The variable spectrum of anterior mitral valve leaflet restriction in rheumatic heart disease screening

Hunter, L D; Doubell, Anton; Pecoraro, Alfonso; Monaghan, Mark; Lloyd, Guy; Lombard, Carl; Herbst, Philip

doi:10.1111/echo.15039

Cited by 6 publications

(11 citation statements)

References 13 publications

(27 reference statements)

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“…Second, the MM criteria provide strict, echocardiographic definitions for leaflet restriction of the MV and AV. The most prominent is a novel definition that recognises subtle AMVL restriction, so-called CDT restriction 17. Third, the criterion of ‘excessive leaflet tip motion’ was not included in the MM assessment.…”

Section: Discussionmentioning

confidence: 99%

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Morpho-mechanistic screening criteria for the echocardiographic detection of rheumatic heart disease

Hunter

Doubell

Pecoraro

et al. 2023

Heart

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IntroductionScreening echocardiography, guided by the current World Heart Federation (WHF) criteria, has important limitations that impede the establishment of large-scale rheumatic heart disease (RHD) control programmes in endemic regions. The criteria misclassify a significant number of normal cases as borderline RHD. Prior attempts to simplify them are limited by incorporation bias due to the lack of an externally validated, accurate diagnostic test for RHD. We set out to assess novel screening criteria designed to avoid incorporation bias and to compare this against the performance of the current WHF criteria.MethodsThe performance of the WHF and the morpho-mechanistic (MM) RHD screening criteria (a novel set of screening criteria that evaluate leaflet morphology, motion and mechanism of regurgitation) as well as a simplified RHD MM ‘rule-out’ test (based on identifying a predefined sign of anterior mitral valve leaflet restriction for the mitral valve and any aortic regurgitation for the aortic valve) were assessed in two contrasting cohorts: first, a low-risk RHD cohort consisting of children with a very low-risk RHD profile. and second, a composite reference standard (CRS) RHD-positive cohort that was created using a composite of two criteria to ensure a cohort with the highest possible likelihood of RHD. Subjects included in this group required (1) proven, prior acute rheumatic fever and (2) current evidence of predefined valvular regurgitation on echocardiography.ResultsIn the low-risk RHD cohort (n=364), the screening specificities for detecting RHD of the MM and WHF criteria were 99.7% and 95.9%, respectively (p=0.0002). The MM rule-out test excluded 359/364 cases (98.6%). In the CRS RHD-positive cohort (n=65), the screening sensitivities for the detection of definite RHD by MM and WHF criteria were 92.4% and 89.2%, respectively (p=0.2231). The MM RHD rule-out test did not exclude any cases from the CRS RHD-positive cohort.ConclusionOur proposed MM approach showed an equal sensitivity to the WHF criteria but with significantly improved specificity. The MM RHD rule-out test excluded RHD-negative cases while identifying all cases within the CRS RHD-positive cohort. This holds promise for the development of a two-step RHD screening algorithm to enable task shifting in RHD endemic regions.

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Section: Discussionmentioning

confidence: 99%

“…All participants from the CRS RHD cohort underwent a comprehensive TTE study. All echocardiographic studies were performed by the primary investigator (LDH) using a predefined screening protocol that has been described previously17(see also online supplemental appendix).…”

Section: Methodsmentioning

confidence: 99%

Morpho-mechanistic screening criteria for the echocardiographic detection of rheumatic heart disease

Hunter

Doubell

Pecoraro

et al. 2023

Heart

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“…Given the magnitude of the difference in this finding, we consider that true differences in the populations studied are a less likely explanation than the variance in the definitions employed for identifying mild degrees of MV restriction, something we have strictly defined in our study. 17 Furthermore, when seen in chronic rheumatic disease, the criteria of excessive anterior MV leaflet tip motion and restricted posterior MV leaflet motion tend to describe the same mechanistic observation of ‘pseudoprolapse’ of the AMVL, the most frequently identified mechanism of RHD-related MR. 11 Here, the finding of excessive leaflet tip motion does not relate to true prolapse but rather describes cases where the tip of the AMVL appears to move excessively relative to a restricted PMVL tip. Importantly, in these cases, the AMVL tip remains well above the MV annulus.…”

Section: Discussionmentioning

confidence: 99%

“…Participants were screened with a portable handheld device [HH; General Electric (GE™) V-scan] using a pre-defined study protocol that has been previously described. 17 This was followed by a comprehensive validation TTE study using a GE™ Vivid I portable laptop machine with a 2- to 3.6-MHz transducer probe (GE™ 3S). The validation study was performed according to the current BSE guideline for a standard adult TTE.…”

Section: Methodsmentioning

confidence: 99%

Screening for subclinical rheumatic heart disease: addressing borderline disease in a real-world setting

Hunter

Pecoraro

Doubell

et al. 2021

European Heart Journal Open

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Introduction The World Heart Federation (WHF) criteria identify a large borderline rheumatic heart disease (RHD) category that has hampered the implementation of population-based screening. Inter-scallop separations (ISS) of the posterior mitral valve leaflet (PMVL), a recently described normal variant of the mitral valve, appears to be an important cause of mild mitral regurgitation (MR) leading to misclassification of cases as WHF ‘borderline RHD’. This study aims to report the findings of the Echo in Africa project (EIA), a large-scale RHD screening project in South Africa and determine what proportion of borderline cases would be re-classified as normal if there were a systematic identification of ISS-related MR. Methods A prospective cross-sectional study of underserved secondary schools in the Western Cape was conducted. Participants underwent a screening study with a handheld (HH) ultrasound device. Children with an abnormal HH study were re-evaluated with a portable laptop echocardiography machine. A mechanistic evaluation was applied in cases with isolated WHF ‘pathological’ MR (WHF ‘borderline RHD’). Results 5255 participants (mean age 15± years) were screened. 3439 (65.8%) were female. 49 cases of WHF ‘definite RHD’ (9.1 cases/1000 [95% CI, 6.8-12.1 cases/1000]) and 104 cases of WHF ‘borderline RHD’ (19.5 cases/1000[95% CI,16.0-23.7 cases/1000]) were identified. ISS-related MR was the underlying mechanism of MR in 48/68 cases classified as WHF ‘borderline RHD’ with isolated WHF ‘pathological’ MR (70.5%). Conclusion In a real-world, large-scale screening project, the adoption of a mechanistic evaluation based on the systematic identification of ISS-related MR markedly reduced the number of WHF ‘screen-positive’ cases misclassified as WHF ‘borderline RHD’. Implementing strategies that reduce this misclassification could reduce the cost- and labour-burden on large scale RHD screening programs.

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“…Enrolled patients underwent transthoracic echocardiography (TTE) with transoesophageal echocardiography (TEE) performed in patients without a contraindication for this procedure (26,27). In addition to a standard echocardiographic evaluation (26,27), a detailed assessment of the underlying heart and valvular structure, including an assessment for the presence of RHD, was performed (17,18,(28)(29)(30).…”

Section: Echocardiographic Evaluationmentioning

confidence: 99%

Early surgery determines prognosis in patients with infective endocarditis: outcome in patients managed by an Endocarditis Team—a prospective cohort study

Pecoraro¹,

Herbst²,

Janson³

et al. 2022

Cardiovasc Diagn Ther

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Background: Infective endocarditis (IE) in South Africa is associated with significant morbidity and mortality, despite occurring in younger patients with fewer co-morbidities. Possible contributors include the high rates of blood culture negative endocarditis, high rates of mechanical valve replacement and the lack of inter-disciplinary coordination during management. Methods:The Tygerberg Endocarditis Cohort (TEC) study prospectively enrolled patients with IE between November 2019 and April 2021. All patients were managed by an Endocarditis Team with a set protocol for organism detection and a strategy of early surgery limiting the use of prosthetic material.Results: Seventy-two consecutive patients with IE were included, with a causative organism identified in 86.1% of patients. The majority of patients had a guideline indication for surgery (n=58; 80.6%). The in-hospital mortality rate was 18%, with a 6-month mortality rate of 25.7%. Surgery was performed in 42 patients (58.3%), with prosthetic valve (PVE) replacement in 32 (76.2%), conventional repair surgery in 8 (19.1%) and mitral valve reconstruction in 2 (4.8%) of patients. Patients who underwent surgery had a significantly lower in-hospital (4.8% vs. 56.3%; P<0.01) and 6-month (4.9% vs. 75.0%; P<0.01) mortality rate as compared with patients with an indication for surgery who did not undergo surgery. Conclusions:We have observed a reduction in the 6-month mortality rate in patients with IE following the establishment of an Endocarditis Team, adhering to a set protocol for organism detection and favouring early repair or reconstruction surgery. Patients who underwent surgery had a significantly lower mortality rate than patients with an indication for surgery who did not undergo surgery. Preventable residual mortality was driven by surgical delay.

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The variable spectrum of anterior mitral valve leaflet restriction in rheumatic heart disease screening

Cited by 6 publications

References 13 publications

Morpho-mechanistic screening criteria for the echocardiographic detection of rheumatic heart disease

Morpho-mechanistic screening criteria for the echocardiographic detection of rheumatic heart disease

Screening for subclinical rheumatic heart disease: addressing borderline disease in a real-world setting

Early surgery determines prognosis in patients with infective endocarditis: outcome in patients managed by an Endocarditis Team—a prospective cohort study

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