“Rheumatic Heart Disease” by Emmanuel Rusingiza, MD, for OPENPediatrics

“Rheumatic Heart Disease” by Emmanuel Rusingiza, MD, for OPENPediatrics

Rheumatic Heart Disease, by Dr. Emmanuel Rusingiza. My name is Emmanuel Rusingiza. I’m a Pediatric
Cardiologist at Kigali University Teaching Hospital, Rwanda. I’m going to talk about the diagnosis
and management of rheumatic heart disease. Types of Valvular Diseases. Rheumatic heart disease is the result of damage
to the heart valve which appear after repeated episodes of acute rheumatic fever. Although
initial attacks can lead directly to rheumatic heart disease, early diagnosis of rheumatic
heart disease is very important. So that secondary prophylaxis can be started as soon as possible
to help prevent the progression of the valve disease. Echocardiography is an essential tool to confirm
the diagnosis and to detect any progression of the valvular disease. So now what are the types of rheumatic heart
disease? The types of valvular rheumatic heart disease are the following. The mitral valve
is the most affected in over 90% of cases of rheumatic heart disease. The next common
affected valve is the aortic valve. And usually disease of the aortic valve is associated
with the disease of the mitral valve. The tricuspid and pulmonary valves are rarely
directly affected. But the tricuspid regurgitation may appear in advanced mitral valve disease
especially when there is severe pulmonary hypertension. So the valvular lesions include the mitral
regurgitation, which is found most commonly in children and young adults. The mitral stenosis,
which represents longer term chronic changes to the mitral valve more commonly seen in
adults. All the children can present both mitral stenosis and mitral regurgitation.
Aortic regurgitation is not uncommon. And aortic stenosis is almost never seen as an
isolated lesion. Symptoms. The symptoms of rheumatic heart
disease depend on the valve lesion and it’s severity. Symptoms may not show for many years
until the valve disease becomes severe. Initial symptoms of rheumatic heart disease are the
symptoms of early heart failure, which are the breathlessness on exertion, general weakness,
cough, and sometimes hemoptysis based on the level of the pulmonary edema, orthopnea, paroxysmal
nocturnal dyspnea, peripheral edema, which can be generalized after awhile if there is
no intervention. Signs of chronic malnutrition may occur as complication due to long-term
heart condition. Specific symptoms include palpitations, in
case of atrial fibrillation, particularly with mitral stenosis. And in this case, there
is an associated risk of embolic events. Stroke, when there is cerebral embolism in case of
atrial fibrillation and/or effective endocarditis of the mitral or aortic valve, but also sometimes
severe mitral stenosis can cause stroke. People with aortic valve disease may experience syncope
in addition to heart failure symptoms. Physical Examination. Physical examination is a very important step.
And the clinical examination should include assessment of severity and complications,
including signs of heart failure, which are tachypnea, tachycardia, edema, raised jugular
venous pressure, hepatomegaly, lung crackles, and so on. The presence of atrial fibrillation
and the presence of stroke must be assessed as well. The auscultation for the mitral regurgitation
reveals a pansystolic murmur heard loudest at the apex and radiating laterally to the
axilla. [MITRAL REGURGITATION MURMUR] Mitral stenosis reveals a low-pitched diastolic
rumble heard the best at the apex. [MITRAL STENOSIS MURMUR] In case of aortic regurgitation, there is
a diastolic blowing decrescendo murmur best heard at the left sternal border with the
person sitting up. [AORTIC REGURGITATION MURMUR] In case of aortic stenosis, the murmur is
a loud, low-pitched, midsystolic ejection murmur best heard in the aortic area and radiating
to the neck. [AORTIC STENOSIS MURMUR] Investigations. The investigations include
electrocardiography, which is essential to determine the cardiac rhythm and other abnormal
patterns. Chest x-ray helps to assess the size of the heart chambers and to detect pulmonary
congestion. Echocardiography is here the gold standard exam. It confirms the diagnosis and
detects any rheumatic valve damage, helps determine its severity, and assesses left
ventricular function. Additional investigations include FBC, electrolytes,
especially sodium and potassium, renal function tests, and liver function tests. Let us insist
a little bit on the echocardiography. In 2011, the World Heart Federation has developed the
criteria to make echocardiography reporting simple, reproducible, and consistent worldwide. The echocardiographic criteria helps in screening
of rheumatic heart disease in schoolchildren. And it is based on morphologic features and
pathological regurgitation for the mitral and aortic valves. There are three diagnostic
possibilities based on the echocardiographic criteria, which are definite rheumatic heart
disease, borderline rheumatic heart disease, and normal valves. These are some few examples of echocardiography
images. This slide shows a parasternal access view, and you can see very well the left ventricle,
the left atrium, the aorta, the mitral valve. Here the mitral valve looks thickened, and
the anterior leaflet, especially on the tip, looks thickened. The posterior one looks retracted. This is a four-chamber view, or apex view,
which shows the thickness of the mitral leaflet and chordae. But mostly, you can see a significant
mitral regurgitation, which is posteriorly directed jet and typical for rheumatic valvular
disease. This slide shows the long axis view of the heart, which shows the thickness of
the mitral valve leaflets and the aortic leaflets. This patient presents severe mitral stenosis,
aortic regurgitation, and aortic stenosis. This is another image of long axis view, which
shows the Doppler on the aortic valve. And there you can see very well the jet of aortic
regurgitation in red. Management. The goal of the management of
rheumatic heart disease is to prevent disease progression and to avoid, or at least delay,
valve surgery. Secondary prophylaxis for prevention of recurrent acute rheumatic fever is the
main strategy. The key elements of the effective management
of rheumatic heart disease are initial assessment, education, and a referral to a medical or heart
specialist, if applies. In case of heart failure, it is recommended to admit the patient for
bed rest and treatment of heart failure with diuretics and ACE inhibitors. Management of atrial fibrillation with the
digoxin and anticoagulation. Regular medical and echocardiographic review. Secondary prophylaxis
is very important to prevent the recurrency of acute rheumatic fever, which come to damage
more the heart valves. The infective endocarditis prophylaxis is very important before dental
and surgical procedures. It is also needed to plan for regular dental care and also contraception,
especially for female adolescents. The complications of rheumatic heart disease
depend upon the affected valve. They are heart failure with severe pulmonary hypertension,
infective endocarditis, stroke, atrial fibrillation, chronic malnutrition, and ventricular dysfunction. The treatment of congestive heart failure
depends upon the nature of the valvular lesion. When it is due to severe mitral and aortic
regurgitation, it is important to admit the patient for bed rest, give heart failure medications,
but, also consider the nutritional support. When the heart failure is due to severe mitral
stenosis, the treatment is done by diuretics, beta blockers, depending upon the score, aspiring
to prevent intra-atrial thrombus and stroke. And the warfarin is absolutely indicated in
the case of atrial fibrillation. The indication for heart surgery is determined
by the severity of the symptoms, the evidence that the heart valves are significantly damaged,
the left ventricle chamber size, and the function. The types of valvular surgery include valvular
repair or valve replacement by either a prosthetic valve or a mechanical valve. Factors to absolute contraindication to valve
surgery are poor left ventricle function with valve regurgitation. Severe pulmonary hypertension
may pose an unacceptable risk for cardiac surgery. Good nutritional status improves
post-operative outcomes. Anticoagulation is indicated for patients who undergo valvular
replacement. The commonly used drug is Coumadin, or warfarin.
The treatment with warfarin needs to be monitored following replacement with mechanical valves.
Good anticoagulation management requires standardized anticoagulation measurement using the International
Normalized Ratio called INR. This table summarizes the indications, the
goal of INR, and the duration of anticoagulation therapy. As you can see, most of the goal
for INR is between 2.5 and 3.5. And when there is a mechanical valve, the direction of therapy
is lifelong. After cardiac surgery, it’s very important to plan regular long-term follow-up.
The conservative valve procedures, like valve repair, require close observation to detect
the re-stenosis or a recurrence of valvular regurgitation. Ensure a secondary prophylaxis is administered
regularly using benzathine penicillin G IM every three to four weeks to prevent recurrent
attacks by acute rheumatic fever. It is also important to monitor the left ventricle and
prosthetic function during the follow-up. Now, endocarditis prevention is another important
point, because infective endocarditis is a serious complication of rheumatic heart disease
and may also occur after heart valve surgery. This uncommonly occurs during dental and surgical
procedures. But often, the source of the infection is not clear. Infective endocarditis most
commonly occurs in the mitral or aortic valve, since these are the most commonly damaged
heart valves. Thank you for watching. Please help us improve the content by providing
us with some feedback.

28 Replies to ““Rheumatic Heart Disease” by Emmanuel Rusingiza, MD, for OPENPediatrics”

  1. Dear sir, i see u r video … its very useful.actually i also affect on Rheumatic Heart disease. in my 16 age…now i also take medicine pencilin injection….if i not take i have little pain of chest joints….

  2. i was take eco sice 2011… my reports…are
    Mitral valve doppler
    MVpeak A 0.80m/s
    MV E/A 1.36
    MVpeak E 1.09 m/s


  3. Hello sir!
    I am Anmol from India. Your upload and info was so helpful for me. As I am suffering from this disease since my early childhood days and since then the treatment is going on, now I am 25 yrs old. Last time when I visited my doc here in Apollo Hospital, Chennai (India) he said to operate and replace the valve but I denied to do so. Shall I go for it?… I know asking you from another said of the world will not make any sense but I am totally confused… Sir please comment down the needful help. Thank you

  4. Dr, thanks to your intervention you provide to children with heart diseases in general . God bless you and increase your knowledge and skills and force in that .

    me as UR/CMHS student I get more form your leaning Video and other leaning tools you give us.
    thanks so much

  5. Sir, I thanks that u uploaded ur vedeo, about Rheumatic heart deseases,..
    . Last weak my daughter rush to hospital, and some examination, is do for her, and the Result is, Rheumatic Heart diseases,, Sir I had a question, about thise,..
    "How long do medication for thise, Rheumatic Heart, DESEASES,. My daughter now she is 21years old,…
    Thanks you, Sir,

  6. thanks for the video about rhd Sir I had a question, about these,..
    "How long do medication for these, Rheumatic Heart, DESEASES,. My daughter now she is 33years old,…
    and had gone ptmc procedure
    Thanks you, Sir,

  7. I am 18 years old and RHD became an issue at age 16. Is there anything extra i should know? It has been weighing on my physical body and mind.

  8. i have reumaric heart disease i got it when i was 18 years old. now im 24… i only got a checked up to the doctor once since that i never return.

  9. I suffered with this for 25 years I had this when I was a child I've been taken la BP vicilon right up til I was 25 and now I'm all better now

  10. Hai sir.i Have rheumatic fever arthritis i was 8 years start. I now 29 year's. I have body pain problem everyday.

  11. I think he forgot to mention dat it usually occurs after throat infection especially after getting infected by streptococcus group A cocci….which is i think the first thing u should find out if a patient comes after an attack…..just my thoughts though….

  12. I have this when I was a kid up untill im 18yrs old. My last 2d echo was in 2014 my doctor said I was clear/curedb is there any chance that might back? Im 23yrs old now

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