CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 AFRICA 297 TR grades, and RV and LA measurements. It was reported that TR frequently exists withMS. Amoderate grade or higher of TR was shown in more than one-third of MS patients.25 TR was considered a complication and indicator of severity of MS.25 Accordingly, in our study, more cases of grade II TR were found in the moderate and severe MS groups. The present study showed that RV size and function, as assessed by TAPSE measurements, were significantly different among grades of MS, with the worst values seen in patients with severe MS. Actually, the RV dysfunction occurring in MS is attributed to LA hypertension with subsequent chronic pulmonary venous congestion and increased RV afterload. It was also suggested that depression of right myocardial function could be the sequel of direct RV rheumatic involvement, resulting in inflammation and necrosis of the myocytes, and further fibrosis and calcification.26 Our findings are congruent with the study by Ahmed et al,27 who reported that RV systolic function was significantly different between patients with different grades of MS. Significant changes in LA measurements among different grades of MS, which were found in our study, is consistent with data from previous studies. In the study by Ahmed and Awan,28 LA enlargement was observed in cases of MS, and the difference was according to the grade of MS. LA enlargement was reported to be the first sign of severity of MS.25 With regard to the primary outcome of this study, MVA showed a statistically highly significant positive correlation with LA and RV function, and statistically significant/ highly significant negative correlation with their dimensions. Re-analysis of patients with isolated MS revealed the same significant association. The association between MVA and LA function was re-analysed in the current study using a ROC curve for assessment of LA function in predicting significant MS (moderate and severe MS). The AUC was 0.813, denoting good performance, with a statistically highly significant p-value. Moreover, MVA was found to be a predictor of LA function during the regression analysis (p = 0.000). The association between the MVA and LA size and function was in harmony with the pathophysiological changes, since the narrower the MVA, the higher the impact on the LA function and the more compensatory dilatation of the LA chamber. A few studies correlated MVA with echocardiographic findings. In agreement with our findings, Shojaeifard et al.,29 using a different parameter for LA function, peak LA longitudinal strain (PALS), demonstrated a significant correlation between the PALS measurements and MVA. Zulfa et al.24 tested the correlation between MVA and RV function as measured by TAPSE. They found a positive linear relationship between both, which is in harmony with the present study findings. This was also found in the study by Inci et al.30 This significant association suits the previously described reflection of MS on the RV function. The study of Iqbal et al.23 reported a weak correlation between LA size and MVA with an insignificant p-value, which is contradictory to our findings. With regard to the secondary outcome in our study, the ECG findings demonstrated that 47 patients were in sinus rhythm, while the remaining 34 were in AF (42%). Our figures are in the range that was previously described by Sahin et al.31 They reported that AF occurred in 40–75% of patients with MS. The present study showed that a higher percentage of patients with severe MS was in AF (58.1%). However, the difference between patients of both categories in the distribution of different grades of MS was not significant (p = 0.06). Patients in AF had statistically significantly higher LA areas and volumes, and statistically significantly lower LA function (p = 0.003). Within the same context, Shojaeifard et al.29 revealed that LA function, as measured by PALS, was significantly lower in AF patients than in those with MS in sinus rhythm. Nikdoust et al.32 evaluated LA function using a different parameter, early diastolic strain. They also demonstrated lower function in patients with AF. Caso et al.33 reported a significant decline in atrial strain measurements in AF patients. The relationship between the existence of AF and LA size was described in previous studies. In the study of Shrestha et al.,34 the majority of patients with AF showed LA size ≥ 4.0 cm, with a mean LA size of 4.6 cm. Bratt et al.35 demonstrated that LA volume was an independent predictor of the AF status. Strength and limitations The strength of this work is that it is one of the few studies assessing the correlation between MVA and LA function. However, the relatively small sample size is a limitation. Also, LA volume assessment by 2D echocardiography is limited by significant geometric assumptions and low reproducibility because of diverging position and orientation of imaging planes. However, in this study, we excluded a large number of cases due to poor echogenic window of the LA, which could affect the validity of the main result. While 3D echocardiography and cardiac magnetic resonance imaging can undoubtedly increase the accuracy of determining the LA size, these techniques are not commonly available. Furthermore, multicentric, largescale studies using advanced echocardiographic procedures are recommended. Conclusion There was a positive correlation between LA function and MVA in rheumatic MS patients. AF was associated with the severity of MS. References 1. Vaideeswar P, Butany J. Valvular heart disease. In: Buja LM, Butany J, eds. Cardiovascular Pathology. 4th edn. [Internet]. San Diego: Academic Press, 2016; Chapter 12: 485–528. Available from: https://www.sciencedirect.com/science/article/pii/B9780124202191000124 2. Guilherme L, Kalil J. Rheumatic heart disease: molecules involved in valve tissue inflammation leading to the autoimmune process and anti-S pyogenes vaccine. Front Immunol 2013; 4: 352. 3. Coffey PM, Ralph AP, Krause VL. The role of social determinants of health in the risk and prevention of group A streptococcal infection, acute rheumatic fever and rheumatic heart disease: A systematic review. PLoS Neglected Trop Dis 2018; 12(6): e0006577. 4. Vieira MLC, Branco CE de B, Gazola ASL, Vieira PPAC, Benvenuti LA, Demarchi LMMF, et al. 3D echocardiography for rheumatic heart disease analysis: ready for prime time. Front Cardiovasc Med 2021; 8: 715. 5. De Vecchi A, Marlevi D, Nordsletten DA, Ntalas I, Leipsic J, Bapat V, et al. Left ventricular outflow obstruction predicts increase in systolic pressure gradients and blood residence time after transcatheter mitral
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