Cardiovascular Journal of Africa: Vol 32 No 5 (SEPTEMBER/OCTOBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 5, September/October 2021 AFRICA 261 Profile of adult patients presenting for rheumatic mitral valve surgery at a tertiary academic hospital Nolwazi Mokitimi, Katherina van der Donck, Hlamatsi Moutlana, Palesa Motshabi Chakane Abstract Background: Peri-operative morbidity and mortal- ity are increased in patients with rheumatic heart disease. Pre-operative risk stratification is imperative for optimisation and a better outcome. Methods: This was a descriptive, retrospective, contextual study. A consecutive convenience sampling method was used. Eighty-nine patients who underwent mitral valve surgery at Charlotte Maxeke Johannesburg Academic Hospital between January 2014 and December 2015 were enrolled. The objec- tives of the study were to describe the demographic profile of the patients presenting for rheumatic mitral valve surgery, describe their peri-operative cardiovascular and echocardio- graphic parameters, and risk stratify according to their clini- cal and echocardiographic parameters. Demographic, echo- cardiographic and laboratory data as well as the cardiovas- cular examination were analysed. Descriptive statistics using proportions (percentages), means (standard deviations) or medians (interquartile ranges) were used where appropriate. Results: A total of 102 patients were reviewed. Thirteen were excluded due to significant missing data. Of the 89 analysed, all had demographic data, 81 had cardiovascular clinical examination data, 82 had echocardiographic data and 52 had laboratory data. Forty-seven patients presented with mitral regurgitation (MR) and 35 had mitral stenosis (MS). Data included two mixed mitral valve disease patients with predominant regurgitation who were classified under the MR group. In total, 45% (39 patients) had arrhythmias and 49% (42 patients) had congestive cardiac failure at presentation for surgery. The overall mean (SD) pulmonary artery systolic pressure was 57 (20) mmHg and mean (SD) left atrial size was 53 (11) mm. Those with MS presented with mean (SD) mitral valve area of 0.9 (0.2) cm². Of the analysed MR patients, 51% presented with left ventricular ejection fraction < 60% and 55% with left ventricular end-systolic diameter > 40 mm. Among the analysed MS patients, 59% had mitral valve area < 1 cm 2 . A substantial number (49% MR and 54% MS) of collected records were not eligible for analysis and stratifica- tion using the American Heart Association/American College of Cardiology (ACC/AHA) guidelines for valvular heart dis- ease due to missing vital information. Of the 24 MR patients analysed utilising the 2014/2017 AHA/ACC guidelines, 13 had asymptomatic severe MR (stage C) and 11 had sympto- matic severe MR (stage D). One patient had progressive MS (stage B), eight had asymptomatic severe MS (stage C) and seven had symptomatic severe MS (stage D). Conclusion: The majority of those who could be stratified presented in stages C and D of disease progression; however, they also presented with concomitant clinical and echocar- diographic features that placed them at high risk of peri- operative morbidity. Keywords: clinical profile, mitral valve, rheumatic heart disease, stratification Submitted 30/8/19, accepted 25/5/21 Published online 20/7/21 Cardiovasc J Afr 2021; 32 : 261–266 www.cvja.co.za DOI: 10.5830/CVJA-2021-024 The estimated worldwide prevalence of rheumatic heart disease was 15.6 million in 2008, with 282 000 new cases arising each year, and 233 000 deaths per year in developing countries. 1 In 2010, the incidence of cardiac failure due to rheumatic heart disease in a South African township was reported to be between 30 per 100 000 per year in individuals aged 14 to 19 years and 53 per 100 000 per year in individuals 60 years and older. 2,3 The commonest infectious cause of valvular heart disease in developing countries is Group A β haemolytic streptococcal infection. The mainstay treatment for valvular heart disease in these countries remains open-heart surgery due to late presentation of patients. 4 The presence of complications such as arrhythmias, congestive cardiac failure, infective endocarditis and pulmonary hypertension increases mortality rates. 5-7 In 2004, Oli et al . 7 found that out of 457 patients with cardiovascular disease, 121 (26.5%) were from rheumatic heart disease and 70% of these died from congestive cardiac failure secondary to rheumatic heart disease. Patients presenting for open-heart surgery pose anaesthetic challenges peri-operativelydue inpart tocomplications emanating from pre-operative low left ventricular ejection fraction (LVEF) and prolonged cross-clamp time. 8 An observational study assessing the value of pulmonary artery pressure (PAP) in predicting in-hospital and one-year mortality rates after valve- replacement surgery in patients with rheumatic mitral valve disease reported gradual but significant increases in in-hospital mortality rates as the PAP increased. 6 The timing of referral for surgery might therefore be important and may impact on the peri-operative course of patients. Stratification of these patients pre-operatively is imperative to develop management plans tailored to each patient. Towards Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Nolwazi Mokitimi, FCA (SA) Hlamatsi Moutlana, FCA (SA) Palesa Motshabi Chakane, PhD, motshabi.chakane@gmail.com Department of Cardiothoracic Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Katherina van der Donck, FCP (Cardio) (SA)