant differences noted in morphological parameters
between the two groups. There was also no significant difference
observed in pulmonary pressures between the two groups (
p
=
0.70).
Patients were followed up regularly at the cardiology clinic.
Overall, complications occurred in 143 (44.7%) patients. Embolic
events were diagnosed in 11 patients (3.4%). Infective endocarditis
was diagnosed clinically in 34 (10.6%) patients during the course
of their illness. In addition to the 23 (7.2%) patients who
presented
ab initio
in heart failure, signs of decompensated heart
failure developed in a further 94 (29.4%), totalling 117 (36.6%)
patients in all with heart failure during the course of their illness.
Eight patients (2.5%) died: seven were young (< 16 years),
and the eighth was a 70-year-old female who died in intractable
heart failure from poor LV function (Table 3). Three subjects
died prior to surgery and the remaining five died during the
postoperative period. Four of the patients who died had active
carditis and two had infective endocarditis.
Eighty-one patients were lost to follow up. Survival status
of the patients lost to follow up was established telephonically
as well as by checking the national registry of deaths. In this
manner it was established that a further 24 patients had died out
of hospital, yielding a total of 32 deaths (10%).
Surgery was performed in 216 patients. Mitral valve
replacement was performed in all but 13 subjects who underwent
mitral valve repair. A mechanical prosthesis was deployed
using the technique of chordal preservation in order to prevent
worsening LV function postoperatively. Valve repair was
undertaken by one surgeon trained in this procedure and was
performed in subjects in sinus rhythm and in those who were not
considered to have active carditis. This constituted a minority
of subjects with suitable anatomy. Mitral valve repair included
chordal shortening and mitral ring annuloplasty.
Evidence of active rheumatic carditis was present in all 34
(10.6%) patients diagnosed clinically; most of these subjects were
in the paediatric and teenage groups. Of the 216 patients who
underwent surgery, over one-third (37%) had prolapse of the
AML, which was due to ruptured chordae in 41 (19%) patients.
Furthermore, chordal elongation was present in 63 (29.2%)
patients. A chronic rheumatic process characterised by leaflet
thickening was found in 135 (62.5%) patients, and evidence
of fibrosis with subvalvular thickening in 37 (17%) and leaflet
calcification in 19 (8.8%).
There were 34 patients who were clinically diagnosed with
infective endocarditis during the course of the illness; of these,
25 (73.5%) patients had echocardiographic features suggestive of
vegetations and underwent surgery. At surgery, vegetations were
confirmed in 14 (56%) subjects and one had a chordal abscess.
In the remaining 10 (40%), there were no findings of infective
endocarditis at operation; instead eight (80%) had chordal
rupture and two (20%) had chordal elongation. The 15 with
Table 2. Echocardiographic findings in age groups < 25 vs > 25 years
Variable
7–25 years
(n =224)
> 25 years
(n = 96) p-value
EDD, mm*
59.1 ± 7.6 61.9 ± 8.7 0.0041
ESD, mm*
37.8 ± 7.4 41.3 ± 7.1 0.0001
EF, %*
61.4 ± 8.9 59.0 ± 6.3 0.0171
LA, mm*
66.1 ± 8.7 67.8 ± 9.2 0.1164
RV-RA gradient*
48.9 ± 19.0 44.8 ± 17.7 0.0720
↑
Leaflet thickening (%)
100.0
99.0
0.1260
Commissural fusion (%)
1.0
2.1
0.3797
Restricted PML
18.0
25.0
0.1432
Subvalvular thickening (%)
11.4
24.0
0.0033
Leaflet calcification (%)
2.8
21.9
0.0020
Leaflet prolapse (%)
65.1
52.1
0.1321
Ruptured chordae (%)
85.9
25.0
0.0481
MR severity
Moderate/severe (%)
26.0/74.1
17.7/82.3 0.0964
*Data are presented as mean ± SD
LA: left atrium; LV: left ventricle; LVEDD: left ventricular end-diastolic
diameter; LVEF: left ventricular ejection fraction; LVESD: left ventricular
end-systolic diameter; MR: mitral regurgitation; PML: posterior mitral leaflet;
RV-RA: right ventricle – right atrium gradient.
Ruptured chordae and leaflet prolapse were more frequent in the young, while
subvalvular damage and valve calcification were frequent findings in older
subjects.
Table 3. Profile of patients who died
Age (years) Gender NYHA ESD (mm) EF (%) (admission) EF (%) (late)* Complications Surgery Valve findings
13
F 4
48
65
22
HF
Y Thickened with elongated chordae
14
F 4
48
55
24
HF
N Thickened with, subvalvular disease
8
F 4
38
70
34
HF
Y Chordal elongation
16
F 3
35
65
18
HF
Y Valve prolapse and chordal rupture
14
M 4
38
56
22
HF
Y Valve prolapse
11
F 4
35
75
30
HF, IE,
N Thickened with vegetations
16
M 3
47
52
20
HF
N Thickened with, subvalvular disease
70
F 2
29
51
38
HF, IE
Y Calcified with vegetations and subvalvular disease
*EF prior to demise. EF: ejection fraction; ESD: end-systolic diameter; F: female; HF: heart failure; IE: infective endocarditis; M: male; NYHA: York Heart Associa-
tion. Two patients had infective endocarditis, and of these, one was an elderly woman. Four were young subjects with active carditis.