14 / 60
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 2, March/April 2021
68
AFRICA
recorded in the echocardiographic reports. Comments on annular
dilatation in the 6% at surgery (Tables 4, 5) were recorded by the
surgeon who performed mitral valve repair on the few cases and
for the limited period that he was in the department. Also it
must be pointed out that valve thickness at surgery was based
on macroscopic appearances, and formal measurements of
valve thickness were not performed by the surgeon. Similarly,
both leaflet thickness and chordal thickening were subjectively
assessed at echocardiography and may be subject to error if gain
settings are not optimal.
Excessive valve echoes and leaflet motion were often
misdiagnosed as chordal rupture and shown to be due to chordal
lengthening at surgery. Transoesophageal echocardiography
would have distinguished between chordal rupture and chordal
elongation but this procedure was not routinely performed in
patients with severe MR. Furthermore, this procedure would
have given a better understanding of the subvalvular apparatus
and the degree of chordal elongation prior to surgery.
Despite its limitations, there are important strengths to our
study. An important aspect of our study was that we were able
to confirm or refute the echocardiographic findings in two-thirds
of our patients who underwent valve-replacement surgery.
However, the lack of histopathological correlation is a serious
limitation of our study since it would have corroborated our
contention that ongoing carditis was a major cause of severe
regurgitation, particularly in our younger subjects. Nevertheless,
the morphological findings of chordal elongation with valve
prolapse and chordal rupture at surgery suggested active carditis
in many of these patients.
12,15
At surgery, leaflet thickening
was not as common and was probably over-diagnosed at
echocardiography. We attributed the over-diagnosis of increased
leaflet thickness at echocardiography to excessive leaflet motion
associated with leaflet prolapse and/or chordal rupture.
Conclusion
In this study, isolated MR occurred in 10% of all patients
with rheumatic MR. A significant percentage of these subjects
presented with active carditis characterised by chordal
elongation, frequent valve prolapse and chordal rupture,
associated with a high burden of cardiovascular complications,
including death. This pattern of MR with ongoing carditis and
valve damage that continues into early adulthood is a reflection
of rural populations in KZN, with poorer socio-economic
circumstances compounded by difficulty of access to care and
lack of availability of antibiotic prophylaxis. This has resulted
in recrudescences of carditis well into early adulthood, and
emphasises the need for ongoing rheumatic fever prophylaxis at
least until the age of 35 years. These findings have serious public
health implications in adopting the WHO strategy of targeting a
25% reduction in mortality from RHD by the year 2025.
10
References
1.
Carapetis JR, Steer AC, Mulholland EK,
et al
. The global burden of
group a streptococcal diseases.
Lancet Infect Dis
2005;
5
: 685–694.
2.
Paar JA, Berrios NM, Rose JD,
et al
. Prevalence of rheumatic heart
disease in children and young adults in Nicaragua.
Am J Cardiol
2010;
105
: 1809–1814.
3.
Zühlke LJ, Engel ME, Ganasan K,
et al
. characteristics, complications
and gaps in evidence based interventions in rheumatic heart disease: the
global Rheumatic heart disease Registry (the REMEDY study).
Eur
Heart J
2014;
36
(18): 1115-1122.
4.
Diao M, Kane A, Ndiaye MB,
et al
. Pregnancy in women with heart
disease in sub-Saharan Africa.
Arch Cardiovasc Dis
2011;
104
: 370–374.
5.
Koegelenberg CF, Doubell AF, Orth H. Infective endocarditis in the
western cape province of south Africa: A three-year prospective study.
Q J Med
2003;
96
: 217–225.
6.
Benjamin EJ, Wolf PA, D’Agostino RB. Impact of atrial fibrillation
on the risk of death: the Framingham heart study.
Circulation
1998;
98
:
946–952.
7.
Carapetis JR. Rheumatic heart disease in Asia.
Circulation
2008;
118
:
2748–2753.
8.
Sliwa K, Carrington M, Mayosi BM,
et al
. Incidence and characteristics
of newly diagnosed rheumatic heart disease in urban African adults:
Insights from the Heart of Soweto Study.
Eur Heart J
2010;
31
(6):
719–727.
9.
Zühlke LJ, Engel ME, Watkins D,
et al
. Incidence, prevalence and
outcome of rheumatic heart disease in South Africa: A systematic
review of contemporary studies.
Int J Cardiol
2015;
199
: 375–383.
10. Remenyi B, Carapetis J, Wyber R,
et al.
Position statement of the world
heart federation on the prevention and control of rheumatic heart
disease.
Nat Rev Cardiol
2013;
10
: 284–292.
11. Mayosi B. 2016 National Rheumatic Fever Week: The status of rheu-
matic heart disease in South Africa.
S Afr Med J
2016;
106
(8): 740–741.
12. Essop MR, Nkomo VN. Rheumatic and non-rheumatic valvular
heart disease: epidemiology, management and prevention in Africa.
Circulation
2005;
112
: 3584–3591.
13. Kumar R, Tandon R. Rheumatic fever and rheumatic heart disease: The
last 50 years.
Indian J Med Res
2013;
137
(4): 643–658.
14. Marcus RH, Sarel P, Pocock WA,
et al
. The spectrum of severe rheu-
matic mitral valve disease in a developing country. Correlations among
clinical presentation, surgical pathologic findings, and hemodynamic
sequelae.
Ann of Inter Med
1994;
120
: 177–183.
15. Marcus RH, Sarel P, Pocock WA,
et al
. Functional anatomy of severe
mitral regurgitation in active rheumatic carditis.
Am J Cardiol
1989;
63
:
577–584.
16. Meel R, Peters F, Libhaber E,
et al
. The changing spectrum of rheu-
matic mitral regurgitation in Soweto, South Africa.
Cardiovasc J Afr
2017;
28
(4): 215–220.
17. Lang RM, Badano LP, Mor-Avi V,
et al
. Recommendations for cardiac
chamber quantification by echocardiography in adults: an update from
the American Society of Echocardiography and the European Association
of Cardiovascular Imaging.
Eur Heart J Cardiovasc Imag
2015;
16
: 233–270.
18. Reményi B, Wilson N, Steer A,
et al
. World Heart Federation criteria for
echocardiographic diagnosis of rheumatic heart disease – an evidence-based
guideline.
Nat Rev Cardiol
2012;
28
: 297–309.
19. Chauvaud S, Fuzellier J, Berrebi A,
et al
. Long-term (29 years) results
of reconstructive surgery in rheumatic mitral valve insufficiency.
Circulation
2001;
104
(12 Suppl 1): 112–115.
20. Wilkins GT, Weyman AE, Abascal VM,
et al
. Percutaneous balloon dilata-
tion of the mitral valve: an analysis of echocardiographic variables related
to outcome and the mechanism of dilatation
. Br Heart J
1988;
60
: 299–308.
21. Dajani A, Ayoub E, Bierman F,
et al
. Special writing committee on rheumat-
ic fever, endocarditis and Kawasaki disease of the Council on Cardiovascular
Disease in the young of the American Heart Association. Guidelines for the
diagnosis of rheumatic fever, Jones criteria, 1992 update
. J Am Med Assoc
1992;
268
: 2069–2073.
22. World Health Organisation. Rheumatic fever and rheumatic heart disease.
World Health Org Tech Rep Ser
2001;
923
: 1–122.