Rheumatic heart disease screening by echocardiography: the inadequacy of World Health Organization criteria for optimizing the diagnosis of subclinical disease.

BACKGROUND: Early case detection is vital in rheumatic heart disease (RHD) in children to minimize the risk of advanced valvular heart disease by preventive measures. The currently utilized World Health Organization (WHO) criteria for echocardiographic diagnosis of subclinical RHD emphasize the presence of pathological valve regurgitation but do not include valves with morphological features of RHD without pathological regurgitation. We hypothesized that adding morphological features to diagnostic criteria might have significant consequences in terms of case detection rates. METHODS AND RESULTS: We screened 2170 randomly selected school children aged 6 to 17 years in Maputo, Mozambique, clinically and by a portable ultrasound system. Two different echocardiographic sets of criteria for RHD were assessed: "WHO" (exclusively Doppler-based) and "combined" (Doppler and morphology-based) criteria. Independent investigators reviewed all suspected RHD cases using a higher-resolution, nonportable ultrasound system. On-site echocardiography identified 18 and 124 children with suspected RHD according to WHO and combined criteria, respectively. After consensus review, 17 were finally considered to have definite RHD according to WHO criteria, and 66 had definite RHD according to combined criteria, giving prevalence rates of 7.8 (95% confidence interval, 4.6 to 12.5) and 30.4 (95% confidence interval, 23.6 to 38.5) per 1000 children, respectively (P<0.0001, exact McNemar test). CONCLUSIONS: Important consideration should be given to echocardiographic criteria for detecting subclinical RHD because the number of cases detected may differ importantly according to the diagnostic criteria utilized. Currently recommended WHO criteria risk missing up to three quarters of cases of subclinically affected and therefore potentially treatable children with RHD.

Prevalence of rheumatic heart disease detected by echocardiographic screening.

BACKGROUND: Epidemiologic studies of the prevalence of rheumatic heart disease have used clinical screening with echocardiographic confirmation of suspected cases. We hypothesized that echocardiographic screening of all surveyed children would show a significantly higher prevalence of rheumatic heart disease. METHODS: Randomly selected schoolchildren from 6 through 17 years of age in Cambodia and Mozambique were screened for rheumatic heart disease according to standard clinical and echocardiographic criteria. RESULTS: Clinical examination detected rheumatic heart disease that was confirmed by echocardiography in 8 of 3677 children in Cambodia and 5 of 2170 children in Mozambique; the corresponding prevalence rates and 95% confidence intervals (CIs) were 2.2 cases per 1000 (95% CI, 0.7 to 3.7) for Cambodia and 2.3 cases per 1000 (95% CI, 0.3 to 4.3) for Mozambique. In contrast, echocardiographic screening detected 79 cases of rheumatic heart disease in Cambodia and 66 cases in Mozambique, corresponding to prevalence rates of 21.5 cases per 1000 (95% CI, 16.8 to 26.2) and 30.4 cases per 1000 (95% CI, 23.2 to 37.6), respectively. The mitral valve was involved in the great majority of cases (87.3% in Cambodia and 98.4% in Mozambique). CONCLUSIONS: Systematic screening with echocardiography, as compared with clinical screening, reveals a much higher prevalence of rheumatic heart disease (approximately 10 times as great). Since rheumatic heart disease frequently has devastating clinical consequences and secondary prevention may be effective after accurate identification of early cases, these results have important public health implications.

Cardiac tamponade in Hashimoto's disease.

Myxedematous pericardial effusions, occurring in about one-third of patients with hypothyroidism, usually do not cause symptoms and regress slowly with hormonal treatment. We report a cardiac tamponade inaugural of a Hashimoto's disease.

Effect of left atrial compliance on pulmonary artery pressure: a case report.

BACKGROUND: Left ventricular diastolic dysfunction, with secondary atrial pressure elevation, is a well-known concept. On the contrary, effect of left atrial compliance on pulmonary pressure is rarely considered. CASE PRESENTATION: We report the echocardiographic case of a 9-year-old child who presented severe rheumatic mitral valve regurgitation with a giant left atrium, in contrast to a normal artery pulmonary pressure, testifying of the high left atrial compliance. CONCLUSION: Left atrial compliance is an important determinant of symptoms and pulmonary artery pressure in mitral valve disease.

Screening for rheumatic heart disease: evaluation of a simplified echocardiography-based approach.

AIMS: Portable echocardiography has emerged as a potential tool to detect rheumatic heart disease (RHD) early. Complex echocardiographic criteria used in recent epidemiological studies may be difficult to translate into daily practice in areas where the burden of RHD is greatest and skilled practitioners are lacking. The aim of this study was to evaluate a simplified echo approach for RHD screening among children in low-income countries. METHODS AND RESULTS: Retrospective analysis of data from a cross-sectional echocardiography-based study carried out in 2005 through the examination of 2170 school children in Maputo, Mozambique. We aimed to evaluate the value of a reference set of criteria (defined as a combination of Doppler and morphological rheumatic features of the aortic and/or mitral valves) compared with an easy-to-use single mitral regurgitation jet-length criterion (simplified set of criteria). All suspected lesions (according to reference or simplified criteria) detected in the field by a portable echo machine were reassessed by non-portable echocardiography and then read by three independent experts. Definite RHD cases in both groups were finally ascertained according to the reference criteria. Portable echocardiography detected valve regurgitation in 208 children. According to the reference criteria, 18 children were detected with suspected RHD on site. Of these, 15 children (83%) were considered to have definite RHD, giving a prevalence of 6.9 per 1000 (95% CI: 3.9-11.4). The simplified mitral regurgitation jet-length criteria detected 12 children at school, 11 of whom were subsequently confirmed to have definite RHD, giving an estimated prevalence of 5.1 per 1000 (95% CI: 2.5-9.1) (P = 0.12, exact McNemar test). When compared with the reference criteria, the simplified approach yields a maximum sensitivity of 73% for case detection, with a positive predictive value of 92%. CONCLUSION: Simplified echocardiography-based screening for RHD appears feasible, allowing rapid and appropriate detection of a significant number of RHD cases on site.

Coronary fistula as an unusual cause of angina in a middle-aged man.

Coronary artery fistulas are rare congenital anomalies, most often discovered as an isolated murmur during examination, typically discovered during childhood. We report the case of a middle-aged black man presented with angina pectoris and found to have a large coronary fistula between the left main stem and the right ventricle. The fistula was occluded using transcatheter coils.

Echocardiography of acute mitral prosthesis dehiscence.

We report a 20-year-old man with acute mitral prosthesis endocarditis complicated by valve desinsertion. In developing countries, the lack of surgical facilities makes management of these complications difficult.

Coronary slow-flow phenomenon.

Slow flow of the contrast in normal coronary arteries is a relatively common finding in patients undergoing routine coronary angiography. The severest form of this phenomenon is known as no flow or TIMI and is uncommon, with life-threatening consequences. We describe a case of slow flow in the left anterior descending artery of a female patient undergoing a diagnostic coronary angiogram.

Thoracic aortic aneurysm: direct sign of rupture.

Hypertension, wall thinning and aortic enlargement are the most important factors increasing wall stress and causing aortic aneurysms to rupture. Computed tomography, especially with contrast image enhancement, usually shows the aortic anatomy with great clarity and distinguishes a ruptured aortic aneurysm from an acute aortic syndrome.

Prevalence of congenital heart disease in schoolchildren of sub-Saharan Africa, Mozambique.

A survey conducted by cardiologists in Mozambique provided an opportunity for assessing the prevalence of congenital heart disease in public school children in Maputo. After randomization, a total of 2170 children were examined. Five children had clinical and echographic evidence of congenital heart disease, corresponding to a prevalence of 2.3 in 1000 (95% confidence interval: 1.0 to 5.4), 80% newly discovered during the survey. These findings confirm that congenital heart disease is at least as common in this South African black community as in Caucasians. Early detection of these cardiac diseases in children is important in order to prevent serious complications and to institute endocarditis prevention.