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

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 5, September/October 2021 AFRICA 265 guidelines recommend a higher cut-off for normal LVEF in MR than in other types of heart disease. Risk stratification of patients as per the AHA/ACC guidelines for the current study proved difficult, as 49% of study patients within the MR group and 54% of study patients from the MS group had missing important information necessary for stratification. Of the 51% of the study patients with available important information within the MR group, risk stratification as per the AHA/ACC guidelines showed that 13 (54%) patients had asymptomatic severe MR or stage C and 11 (46%) had symptomatic severe MR or stage D. Stratification for MS patients showed that one patient (6%) had progressive MS or stage B; eight (50%) had asymptomatic severe MS or stage C, and seven (43%) had symptomatic severe MS or stage D. All patients in the current study underwent mitral valve replacement irrespective of the stage of disease at which they presented. As these data are retrospective, the reasons behind the decision regarding the choice of surgery/intervention and controversies thereof cannot be discussed. The decision, however, is often informed by other factors such as valve morphology, presence or absence of left atrial clot, mixed valve disease and availability of expertise. The current study was undertaken to understand the profile of adult patients presenting for rheumatic mitral valve surgery and to open discussions and plan to further assess outcome in later studies. It is important to note that with the AHA/ ACC guidelines ‘the focus is on medical practice in the United States, but guidelines developed in collaboration with other organisations may have a global impact’, 10 as patient populations may differ. Presentation with signs and symptoms associated with adverse outcome in the current study was similar in pattern to findings by Sliwa et al . 3 in ‘insights from the Heart of Soweto study’, as it found that 66% of newly diagnosed rheumatic heart disease patients presented as stage D on the AHA/ACC guidelines. Perhaps the report of our study, similar to that in Sliwa et al ., 3 which reported on a feeder population into our institution, also indicates a delay in surgical intervention. Severe symptoms at initial diagnosis of rheumatic heart disease are a major predictor of mortality, therefore early presentation, before the development of complications, could lead to better outcomes as pulmonary hypertension, arrhythmias and heart failure are associated with high mortality and morbidity rates. A further investigation on outcome measures and waiting time from presentation to surgery is desirable. Conclusion Most study patients were black adult females. Approximately half of the patients in this study presented with heart failure. Although limited by inadequate echocardiographic data for stratification in about half of the study population, this data showed that predominantly female patients presented with moderate to severe disease, as evidenced by left atrial size, PAP and valve area parameters in both the stenotic and regurgitant groups. This conclusion is however not generalisable and may yield different results with a larger sample size. Poor records of echocardiographic data entry made it difficult to stratify a significant number of patients according to recommendations. Much improvement is needed in this regard. Although the study did not look at outcomes, the echocardiographic and clinical parameters assessed, such as LVEF, left atrial size, PAP, arrhythmias and heart failure, which are known to be associated with increased morbidity and mortality rates, indicate the possibility of a poor outcome. A follow-up outcome study would be ideal to elucidate this. This research was done as partial fulfilment of a Master of Medicine degree. References 1. Robertson KA, Mayosi BM. Rheumatic heart disease: social and economic dimensions. S Afr Med J 2008; 98 (10): 780–781 2. Mayosi BM, Gamra H, Dangou JM, Kasonde J, for the 2nd All-Africa Workshop on Rheumatic Fever and Rheumatic Heart Disease partici- pants. Rheumatic heart disease in Africa: the Mosi-o-Tunya call to action. Lancet Glob Health 2014; 2 (8): e438–439. 3. Sliwa K, Carrington M, Mayosi BM, Zigiriadis E, Mvungi R, Stewart S. 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. 4. Bloomfield GS, Barasa FA, Doll JA, Velazquez EJ. Heart failure in sub- Saharan Africa. Curr Cardiol Rev 2013; 9 (2): 157–173. 5. Prasad A, Kumar S, Singh B, Kumari N. Mortality due to rheumatic heart disease in developing world: a preventable problem. J Clin Exp Cardiol 2017; 8 (503): 2. 6. Jiang L, Wei XB, He PC, Feng D, Liu YH, Liu J, et al . Value of pulmo- nary artery pressure in predicting in-hospital and one-year mortality after valve replacement surgery in middle-aged and aged patients with rheumatic mitral disease: an observational study. Br Med J Open 2017; 7 (5): e014316. 7. Oli K, Asmera J. Rheumatic heart disease in Ethiopia: could it be more malignant? Ethiop Med J 2004; 42 (1): 1–8. 8. Ellenberger C, Sologashvili T, Cikirikcioglu M, Verdon G, Diaper J, Cassina T, et al. Risk factors of postcardiotomy ventricular dysfunction in moderate-to-high risk patients undergoing open-heart surgery. Ann Card Anaesth 2017; 20 (3): 287–296. 9. Nishimura R, Otto C, Bonow R, Carabello B, Erwin 3rd J, Guyton R, et al . AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129 : 157–185. 10. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, 3rd, Fleisher LA, et al . 2017 AHA/ACC focused update of the 2014 AHA/ACC Guideline for the management of patients with valvu- lar heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135 (25): 1159–1195. 11. Kim JB, Kim HJ, Moon DH, Jung SH, Choo SJ, Chung CH, et al . Long-term outcomes after surgery for rheumatic mitral valve disease: valve repair versus mechanical valve replacement. Eur J Cardiothorac Surg 2010; 37 (5): 1039–1046. 12. Faheem M, Hafizullah M, Gul A, Jan HU, Khan MA. Pattern of valvular lesions in rheumatic heart disease. J Postgrad Med Inst 2007; 21 (2): 99–103. 13. Joseph N, Madi D, Kumar GS, Nelliyanil M, Saralaya V, Rai S. Clinical spectrum of rheumatic Fever and rheumatic heart disease: a 10 year experience in an urban area of South India. N Am J Med Sci 2013; 5 (11): 647–652. 14. Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE. Mitral