Screening for asymptomatic rheumatic heart disease: Understanding the mechanisms key to the diagnostic criteria

Herbst, Philip

doi:10.24170/12-3-1716

Cited by 10 publications

(15 citation statements)

References 21 publications

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“…These terms are synonymous and generate the so-called AMVL 'pseudoprolapse' which cannot be regarded as true prolapse, as the AMVL is seen to be in its normal position at end-systole and does not cross the annular plane. 16 Pseudoprolapse of the AMVL generates the characteristic posteriorly directed jet of rheumatic MR with a similar broad Doppler jet exhibited on the optimised PSSAX view (online supplemental clips 5-7).…”

Section: Restricted Leaflet Motionmentioning

confidence: 94%

Interscallop separations of the posterior mitral valve leaflet: a solution to the ‘borderline RHD’ conundrum?

et al. 2020

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ObjectiveThe World Heart Federation (WHF) criteria incorporate a Doppler-based system to differentiate between ‘physiological’ and ‘pathological’ mitral regurgitation (MR)—a sole criterion sufficient for the diagnosis of WHF ‘borderline’ rheumatic heart disease (RHD). We have identified that interscallop separations (ISS) of the posterior mitral valve (MV) leaflet, can give rise to pathological MR in an otherwise-normal MV. We aimed to establish and compare the prevalence of ISS-related MR among South African children at high and low risk for RHD.MethodsA prospective cross-sectional echocardiographic study of 759 school children (aged 13–18) was performed. Cases with MR≥1.5 cm underwent a second comprehensive study to determine the prevalence of RHD according to the WHF guideline and establish the underlying mechanism of MR.ResultsOf 400 high-risk children, two met criteria for ‘definite RHD’ (5 per 1000 (95% CI 1.4 to 18.0); p=0.5) and 11 for ‘borderline RHD’ (27.5 per 1000 (95% CI 15.4 to 48.6)). Of 359 low-risk children, 14 met criteria for borderline RHD (39 per 1000 (95% CI 23.4 to 64.4)). Comprehensive echocardiography identified an underlying ISS as the mechanism of isolated pathological MR in 10 (83.3%) high-risk children and 11 low-risk children (78.5%; p>0.99).ConclusionsISS are a ubiquitous finding among South African schoolchildren from all risk profiles and are regularly identified as the underlying mechanism of WHF pathological MR in borderline RHD cases. A detailed MV assessment with an emphasis on ascertaining the underlying mechanism of dysfunction could reduce the reported numbers of screened cases misclassified as borderline RHD.

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Section: Restricted Leaflet Motionmentioning

confidence: 94%

Interscallop separations of the posterior mitral valve leaflet: a solution to the ‘borderline RHD’ conundrum?

et al. 2020

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“…Although echocardiography is presently the most discriminating tool, a deeper understanding of the disease mechanisms that underlie morphological changes will no doubt facilitate a more rational diagnostic criteria. [68]…”

Section: Problems With Echocardiographic Screening For Rheumatic Hearmentioning

confidence: 99%

“…It is, however, unclear at this stage that the group with isolated morphological change is insignificant and can be ignored. [68] The original WHO Doppler-only criteria were derived from criteria designed to diagnose acute rheumatic carditis during episodes of ARF by differentiating functional from pathological regurgitation and ignored morphological valvular changes that characterize more chronic rheumatic cardiac involvement. [357980] Marijon et al .…”

Section: Problems With Echocardiographic Screening For Rheumatic Hearmentioning

confidence: 99%

Rheumatic heart disease screening

Dougherty

Khorsandi

Herbst

2017

Annals of Pediatric Cardiology

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Rheumatic heart disease (RHD) is a disease of poverty, is almost entirely preventable, and is the most common cardiovascular disease worldwide in those under 25 years. RHD is caused by acute rheumatic fever (ARF) which typically results in cumulative valvular lesions that may present clinically after a number of years of subclinical disease. Therapeutic interventions, therefore, typically focus on preventing subsequent ARF episodes (with penicillin prophylaxis). However, not all patients with ARF develop symptoms and not all symptomatic cases present to a physician or are correctly diagnosed. Therefore, if we hope to control ARF and RHD at the population level, we need a more reliable discriminator of subclinical disease. Recent studies have examined the utility of echocardiographic screening, which is far superior to auscultation at detecting RHD. However, there are many concerns surrounding this approach. Despite the introduction of the World Heart Federation diagnostic criteria in 2012, we still do not really know what constitutes the most subtle changes of RHD by echocardiography. This poses serious problems regarding whom to treat and what to do with the rest, both important decisions with widespread implications for already stretched health-care systems. In addition, issues ranging from improving the uptake of penicillin prophylaxis in ARF/RHD-positive patients, improving portable echocardiographic equipment, understanding the natural history of subclinical RHD and how it might respond to penicillin, and developing simplified diagnostic criteria that can be applied by nonexperts, all need to be effectively tackled before routine widespread screening for RHD can be endorsed.

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“…However, the criteria are potentially weakened by the incorporation of a non-specific Doppler-based evaluation of regurgitant valvular lesions that could erroneously include cases with ‘congenital MR’ into the ‘borderline RHD’ group ( 4 , 5 , 6 , 7 ).…”

Section: Introductionmentioning

confidence: 99%

“…A large-scale RHD screening program in both high- and low-risk RHD communities in the Western Cape, South Africa (unpublished data from the Echo in Africa (EIA) program) has identified that a normal variant of the posterior mitral valve leaflet (PMVL) – so-called ‘prominent posterior leaflet inter-scallop separation’ ( 5 ) – may be responsible for a proportion of screened cases identified as ‘borderline RHD’ with isolated WHF ‘pathological’ MR.…”

Section: Introductionmentioning

confidence: 99%

Inter-scallop separations of the posterior leaflet of the mitral valve: an important cause of ‘pathological’ mitral regurgitation in rheumatic heart disease screening

et al. 2018

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SummaryThe 2012 World Heart Federation (WHF) criteria for echocardiographic diagnosis of rheumatic heart disease (RHD) identify that the finding of ‘pathological’ mitral regurgitation (MR) in a screened individual increases the likelihood of detecting underlying RHD. Cases of isolated ‘pathological MR’ are thus identified as ‘borderline RHD’. A large-scale echocardiographic screening program (Echo in Africa) in South Africa has identified that inter-scallop separations of the posterior mitral valve leaflet (PMVL) can give rise to ‘pathological’ MR. The authors propose that this entity in isolation should be identified and excluded from the WHF ‘borderline RHD’ category. In this case report, we present two examples of ‘pathological’ MR related to inter-scallop separation from the Echo in Africa image database. We further provide screening tips for the accurate identification of this entity.

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Screening for asymptomatic rheumatic heart disease: Understanding the mechanisms key to the diagnostic criteria

Abstract: SCREENING FOR RHEUMATIC HEART DISEASEThe burden of rheumatic heart disease (RHD) remains unacceptably high in the third world, including Sub-Saharan Africa.

Cited by 10 publications

References 21 publications

Interscallop separations of the posterior mitral valve leaflet: a solution to the ‘borderline RHD’ conundrum?

Interscallop separations of the posterior mitral valve leaflet: a solution to the ‘borderline RHD’ conundrum?

Rheumatic heart disease screening

Inter-scallop separations of the posterior leaflet of the mitral valve: an important cause of ‘pathological’ mitral regurgitation in rheumatic heart disease screening

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