Rheumatic Heart Disease by Dr. Emmanuel Rusingiza. My name is
Emmanuel Rusingiza. I'm a pediatric cardiologist at Kigali
University Teaching Hospital, Rwanda. I'm going to talk about
the diagnosis, and management of Rheumatic Heart Disease. Types
of valvular diseases. Rheumatic heart disease is the result of
damage to the heart valves, which occur after repeated episodes of
acute rheumatic fever. Although initial attacks can lead
directly to rheumatic heart disease, early diagnosis of
rheumatic heart disease is very important. So that secondary
prophylaxis can be started as soon as possible. To help
prevent the progression of the valve disease. echocardiography
is essential tool to confirm the diagnosis and detect any
progression of valvular disease. So now what are the types of
robotic hobbies? The types of valvular rheumatic heart disease
are the following. The mitral valve is the mostly affected in
often NT percent of cases of rheumatic heart disease. The
next common affected valve is the aortic valve. And usually,
disease of the artic valve is associated with the disease of
the mitral valve. The trucker speed and pimoroni valves are
very directly affected. But the tricuspid regurgitation may
occur in advanced mitral valve disease, especially when there
is severe pulmonary hypertension. So the valvular
lesions include the mitral regurgitation, which is found
most commonly in children and young adults. The mitral
stenosis, which represents longer term, chronic changes to
the mitral valve, more commonly seen in adults, all the children
can present both mitral stenosis, and mitral
regurgitation. artic regurgitation is not uncommon,
and Arctic stenosis is almost never seen as an isolated
lesion. Symptoms The symptoms of rheumatic heart disease depend
on the valve lesion and its severity. Symptoms may not show
for many years until the valve disease becomes severe. initial
symptoms of rheumatic heart disease are the symptoms of
every heartbeat, which are the breathlessness on exertion,
general weakness, cough and sometimes haemoptysis based on
the level of the pulmonary edema, or top near paroxysmal
nocturnal this near peripheral edema, which can be generalized
afterward if there is no intervention, signs of chronic
malnutrition may occur as complication due to long term
heart condition. specific symptoms include palpitations,
in case of atrial fibrillation, particularly with mitral
stenosis. And in this case, there is an associated risk of
embolic events. Stroke when there is cerebral embolism, in
case of atrial fibrillation, and are effective endocarditis of
the mitral or artic valve, but also sometimes, severe mitral
stenosis can cause stroke. People with artic valve disease
may experience syncope in addition to heart failure
symptoms. Physical examination, a physical examination is a very
important step. And the clinical examination should include
assessment of severity and complications, including signs
of heart failure, which are to keep near back cardio, edema,
raised jugular venous pressure hepatomegaly, lung crackles and
so on.
The presence of atrial fibrillation and the presence of
stroke must be assessed as well. The auscultation for the mitral
regurgitation reveals a pan systolic murmur healed loudest
at the optics and radiating laterally to the axilla.
mitral stenosis reveals a low pitched the historical rumble.
Here the best are the epics.
In case of artic regurgitation, there is a historic blowing the
Christian Omarama based here at the left center border with the
person sitting up
in case of Article stenosis, the mama is loud, low pitched mid
systolic ejection mama based here in the Artic, Aria and
radiating to the neck.
Investigations. The investigations include
electrocardiography, which is essential to determine the
cardiac rate and other abnormal patterns. Just X ray helps to
assess the size of the heart chambers and detect pulmonary
congestion echocardiography is here the gold standard exam. It
confirms the diagnosis and detect any rheumatic valve
damage help determine its severity and assess left
ventricular function. Additional investigations include if DC
electrolyte, especially sodium and potassium, the renal
function test and liver function tests. Let us insist a little
bit on the echocardiography. In 2011. The World Heart Federation
has developed the criteria to make echocardiography reporting
simple, reproducible and consistent worldwide. They
echocardiography criteria helps in screening of rheumatic heart
disease in schoolchildren, and it is based on morphological
features and pathological regurgitation for the mitral and
aortic valves. There are three diagnostic possibilities based
on the echocardiography criteria, which are defined it
rheumatic heart disease, borderline rheumatic heart
disease, and normal false. These are some few examples of
echocardiography images. This slide shows a parasternal long
axis view and you can't see very well the left ventricle, the
left atrial der the mitral valve, here, the mitral valve
looks thickened, and the anterior leaflet especially on
the tip looks second, the posterior one looks retracted.
This is a full chamber view or APICs view, which shows the
thickness of the mitral leaflets and Cordy. But mostly, you can
see a significant mitral regurgitation, which is
posterior li directed jet and typical for rheumatic valvular
disease. This slide shows the long axis view of the heart
which shows the thickness of the mitral valve leaflets and the
Artic leaflets. This patient presents severe mitral stenosis,
artic regurgitation and artic stenosis. This is another image
of long axis view, which shows the Doppler on the Artic valve,
and you can see very well the death of articular vegetation in
red. Management. The goal of the management of rheumatic heart is
CCE is to prevent disease progression and to avoid or at
least delay valve surgery. Secondary prophylaxis for
prevention of remote of recurrent acute rheumatic fever
is the main strategy. The key elements of the effective
management of rheumatic heart disease, our initial assessment,
education and referral to a medical or heart specialist if
applies. In case of heart failure, it is recommended to
admit the patient for bedrest and treatment of heart failure
with Duratex and AC inhibitors, management of atrial
fibrillation with digoxin and anticoagulation. Regular medical
and echocardiographic review. Secondary prophylaxis is very
important to prevent the recurrency of acute rheumatic
fever, which come to damage more the heart valves. The infective
endocarditis prophylaxis is very important before dental and
surgical procedures. It is also needed to plan for regular
dental care, and also contraception especially for
female adolescents.
The complications of rheumatic heart disease depend upon the
affected valve. They are heart failure, with severe pulmonary
hypertension, effective endocarditis, stroke, atrial
fibrillation, chronic malnutrition, and from tricular
dysfunction. The treatment of congestive heart failure depends
upon the nature of the variation. When it is due to
severe mitral and aortic regurgitation, it is important
to admit the patient for bed rest, give failure medications,
but also consider the nutritional support. When the
heart failure is due to severe mitral stenosis. The treatment
is done by theoretics beta blocker, depending upon this
cold aspirin to prevent intra atrial thrombus and stroke. And
the Warfarin is absolutely indicated in case of atrial
fibrillation. The indication for heart surgery is determined by
the severity of the symptoms. The evidence that the heart
valves are significantly damaged, the left ventricle
chamber size and the function the types of vascular surgery
include vascular repair or valve replacement by Ada, a by a
prosthetic valve or a mechanical valve factors to absolute
contraindication to valve surgery. Poor left ventricle
function with valve regurgitation. Severe pulmonary
hypertension may pose a in an acceptable risk for cardiac
surgery. Good nutritional status improves post operative
outcomes. anticoagulation is indicated for patients who
undergo valve replacement, the commonly used drug is Coumadin
or warfarin. The treatment with Warfarin needs to be monitored
following replacement with mechanical valves. Good
anticoagulation management requires standardized
anticoagulation measurement using the international
normalized ratio called INR. This table summarizes the
indications the goal of iron ore and alteration of
anticoagulation therapy. As you can see, most of the guard for
iron ore is between 2.5 and 3.5. And when there is a mechanical
Vive, the duration of therapy is lifelong. After cardiac surgery,
it's very important to plan regular long term follow up. The
conservative valve procedures like valve repair, require close
observation to detect restenosis or a recurrence of valvular
regurgitation. Assura secondary prophylaxis is administered
regularly using benzathine penicillin G. im every three to
four weeks to prevent recurrent attacks by acute rheumatic
fever. It is also important to monitor the left ventricle and
prosthetic function you During the follow up now, under credit
is prevention is another important point. Because
effective endocarditis is a serious complication of
rheumatic heart disease, and may also occur after heart valve
surgery. These uncommonly occurs during dental and surgical
procedures, but often, the source of the infection is not
clear. Effective endocarditis most commonly occurs in the
mitral or artic valve, since these are the most commonly
damaged heart valves, thank you for watching. Please help us
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