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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 2, March/April 2021
62
AFRICA
Cardiovascular Topics
The spectrum of rheumatic mitral valve regurgitation
presenting to Inkosi Albert Luthuli Central Hospital,
KwaZulu-Natal, over a 10-year period
Nomthandazo Lynn Zwane, Somalingum Ponnusamy, Datshana Prakesh Naidoo
Abstract
Background:
Recent evidence suggests that there is a change
in the profile of rheumatic mitral regurgitation (MR) in South
Africa to a pattern of chronic fibrotic valvular disease.
Objective:
This study describes the clinical profile of patients
with rheumatic MR in the province of KwaZulu-Natal
(KZN).
Methods:
A retrospective chart review was performed on
patients seven years and older with moderate to severe rheu-
matic MR referred to Inkosi Albert Luthuli Central Hospital
from 2006 to 2015.
Results:
There were 320 patients meeting the study criteria
(mean age 22.2 ± 15.8 years, male:female 1:2). Severe dys-
pnoea was present in 45.9% of patients, heart failure in 117
(36.6%) and atrial fibrillation in 13.8%. Three patients were
diagnosed with active carditis at initial presentation and a
further 31 had evidence of carditis during follow up. Of the
216 patients who underwent surgery, over one-third (37%)
had prolapse of the anterior mitral leaflet, which was due to
chordal elongation (
n
= 63, 29.2%) and/or ruptured chordae
(
n
= 41, 19%). There were 32 deaths (10%) and of these, 27
(8.4%) patients died prior to surgery.
Conclusion:
Rheumatic MR in KZN predominantly affects
the young, with concomitant carditis resulting in high morbid-
ity and mortality rates.
Keywords:
rheumatic MR, rheumatic carditis, echocardiography,
chordal elongation, mitral valve surgery
Submitted 26/2/20, accepted 14/7/20
Published online 16/3/21
Cardiovasc J Afr
2021;
32
: 62–69
www.cvja.co.zaDOI: 10.5830/CVJA-2020-029
The epidemiology of non-communicable diseases in low- and
middle-income countries highlights rheumatic heart disease
(RHD) as one of the leading causes of death, accounting for up
to 1.4 million deaths worldwide per year.
1,2
The gravity of this
problem is defined by the degree of complications associated
with the disease, such as atrial fibrillation, heart failure, stroke,
infective endocarditis and death.
3-7
Recent hospital-based studies
in South Africa (SA) reveal an incidence of congestive heart
failure secondary to RHD of 25 cases per 100 000 per year.
8,9
Despite the magnitude of the problem, there is a paucity of
data on the disease characteristics, including the demographic
pattern, clinical presentations, complications and management
in the majority of South African provinces, KwaZulu-Natal
(KZN) included.
9
In light of this problem, the World Health
Organisation (WHO) has called for a clear documentation of the
contemporary clinical characteristics of the disease together with
notification of new cases,
10
and has targeted a 25% reduction in
mortality rate from RHD and other non-communicable diseases
by the year 2025.
10
During the 2016 National Rheumatic Fever
week, it was pointed out that SA has the conditions required for
successful eradication of RHD, provided detailed characteristics
of the disease are well documented and ensuing guidelines
implemented.
11
RHD affects all cardiac valves to varying degrees
12,13
and
remains the predominant cause of mitral regurgitation (MR)
in geographically low- and middle-income regions, including
the South African context.
12
While rheumatic MR has been well
documented in some parts of SA,
12,14-16
uncertainty remains about
the disease characteristics in the KZN population.
Approximately 30 years ago, Marcus
et al
.
14
published a study
on 700 patients with rheumatic valvular heart disease from Chris
Hani Baragwanath Academic Hospital (CHBAH) in which he
detailed demographic, echocardiographic and surgical data on
MR. These data revealed a disease process mainly affecting
young individuals with concomitant acute rheumatic carditis.
14
In a study in 1989, Marcus
et al
.
15
performed echocardiographic
analyses on 73 young patients (mean age 13 years) with acute
rheumatic carditis and severe MR. Here the majority (94%) of
the study population had anterior mitral leaflet (AML) prolapse,
as noted on the echocardiogram and confirmed at surgery. It
was concluded that the mechanism of severe rheumatic MR in
acute carditis was mainly due to annular dilatation and chordal
elongation.
15
In a more recent prospective cross-sectional study at the
CHBAH, Meel
et al
.
16
described a change in the demographic
Department of Internal Medicine, University of KwaZulu-
Natal, Durban, South Africa
Nomthandazo Lynn Zwane, MB BCh, MMed (UKZN), FCP (SA)
Department of Cardiology, University of KwaZulu-Natal,
Durban, South Africa
Somalingum Ponnusamy, MB ChB, FCP (SA), Cert Cardiol
(Physicians) (SA)
Datshana Prakesh Naidoo, MD, FRCP,
naidood@ukzn.ac.za