RESUMEN
ObjectiveThis study aimed to investigate potential missed diagnoses of acute rheumatic fever and rheumatic heart disease during hospital-based care among persons subsequently identified with these conditions.MethodsThis retrospective cohort study used linked emergency department and inpatient administrative records from Queensland, Northern Territory, South Australia, and New South Wales during 2003-2018 (varying between jurisdictions by completeness of data) of all persons first identified with acute rheumatic fever or rheumatic heart disease while aged 8-24years. Using coded discharge diagnoses from the preceding 3years, we identified presentations (e.g. joint pains or heart murmur without specific identified cause) that potentially mimic and thereby represent a missed opportunity to detect acute rheumatic fever or rheumatic heart disease. Sociodemographic factors associated with experiencing ≥1 mimic diagnoses were investigated using multivariable logistic regression models.ResultsAmong 1855 persons, 65 (3.5%) (using narrow diagnostic inclusions) and 146 (7.9%) (with broad inclusions) experienced ≥1 mimic diagnosis. Joint disorders predominated. Mimics categorised as 'high-likelihood' (most specific) were more frequent among persons subsequently diagnosed as young adults (18-24years) than as children (8-12years) (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.34-4.47), and those from low-risk ethnic groups (including Australian-born non-Indigenous persons) compared with Aboriginal and Torres Strait Islander peoples (OR 2.44, 95% CI 1.02-5.85).ConclusionMissed opportunities to detect acute rheumatic fever and rheumatic heart disease continue to occur in Australian hospitals, and present disproportionately among persons from demographic groups considered to be at low risk, suggesting the need for enhanced clinical suspicion in these groups.
RESUMEN
The impact of mitral regurgitation (MR) from pediatric rheumatic heart disease (RHD) and its effect on left ventricular (LV) remodeling and function following surgical intervention is uncertain. The objective is to explore the impact of mitral valve (MV) surgeries on myocardial mechanics, remodeling and function and identify pre-operative predictors of post-operative dysfunction which may contribute to the optimal timing of intervention. A retrospective review of echocardiographic data was performed of eighteen pediatric patients with RHD (median 9yrs, IQR 6-12) who underwent MV surgery. Echocardiograms pre-operatively and a median of 13.5 months (IQR 10.2-15) following intervention were compared to controls. Pre-operative LV end-diastolic indexed volumes (LVEDVi) were significantly increased compared to controls and remained persistently larger post-operatively. LV ejection fraction (LVEF) (pre 62.6% ± 6.1, post 51.7% ± 9.7, p = 0.002), and global longitudinal strain (GLS) (pre - 24.3 ± 4.1, post - 18.2 ± 2.6, p < 0.001) decreased post-operatively at mid-term follow-up. Pre-operative LVEDVi was a significant predictor of post-operative LVEF, with a cut-off of ≥ 102 ml/m2 associated with LV dysfunction (LVEF < 55%; sensitivity 70%, specificity 75%). Pre-operative LVEDVi also negatively correlated with GLS (r = - 0.58, p = 0.01). LV dimensions and volumes remain persistently larger than controls while LV function decreases post-surgical alleviation of MR in paediatric RHD. Pre-operative LVEDVi predicted post-operative LV dysfunction and utilising LV indexed volumes in directing timing of surgical planning should be considered. Further studies are required to investigate whether timely alleviation of MR before significant LV dilatation and remodeling occur may substantially prevent LV dysfunction and improve outcomes.