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

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 5, September/October 2021 AFRICA 263 the mean (SD) left ventricular end-systolic diameter (LVESD) was 39 (14) mm. Of the female patients, 28% had enlarged left atrial size while 43% had high PAP. Normal LVEF of more than 60% was found in 51% of MR patients and 55% had left ventricular end-systolic diameters of less than 40 mm. Echocardiographic data for MR are shown in Table 4. Seventy-nine per cent of the effective regurgitant orifice area data were incomplete from the charts. These data are necessary for patient stratification. Echocardiographic parameters for MS patients showed a mean (SD) mitral valve area of 0.9 (0.2) cm², and a mean (SD) left atrial size of 54 (13) mm for female patients and 52 (7) mm for male patients. The mean (SD) PAP was 60 (19) mmHg. Critically stenosed mitral valve disease with a mitral valve area of less than 1 cm² was found in 59% of patients, and 69% of MS patients had severely elevated PAP. Echocardiographic data for MS are shown in Table 5, however, similar to MR, some charts had missing parameters. Patient stratification as per the AHA/ACC guidelines for valvular heart disease combines symptoms at presentation, haemodynamic consequences and valve anatomy for disease severity staging. In the current study, the pre-operative cardiovascular examination findings representing symptoms and signs were collected, together with the pre-operative echocardiography findings, which demonstrated valvular structure and haemodynamic consequences (Table 6). Review of the data for MR patients (47) for the purposes of stratification revealed incomplete parameters in 23 (49%) patients. Of the remaining 24 (51%), 13 (54%) were stratified as asymptomatic severe MR or stage C and 11 (46%) as symptomatic severe MR or stage D. Stratification for MS patients (35) showed that 19 (54%) study patients had incomplete data. Only 16 (46%) could therefore be analysed, with one patient (6%) having progressive MS or stage B, eight (50%) with asymptomatic severe MS or stage C, and seven (43%) with symptomatic severe MS or stage D. Discussion Rheumatic heart disease is a preventable medical condition, which has been eradicated in high socio-economic countries. In South Africa, where the disease is still prevalent, there are limited reported data on peri-operative risk stratification of patients with rheumatic heart disease. Our study, therefore, drew references predominantly from non-peri-operative epidemiological studies. Different studies report varied ages at presentation of rheumatic heart disease. The mean (SD) age at presentation to surgery in the current study was found to be 42 (12) years. An epidemiological study by Sliwa et al ., 3 which was conducted in Soweto, Johannesburg, looked at new onset of presentation of rheumatic heart disease and reported a median (IQR) age of 42 (31–55) years. Similarity in age between this study and that by Sliwa et al . 3 may be attributed to the fact that both studies were in the same geographical area of Johannesburg. Kim et al . 11 reviewed patients post mitral valve surgery in South Korea and reported the mean age as 49 (12) years. Faheem et al . 12 reported the mean age of new onset of presentation in a Pakistani population at 22 (6) years, while Joseph et al . 13 found the mean age of new onset of presentation to be 33 (18) years. Their study was conducted in an urban area of south India. Data from the current study could be used to indicate only age at presentation to surgery in relation to clinical picture, as these patients may have been Table 3. Echocardiographic data of interest for both MR and MS Mean (SD) Min–max range Left atrial size (mm), n = 64 53 (11) 30 – 91 Female, n = 40 54 (13) 30 – 91 Male, n = 24 51 (6) 41 – 60 PAP (mmHg), n = 67 57 (20) 21 – 101 PAP, pulmonary artery pressure. Table 4 Echocardiographic data for MR Variables Number (%) Left atrial size (mm), n = 35 Female < 43 3 (9) Male < 47 6 (17) Female 43 – 47 4 (11) Male 47 – 52 4 (11) Female > 47 13 (37) Male > 52 5 (15) Pulmonary artery pressure (mmHg), n = 32 Mild < 30 5 (16) Moderate 30 – 50 7 (22) Severe > 50 20 (62) Left ventricular ejection fraction (%), n = 47 > 60 23 (49) < 60 24 (51) Left ventricular end-systolic diameter (mm), n = 38 < 40 21 (55) > 40 17 (45) Effective regurgitant orifice area (cm²), n =10 < 0.4 4 (40) ≥ 0.4 (+ haemodynamic changes) 6 (60) Table 5. Echocardiographic data for MS Variables Number (%) Mitral valve area (cm²), n = 32 1.5 – 1.0 13 (41) < 1.0 19 (59) Left atrial size (mm), n = 27 Female < 43 2 (7) Male < 47 2 (7) Female 43 – 47 5 (19) Male 47 – 52 2 (7) Female > 47 12 (45) Male > 52 4 (15) Pulmonary artery pressure (mmHg), n = 32 Mild < 30 1 (3) Moderate 30 – 50 9 (28) Severe > 50 22 (69) Table 6. Stratification (stage of presentation) as per AHA/ACC guidelines for valvular heart disease Symptoms, haemodynamic consequences and valve haemodynamics MR, n (%) MS, n (%) Stage B (progressive disease) – 1 (3) Stage C (severe asymptomatic disease) 13 (28) 8 (23) Stage D (severe symptomatic disease) 11 (23) 7 (20) Incomplete vital information 23 (49) 19 (54)