Preoperative and operative assessment of the 367 patients operated on for rheumatic mitral stenosis with closed mitral commissurotomy (CMC) at the regional hospital in Archangel, northwest Russia, between 1965 and 1993.
Mean age at first attack of rheumatic fever was 15 years +/- 1.09 years. Mean age at time of surgery was 33.4 years +/- 0.92. Preoperatively, most patients (67%, n = 245) were in New York Heart Association stage III; 29% (n = 107) in stage IV. Digital commissurotomy alone was performed in 16% (n = 57) and a transventricular dilator was used in 84% (n = 310). Operative blood loss was average (384.4 ml +/- 34 ml); 20% (n = 73) developed wound infection, 21% (n = 77) pericarditis. In-hospital stay was above 50 days for both sexes. In-hospital mortality was 1.6% (n = 6).
Rheumatic heart disease developed rapidly in these patients. CMC has a place as a low cost treatment of mitral stenosis when a heart lung machine is not available.
Mitral valve disease (MVD) is a significant clinical problem that is becoming more common in the 21st century. The pathogenesis of MVD seems to be changing and is not well understood.
The present study details the morphological findings in 192 native mitral valves excised over a one-year period at the Toronto General Hospital, Toronto, Ontario. The mean patient age was 59.7+/-12.3 years at operation.
There were 106 men (55.2%) and 86 women (44.8%) in the present study. The most frequent changes in the surgically excised valvular leaflets were fibrosis (78.6%) and thickening (66.2%). Fusion (32.3%) and calcification (25.2%) were common changes at the commissures. Chordae tendineae most often showed evidence of thickening (47.9%) and fibrosis (37.0%). In total, 110 valves showed mitral incompetence (57.3%), 72 showed mitral stenosis (37.5%), and 10 showed a combination of stenosis and incompetence (5.2%).
In the present series, MVD was most frequently caused by postinflammatory (rheumatic) valve disease (RVD) (35.9%), followed by myxomatous degeneration (33.3%). Patients with RVD were usually female (66.7%), while those with myxomatous degeneration were more likely to be male (76.6%). RVD remains a significant problem even though the incidence of acute rheumatic fever with cardiac involvement has declined in Canada. This most likely reflects the current sociodemographic composition of the referral population.
Cites: Am Fam Physician. 2000 Jun 1;61(11):3343-50, 3353-410865929
296 patients who were operated between 1965 and 1993 with mitral commissurotomy, were included in this retrospective study of rheumatic heart disease in North-West Russia. There were 117 (39.5%) reported cases of acute rheumatic fever, with either polyarthritis (n = 88), carditis (n = 23), or Sydenham's chorea (n = 6). There were no reported cases of erythema marginatum and subcutaneous nodules. The first case of acute rheumatic fever in our patients was in 1924. More than 50% of the patients (164) did not get the diagnosis acute rheumatic fever, and became aware of their rheumatic heart disease only when symptoms of mitral stenosis appeared. 15 patients had a subclinical attack of rheumatic fever, i.e. not all of Jones' criteria were fulfilled. At onset of acute rheumatic fever, the mean age was 15 years, when valvular disease was confirmed 24 years, and 33 years at mitral surgery. Dyspnea (n = 293) was the most common symptom of mitral stenosis, followed by atrial fibrillation (n = 105). 15 patients developed cerebral stroke. The Archangel Health Region has one of the highest prevalences of rheumatic heart disease in Europe (3.7/1,000 in those above 16 years of age, 1993). There is high mortality and the disease develops rapidly.