Rheumatic heart disease in childhood: comparative study between Japan and Thailand.

This report showed the comparative study of the rheumatic fever and rheumatic heart disease in Japan and Thailand. At first, there is remarkable difference about the incidence of the rheumatic heart disease. The incidence of the rheumatic heart disease in Thailand was one hundred times that in Japan. Secondly, there is particular difference about the course of mitral stenosis in childhood. In Japan common pattern of rheumatic heart disease was slight mitral insufficiency and mitral stenosis was seldom. In Thailand mitral stenosis was observed in 5% on rheumatic heart disease, and mitral stenosis developed early following an attack of rheumatic fever. These differences were supposed due to the socio-economic state in each country.     

Natural history of rheumatic carditis. A follow-up of more than 20 years

In this retrospective study of 43 patients of the National Institute of Cardiology of Mexico, 20 to 35 years after the first attack of rheumatic carditis shows that the prognosis of the heart valve disease is directly influenced by the number of attacks of rheumatic fever. In fact, when patients had only one rheumatic attack the secuelae was mild mitral regurgitation (19%), without hemodynamic significance, with less proportion of mitral stenosis (15%), or aortic regurgitation (7.6%), less plurivalvular lesions (16%), or required heart surgery (15%). In the other hand, when the patients suffered three rheumatic attacks had more proportion of mitral stenosis (33%), aortic regurgitation (41%), pluryvalvular lesions (38%) and required more heart (50%). We conclude that prophylactic treatment is important in patients with chronic rheumatic heart disease.     

Mid-systolic click and mitral valve prolapse following mitral commissurotomy

Five patients with rheumatic mitral stenosis were observed to have mid-systolic clicks with murmurs of mitral regurgitation at various intervals after mitral commissurotomy. In two patients echocardiography showed an unusually rapid posterior deflection of the mitral valve coinciding exactly with a systolic nonejection click. It is speculated that the shortened, fused chordae tendineae, compromised by mitral commissurotomy, rigidly hold the valve leaflets fixed at the onset of systole. During systole, ventricular conformational changes, in the face of marginal coaptation of thickened and fibrotic mitral leaflets, allow the mitral valve to be forced abruptly towards the left atrium with great velocity. This is manifested by a loud systolic click and, in some patients, a near vertical posterior systolic deflection of the mitral valve on the echocardiogram. The systolic click may occur without echocardiographic or angiographic evidence of mitral valve prolapse. Unusually loud mid-systolic clicks can be heard in patients with rheumatic heart disease after mitral commissurotomy and may be accompanied by a distinctive echocardiographic appearance of the mitral valve.     

Prevalence of rheumatic fever and rheumatic heart disease in school children in a rural community of the hill region of Nepal

A survey of school children aged 5 to 16 years living in a rural community of the hill region of Nepal, situated about 15-22 km outside Kathmandu city, was conducted to determine the prevalence of rheumatic fever (RF) and rheumatic heart disease (RHD). Of the 4,816 eligible children enrolled in the selected schools, 4,452 (92.4%) were examined. WHO expert committee criteria (1966) was used for the diagnosis and classification of rheumatic fever. Chest x-ray, electro-cardiography, echocardiography and Doppler study were done in all suspected cases of rheumatic heart disease. Six cases of RHD (1 pure mitral stenosis, 3 mitral regurgitation and 2 combined mitral stenosis and regurgitation) were identified giving overall prevalence rate of 1.35 per thousand. No case with active rheumatic fever could be identified. This is the first study on prevalence of RF/RHD in Nepal. The prevalence rate is lower than that reported from neighbouring countries.     

Underlying cardiac lesions in adults with infective endocarditis. The changing spectrum

The spectrum of recognized cardiac lesions underlying infective endocarditis has been changing as a result of the decline in incidence of rheumatic heart disease, the recognition of the entity of mitral valve prolapse, and the improvement in cardiac diagnostic techniques. Sixty-three cases of native valve endocarditis diagnosed in Memphis hospitals between 1980 and 1984 were reviewed. All diagnoses of underlying cardiac lesions were confirmed by two-dimensional echocardiography, cardiac catheterization, and/or histopathologic examination of valve tissues. Major categories of underlying lesions were as follows: mitral valve prolapse, 29 percent; no underlying disease, 27 percent; degenerative lesions of the aortic or mitral valve, 21 percent; congenital heart disease, 13 percent; rheumatic heart disease, 6 percent. Thus, mitral valve prolapse and, in the elderly, degenerative lesions have displaced rheumatic and congenital heart diseases as the major conditions underlying endocarditis. Redundancy of the mitral valve leaflets was noted in 17 of 18 patients in whom endocarditis was superimposed upon mitral valve prolapse. The risk of infective endocarditis appears to be substantially increased in the subset of patients with mitral valve prolapse who exhibit valvular redundancy.     

Mitral valve prolapse in patients with prior rheumatic fever

It is known that rheumatic heart disease frequently results in isolated mitral regurgitation without concomitant mitral stenosis, especially in countries with a high prevalence of rheumatic fever. However, more recent surgical pathologic data also have demonstrated a high incidence of mitral valve prolapse in cases of rheumatic heart disease, which suggests that rheumatic fever may be a cause of mitral valve prolapse. To determine whether this association of mitral valve prolapse and rheumatic heart disease is present in a stable clinic population, we studied 30 patients who had an apical systolic murmur and a well-documented history of rheumatic fever with dynamic auscultation, two-dimensional echocardiography, and pulsed Doppler examinations. Twenty of the 30 patients (67%) had findings on physical examination consistent with isolated mitral regurgitation and 25 patients (84%) had mitral regurgitation by Doppler examination. Echocardiography demonstrated mitral valve prolapse in 24 patients (80%), whereas only one of the total study group had echocardiographic findings consistent with mitral stenosis. We conclude that (1) the presence of an isolated systolic murmur in patients with a history of rheumatic fever frequently represents pure mitral regurgitation secondary to mitral valve prolapse and (2) postinflammatory changes in valvular tissue resulting from rheumatic fever may be the etiology of mitral valve prolapse in these patients.     

Chordae tendineae rupture complicating the systolic click-late systolic murmur syndrome

In a patient with a documented nonejection systolic click and late systolic murmur, acute mitral insufficiency developed as a result of spontaneous rupture of mitral chordae tendineae. There was no evidence of previous endocarditis, rheumatic fever or congenital heart disease. The ballooning mitral valve syndrome has previously been considered relatively benign. Chordal rupture has been predicted, and presumptive cases have been alluded to by several investigators. This well documented report of such a complication casts further doubt on the benignity of the syndrome.     

Isolated left ventricular noncompaction in association with rheumatic mitral stenosis

Fifty year old man with a known case of chronic rheumatic heart disease with atrial fibrillation was presented with severe mitral stenosis. He was incidentally detected to have noncompaction of left ventricle on echocardiography and Doppler examination. He underwent successful percutaneous trans-luminal mitral commissurotomy (PTMC) for severe mitral stenosis. This is the first reported case of isolated ventricular noncompaction (IVNC) associated with acquired chronic rheumatic mitral stenosis.     

Mitral valve replacement in childhood. A report of 51 patients

The mitral valve was replaced in 51 children under the age of 16 years. A Starr-Edwards ball valve was used in 32, a mounted inverted homograft in 16, and other lateral flow orifice valves in 3.Four had congenital mitral valve incompetence, one had a cardiomyopathy while the other had chronic rheumatic heart disease; there was pure mitral incompetence in 34, mixed mitral valve disease in 8, and dominant stenosis in 4. They were Grade 3 or 4 disable before operation. The severity of their disease was noteworthy.Six patients died in relation to the operation and there was one late death.The improvement in clinical status was dramatic. Only 5 have mild residual disability, a consequence of the progression of the rheumatic process, further deterioration of aortic-valve function, or unexplained left ventricular myopathy.Half the patients with a Starr-Edwards replacement were treated with anticoagulants for 3 months only. One embolic episode occurred.Mitral valve replacement is indicated in patients with severe symptoms from mitral valve disease and age should not be a contraindication to operation.     

577例风湿性二尖瓣膜病患者术前心电图观察

目的 观察风湿性二尖瓣膜病患者入院头三天的心电图改变和心电图与心胸比值，左房内径及心功能的关系。方法577例风湿性二尖瓣膜病入院预作瓣膜替换术患者，其中447例为MS MR，93例为单纯MS，37例为单纯MR。所有患者入院头三天内完成12导联心电图、X线胸片和超声心动图检查。(1)心电图改变：577例中，持久房颤68％，不同心室肥厚50％，ST-T改变24％，室早15％，其中9例伴短阵室速，RBBB占11．3％，在窦性心律中LAH或RAH占70％；(2)房颤和窦速加重血流动力学改变和使心功能恶化。结论掌握心电图改变和了解心电图与心功能的关系，将有益于指导临床治疗。     

43例二尖瓣腱索断裂的外科治疗

本文总结４３例二尖瓣腱索断裂的诊断和外科治疗经验。全组病例均有不同程度的心功能不全,２６例行二尖瓣置换术（ＭＶＲ）,１７例行瓣膜修复成形术。术后存活３９例,４例围手术期死亡（死亡率９．３％）。存活病例术后随访２～５７个月。除其中１例风湿性病变患者行二尖瓣、三尖瓣成形术,术后１年又出现二尖瓣中度关闭不全外,其余心功能均有不同程度改善。我们初步认为风湿性病变及心内膜炎患者以ＭＶＲ为宜,退行性病变及先心病者应根据病理类型选择手术方式,多考虑二尖瓣成形术     

Four year follow-up of Black schoolchildren with non-ejection systolic clicks and mitral systolic murmurs

In 1972 we conducted a survey of 12,050 urban Black schoolchildren and detected 168 (prevalence rate of 14 per 1,000) with a non-ejection systolic click (NESC), a late systolic murmur, or both. The etiology of the mitral valve abnormality was unknown but we considered that a significant proportion might have early rheumatic heart disease.The ausculatory features four years later of 139 of the original 168 subjects as well as those of 139 age- and sex-matched controls are presented in this study. No cardiac abnormality was detected in as many as 55 of the subjects. Five children now had pansystolic murmurs but the mitral regurgitation was assessed as mild in four. Twenty-five (17.9 per cent) of the controls, 23 of whom had NESCs, had auscultatory features compatible with mitral valve prolapse.These findings do not support our earlier suggestion that a large number of the 1972 subjects have mild rheumatic heart disease. The results are in accord with other studies which have indicated that auscultatory features compatible with mitral valve prolapse are common in “normals” and also that the prognosis of the specific “billowing mitral leaflet syndrome” is generally benign.     

The significance of the left atrial appendage in rheumatic heart disease.

The possible diagnostic value of an enlarged left atrial appendage (LAA) on the posterior-anterior or right anterior oblique chest film as a means of implicating a rheumatic etiology for mitral valve disease in children was investigated. Chest films were examined without prior knowledge of clinical or laboratory data, and the results were later correlated with this information in 113 children and adolescents. The clinical and laboratory data included application of the modified Jones criteria for the diagnosis of acute rheumatic fever, streptococcal antibody titers and clinical and cardiac catheterization findings. In children with mitral valve disease, our data suggest that as enlarged LAA, especially in the presence of pulmonary venous obstruction, is characteristic of rheumatic heart disease. This finding appears to be particularly useful, in conjunction with streptococcal antibody studies, in distinguishing rheumatic from nonrheumatic patients with mitral insufficiency.     

The natural history of aortic valve disease after mitral valve surgery

OBJECTIVES

The present study evaluates the long-term course of aortic valve disease and the need for aortic valve surgery in patients with rheumatic mitral valve disease who underwent mitral valve surgery.

BACKGROUND

Little is known about the natural history of aortic valve disease in patients undergoing mitral valve surgery for rheumatic mitral valve disease. In addition there is no firm policy regarding the appropriate treatment of mild aortic valve disease while replacing the mitral valve.

METHODS

One-hundred thirty-one patients (44 male, 87 female; mean age 61 ± 13 yr, range 35 to 89) were followed after mitral valve surgery for a mean period of 13 ± 7 years. All patients had rheumatic heart disease. Aortic valve function was assessed preoperatively by cardiac catheterization and during follow-up by transthoracic echocardiography.

RESULTS

At the time of mitral valve surgery, 59 patients (45%) had mild aortic valve disease: 7 (5%) aortic stenosis (AS), 58 (44%) aortic regurgitation (AR). At the end of follow-up, 96 patients (73%) had aortic valve disease: 33 AS (mild or moderate except in two cases) and 90 AR (mild or moderate except in one case). Among patients without aortic valve disease at the time of the mitral valve surgery, only three patients developed significant aortic valve disease after 25 years of follow-up procedures. Disease progression was noted in three of the seven patients with AS (2 to severe) and in six of the fifty eight with AR (1 to severe). Fifty two (90%) with mild AR remained stable after a mean follow-up period of 16 years. In only three patients (2%) the aortic valve disease progressed significantly after 9, 17 and 22 years. In only six patients of the entire cohort (5%), aortic valve replacement was needed after a mean period of 21 years (range 15 to 33). In four of them the primary indication for the second surgery was dysfunction of the prosthetic mitral valve.

CONCLUSIONS

Our findings indicate that, among patients with rheumatic heart disease, a considerable number of patients have mild aortic valve disease at the time of mitral valve surgery. Yet most do not progress to severe disease, and aortic valve replacement is rarely needed after a long follow-up period. Thus, prophylactic valve replacement is not indicated in these cases.     

Heart valve surgery in China: yesterday and today

The past 20 years have seen rapid development in heart valve surgery in China. By the late 1990s, there were 6000 heart valve operations performed each year. Statistical analysis has shown that rheumatic heart disease is still the leading cause of valvular damage leading to surgery, as it had been 40 years before. The progressive fibrosis, sclerosis and calcification of the mitral valve that characterises rheumatic heart disease caused high mortality for all forms of mitral valve surgery in China in the 1960s. At that time, the introduction of closed mitral commissurotomy, initially highly effective in alleviating symptoms, was later found to result in re-stenosis in a significant cohort of patients. This was progressively replaced with open mitral commissurotomy. Today, mitral valve replacement represents 60-70% of valvular replacement procedures, followed by double-valve (mitral and aortic) replacement (20-25%). It has been shown both in China and elsewhere that careful selection of patients for an absence of mitral calcification leads to higher success rates for surgery. Heart valve replacement surgery in China now attains international standards in terms of the numbers of cases and surgical outcomes. Further long-term data collection and analysis are essential to aid the further development of the field.     

二尖瓣成形术46例临床分析

目的：总结二尖瓣成形术的治疗经验。方法：回顾近2年我科46例行二尖瓣成形术患的临床资料。瓣膜病变：风湿性7例、退行性变5例、先天性33例、缺血性1例。手术在中低温体外循环心内直视下进行，二尖瓣按瓣下、瓣叶和瓣环的顺序成形，同时矫治合并的心血管畸形。结果：全组无围术期死亡，并发症包括：心包积液2例，胸腔积液3例，低心排综合征1例。术后超声心动图提示二尖瓣未见返流41例，残留反流5例，其余患恢复良好，心功能较术前明显改善。结论：在严格掌握手术适应症的前提下，二尖瓣成形术可取得良好的效果。     

Non-ejection systolic clicks and mitral systolic murmurs in black schoolchildren of Soweto, Johannesburg.

A survey was conducted on 12 050 Black schoolchildren, aged 2 to 18 years, in the South Western Townships of Johannesburg (Soweto), and the prevalence of non-ejection systolic clicks and late systolic murmurs was determined. One or both of these auscultatory findings were detected in 168 children, yielding a prevalence rate of 13-99 per 1000 in the school population. A female preponderance of 1-9:1 was present and there was a strong linear increase in prevalence with age, with a peak rate of 29-41 per 1000 in 17-year-old children. A non-ejection click was the only abnormal auscultatory finding in 123 children (73%) and a mitral systolic murmur in 8 (5%), whereas in 37 (22%) both these findings were present. Of the latter 37 children, the murmur was late systolic in 32; in 5 it was early systolic. Auscultation in different postures was important in the detection of both non-ejection clicks and mitral systolic murmurs. Experience in the detection of these auscultatory findings influenced the frequency with which they were heard. Electrocardiographic abnormalities compatible with those previously described in the billowing mitral leaflet syndrome were present in 11 of 158 children. The aetiology of these auscultatory findings in this community remains unknown. In the same survey, a high prevalence rate of rheumatic heart disease was recorded and the epidemiology of the non-ejection clicks and these mitral systolic murmurs showed similarties to that of rheumatic heart disease. Though the specific billowing mitral leaflet syndrome almost certainly accounts for some of these auscultatory findings, a significant proportion may have early rheumatic heart disease. Further elucidation of this problem is necessary.     

胺碘酮治疗风湿性心脏病快速心房颤动安全性的探讨

目的:研究风湿性心脏病并发心房颤动患者应用胺碘酮治疗的安全性。方法:将137例风湿性心脏病并发心房颤动患者,根据美国心脏病协会1992年修订的Jone标准分为显著风湿活动组:62例;可疑风湿活动组:47例;无风湿活动组:28例。137例均口服胺碘酮,观察室性心动过速的发生情况,分析室性心动过速与风湿活动、瓣膜病种类、心功能状态、二尖瓣瓣口面积及左房大小的关系。结果:多形性室性心动过速的发生与显著风湿活动有显著性关系,但与瓣膜病的种类、心功能状态、二尖瓣瓣膜口面积及左房大小无相关关系。结论:风湿性心脏病心房颤动患者存在风湿活动时,应慎用胺碘酮。     

Epidemiology of rheumatic heart disease among primary school children in western Kenya

A community survey was conducted to determine the prevalence of rheumatic heart disease in Kenyan children in all primary schools in 2 sublocations in Western Kenya. In total, 3631 children (97% school attendance) aged from 5 to 15 years were examined by one experienced physician and 2 cardiologists between September and December 1985. Six children were found to have evidence of rheumatic heart disease, giving a prevalence rate of 1.7/1000. As all cases occurred in the age group between 10 and 15 years, the rate was calculated for this group as 2.4/1000. None of these patients had previously been diagnosed as having rheumatic fever. There were 3 males and 3 females. Four patients had mitral regurgitation, one had aortic regurgitation and one had mitral stenosis. Three had electrocardiographic evidence of left atrial abnormality and one showed findings of left ventricular hypertrophy but two patients had normal tracings. Half were symptomatic with dyspnoea on exertion and two gave a history of fleeting polyarthritis. The socio-economic status (peasant), family size (mean = 6 siblings) and the number of children sleeping per room were the same in both the cases with rheumatic heart disease and their controls. The health workers achieved low scores (mean 26%) with regard to the clinical diagnosis, treatment and prevention of rheumatic fever at the level of primary health care. Rheumatic heart disease, nonetheless, was relatively insignificant in the overall picture of health care of school children in Western Kenya.     

Current etiology of organic mitral insufficiency in adults

Between 1976 and 1981, 173 patients with severe symptomatic mitral incompetence were referred for preoperative assessment. The etiological diagnosis was based on echocardiography, catheterisation, angiography, and, in the 71 patients operated on, the surgical findings. Rheumatic valvular disease was demonstrated in 40 cases (23,1 p. 100), bacterial endocarditis in II cases (6,3 p. 100), myocardial disease in 30 cases (17,3 p. 100) including 19 cases of mitral incompetence during cardiomyopathy with dilatation, and II cases of mitral incompetence during hypertrophic obstructive cardiomyopathy: ischemic heart disease was the underlying cause in 27 patients (15,6 p. 100), congenital heart disease in 9 patients (5,3 p. 100); dystrophic valvular disease (mitral valve prolapse with or without chordal rupture) was detected in 56 cases (32,3 p. 100). These results show a continuing reduction in the incidence of rheumatic fever and an increase in the number of cases of dystrophic mitral valve disease in patients of 50 to 70 years of age, a condition often rapidly progressive with hemodynamic characteristics very similar to those of mitral incompetence observed in ischemic heart diseases.