Rheumatic Heart Disease Worldwide

Trends in infective endocarditis over two decades in a Thai tertiary care setting

Infective endocarditis (IE) is a serious condition with high morbidity and mortality. This retrospective cohort study evaluated the evolution of clinical characteristics, microbiological profiles, and treatment outcomes in 435 Thai IE patients, spanning three distinct periods, at a Chiang Mai tertiary-care hospital. Patients were categorized into three timeframes: 1998-2001 (n = 134), 2012-2015 (n = 117), and 2016-2020 (n = 184). The median patient age significantly increased from 42 years (IQR 34-51) to 58 years (IQR 44-65) (p = 0.003). The study also identified an increased prevalence of co-morbidities in recent years. Notably, there was a marked decrease in the prevalence of rheumatic heart disease, from 23.1 to 10.9% (p = 0.009). Streptococcus suis is a unique and increasingly prevalent cause of IE in northern Thailand. Additionally, the rate of culture-negative IE declined from 38.1 to 23.9% (p = 0.018). Surgical interventions increased from 52.2 to 64.1% (p = 0.072), while the median time to surgery remained constant at 12 days. Despite advancements in diagnosis and treatment, the length of hospitalization remained stable throughout the study periods, and the in-hospital mortality rate consistently stayed at 18.6%. This study highlights significant shifts in the epidemiology and management of IE, indicating persistent challenges in reducing mortality despite improved care.

Serum midkine level and its association with subclinical coronary artery calcification and carotid atherosclerosis in chronic kidney disease

BACKGROUND

There are no studies investigating the role of midkine (MK) in vascular calcification (VC) or vascular disease associated with chronic kidney disease (CKD). This study assessed serum MK level and investigated its relationship with carotid atherosclerosis and coronary artery calcification (CAC) in non-dialysis CKD.

METHODS

The study comprised 80 controls and 185 adult patients with CKD at stages 3-5 who were free of cardiovascular diseases. Acute renal failure, chronic hemodialysis, severe liver disease, inflammatory states, anticoagulation therapy and cancer were excluded. The patients were classified based on presence of CAC score into severe and mild to moderate CAC groups. They were also divided into atherosclerotic and non-atherosclerotic groups based on carotid atherosclerosis. CBC, kidney function tests, lipid profile, intact parathyroid hormone (iPTH), and phosphorus were assessed. Serum levels of MK, tumor necrosis factor- α (TNF- α), interleukin-6 (IL-6), and high-sensitivity C-reactive protein (hs-CRP) were quantitatively tested using ELISA. Cardiac CT scan was done to calculate CAC score. Carotid ultrasonography was used to evaluate carotid intima media thickness (CIMT) and identify plaques.

RESULTS

All CKD categories, including CKD-3, CKD-4, and CKD-5, showed higher rates of carotid plaques (p = 0.007, p < 0.001, and p < 0.001, respectively), higher levels of MK (p < 0.001 for each), and higher CAC scores (p < 0.001 for each) as CKD worsened. Compared to mild to moderate CAC patients, severe CAC patients showed increased CIMT (p < 0.001) and raised serum levels of MK (p < 0.001), TNF-α (p = 0.001), IL-6 (p = 0.002), hs-CRP (p = 0.003), iPTH (p = 0.02), phosphorus (p < 0.001), total cholesterol (TC), and low density lipoprotein-cholesterol (LDL-C). Multivariate linear regression revealed that CAC was reliably predicted by MK (p = 0.008) and serum creatinine (p = 0.001). Carotid atherosclerotic patients had higher serum levels of MK, TNF-α, IL-6, hs-CRP, iPTH, phosphorus, TC, total triglycerides and LDL-C (p < 0.001 for each). Multivariate logistic regression showed that serum MK (p = 0.001), serum creatinine (p = 0.005), age (p < 0.001), iPTH (p = 0.007), and IL-6 (p = 0.024) were significant predictors of carotid atherosclerosis.

CONCLUSIONS

As CKD worsened, MK levels, carotid atherosclerosis and CAC increased. Serum MK was a reliable biomarker for asymptomatic carotid atherosclerosis and CAC in non-dialysis CKD, allowing prompt early diagnosis to avert cardiovascular morbidity and death in the future.

TRIAL REGISTRATION

The trial number was 1138 and its registration was approved by the hospital's Research Ethics Committee in 4/2024.

Age Differences in Aortic Stenosis

Aortic stenosis (AS) is a significant and growing concern, with a prevalence of 2-3% in individuals aged over 65 years. Moreover, with an aging global population, the prevalence is anticipated to double by 2050. Indeed, AS can arise from various etiologies, including calcific trileaflets, congenital valve abnormalities (e.g., bicuspid and unicuspid valves), and post-rheumatic, whereby each has a distinct influence that shapes the onset and progression of the disease. The normal aortic valve has a trilaminar structure comprising the fibrosa, spongiosa, and ventricularis, which work together to maintain its function. In calcific AS, the disease begins with early calcification starting in high mechanical stress areas of the valve and progresses slowly over decades, eventually leading to extensive calcification resulting in impaired valve function. This process involves mechanisms similar to atherosclerosis, including lipid deposition, chronic inflammation, and mineralization. The progression of calcific AS is strongly associated with aging, with additional risk factors including male gender, smoking, dyslipidemia, and metabolic syndrome exacerbating the condition. Conversely, congenital forms of AS, such as bicuspid and unicuspid aortic valves, result in an earlier disease onset, typically 10-20 years earlier than that observed in patients with a normal tricuspid aortic valve. Rheumatic AS, although less common in developed countries due to effective antibiotic treatments, also exhibits age-related characteristics, with an earlier onset in individuals who experienced rheumatic fever in their youth. The only curative therapies currently available are surgical and transcatheter aortic valve replacement (TAVR). However, these options are sometimes too invasive for older patients; thus, management of AS, particularly in older patients, requires a comprehensive approach that considers age, disease severity, comorbidities, frailty, and each patient's individual needs. Although the valves used in TAVR demonstrate promising midterm durability, long-term data are still required, especially when used in younger individuals, usually with low surgical risk. Moreover, understanding the causes and mechanisms of structural valve deterioration is crucial for appropriate treatment selections, including valve selection and pharmacological therapy, since this knowledge is essential for optimizing the lifelong management of AS.

Mapping Current Studies of tRNA Fragments onto Disease Landscape

Transfer-RNA-derived fragments (tRFs) are a relatively recently discovered class of non-coding RNAs derived from both precursor and mature transfer RNAs (tRNAs). Research on these molecules has been expanding rapidly, revealing their diverse roles in cellular processes, both in normal physiology and in disease states, often via post-transcriptional regulation of target genes. Altered tRFs abundances have been implicated in various conditions, where they may act as either drivers of disease progression or as protective agents. For instance, specific tRFs are associated with increased risk for cancer metastasis, while others may suppress tumor cell proliferation. Despite the growing recognition of tRFs as functional RNAs rather than sequencing noise, this field of study faces numerous challenges. Inconsistent naming conventions and variability in experimental approaches hinder the comparison of findings across studies, limiting our understanding of the common roles and mechanisms of tRFs. This review provides a comprehensive analysis of current literature on the various roles of tRFs in different diseases, particularly focusing on four broad areas: cancer, neurological, cardiovascular, and musculoskeletal disorders. We analyze studies that link specific tRFs to various aspects of human diseases and provide a convenient classification of these studies regarding the depth of the provided evidence. Further, we note gaps in current investigations and consider strategies to address methodological inconsistencies, including validation experiments and unified nomenclature. By consolidating research in this manner, we aim to facilitate comparisons across diverse studies, enhancing our ability to identify functional commonalities and furthering our understanding of the mechanisms by which tRFs act.

Heart failure in low-income and middle-income countries

Heart failure (HF) is a complex syndrome which leads to significant morbidity and mortality, poor quality of life and extremely high costs to healthcare systems worldwide. Although progress in the management of HF in high-income countries is leading to an overall reduction in the incidence and mortality of HF, there is a starkly different scenario in low- and middle-income countries (LMICs). There is a substantial lack of data on HF in LMICs, as well as a scarcity of diagnostic tools, limited availability and affordability of healthcare and high burdens of cardiovascular risk factors and communicable diseases. Patients in this setting present with more advanced HF at much younger ages and are, more often, women. In this review, we aim to comprehensively describe the burden of HF from an LMIC perspective, based on the more recent available data. We summarise the major causes of HF that are endemic in these regions, including hypertension, cardiomyopathy, rheumatic heart disease, HIV-associated heart disease and endomyocardial fibrosis. Finally, we discuss the challenges faced by the least developed health systems and highlight interventions that may prove to be more efficient in changing the paradigm of HF of the more vulnerable populations.

Rheumatic heart valve disease: navigating the challenges of an overlooked autoimmune disorder

Despite being a leading cause of morbidity and mortality among young people, affecting predominantly women, rheumatic heart disease (RHD) remains neglected and understudied. This autoimmune condition arises from a complex continuum that begins with repeated Group A Streptococcal (GAS) pharyngitis, leading to acute rheumatic fever (ARF) that eventually results in damage to the heart, mainly affecting the mitral valve. While RHD has been nearly eradicated in high-income countries, it continues to be a significant and active health issue in low- and middle-income countries. The resolution of this disease faces several challenges, including the difficulty of diagnosis and the lack of access to preventive measures in resource-poor communities. Addressing these issues will require a global health collaboration involving healthcare professionals, policymakers, and advocacy groups. However, over the past two decades, there has been a revival of scientific interest, fostering optimism for the future. Recent research has significantly advanced our understanding of RHD, shedding light on the immune-to-autoimmune transition, neoangiogenesis, and lymphangiogenesis processes. Additionally, perspectives of discoveries in biomarkers and the development of genetic, transcriptomic, and provide a solid foundation for further advancements in the field.

Unveiling the Group A Streptococcus Vaccine-Based L-Rhamnose from Backbone of Group A Carbohydrate: Current Insight Against Acute Rheumatic Fever to Reduce the Global Burden of Rheumatic Heart Disease

Group A Streptococcus (GAS) is a widely distributed bacterium that is Gram-positive and serves as the primary cause of acute rheumatic fever (ARF) episodes. Rheumatic heart disease (RHD) is a sequela resulting from repeated ARF attacks which are also caused by repeated GAS infections. ARF/RHD morbidity and mortality rates are incredibly high in low- and middle-income countries. This is closely related to poor levels of sanitation which causes the enhanced incidence of GAS infections. Management of carditis in RHD cases is quite challenging, particularly in developing countries, considering that medical treatment is only palliative, while definitive treatment often requires more invasive procedures with high costs. Preventive action through vaccination against GAS infection is one of the most effective steps as a solution in reducing RHD morbidity and mortality due to curative treatments are expensive. Various developments of M-protein-based GAS vaccines have been carried out over the last few decades and have recently begun to enter the clinical stage. Nevertheless, this vaccination generates cross-reactive antibodies that might trigger ARF assaults as a result of the resemblance between the M-protein structure and proteins found in many human tissues. Consequently, the development of a vaccine utilizing L-Rhamnose derived from the poly-rhamnose backbone of Group A Carbohydrate (GAC) commenced. The L-Rhamnose-based vaccine was chosen due to the absence of the Rhamnose biosynthesis pathway in mammalian cells including humans thus this molecule is not found in any body tissue. Recent pre-clinical studies reveal that L-Rhamnose-based vaccines provide a protective effect by increasing IgG antibody titers without causing cross-reactive antibodies in test animal tissue. These findings demonstrate that the L-Rhamnose-based vaccine possesses strong immunogenicity, which effectively protects against GAS infection while maintaining a significantly higher degree of safety.

Fetuin-A as a plausible biomarker for cardiac valve calcification in rheumatic heart disease patients from North India

BackgroundRheumatic heart disease (RHD) remains a persistent public health challenge, particularly prevalent in developing and underdeveloped regions despite concerted global eradication efforts. The progressive stage of RHD, marked by valvular calcification, necessitates the imperative need to identify prognostic biomarkers. Fetuin-A, well-known for its role as a negative inhibitor of ectopic calcification, is investigated in our study as a potential biomarker for cardiac valve calcification in RHD patients.MethodsIndividuals with confirmed presence of RHD via echocardiography, who exhibited moderate to severe cardiac valve involvement, were enrolled alongside age and sex-matched healthy controls. Enzyme Linked Immunosorbent Assay was performed to analyse serum concentration of fetuin-A in healthy controls and RHD patients. Cytokine profiling was carried out using Cytometric Bead Array.ResultsSixty confirmed RHD patients along with age and sex-matched case-control were evaluated for their serum fetuin-A and serum cytokines levels. Our findings reveal significantly reduced serum fetuin-A levels in RHD patients (1.96 ± 0.608 ng/ml) compared to healthy controls (2.85 ± 0.55 ng/ml) (p < 0.0001). Cytokine profiling shows nearly two-fold elevations in interleukin (IL)-17A, tumor necrosis factor-alpha (TNF-α), interferon-gamma (IFN-γ), IL-6, IL-10, IL-4 and IL-2 levels among RHD patients versus healthy controls, with IL-6 showing the maximum elevation in serum concentration. Pearson's correlation coefficient (r) values indicate a strong negative correlation between fetuin-A levels in RHD patients and various inflammatory cytokines, including IL-17A (-0.9754), IFN-γ (-0.8142), TNF-α (-0.8281), IL-10 (-0.9183), IL-6 (-0.8479), IL-4 (-0.9182) and IL-2 (-0.9430) (p < 0.05, statistically significant).ConclusionThis study suggests that fetuin-A can be explored as a plausible biomarker for cardiac valve calcification and has an inverse correlation with inflammatory cytokines involved in RHD.

NEARER SCAN (LENO BESIK) evaluation of a task-sharing echocardiographic active case finding programme for rheumatic heart disease in Australia and Timor-Leste: protocol for a hybrid type II effectiveness-implementation study

INTRODUCTION

Rheumatic heart disease (RHD) is underdiagnosed globally resulting in missed treatment opportunities and adverse clinical outcomes. We describe the protocol for a study which aims to co-design, implement and conduct an evaluation of a task-sharing approach to echocardiographic active case finding for early detection and management of RHD in high-risk settings in Australia and Timor-Leste.

METHODS AND ANALYSIS

Echocardiograms will be obtained by trained local staff using hand-held echocardiographic devices employing the 'Single Parasternal Long Axis view with a Sweep of the Heart' (SPLASH) technique and interpreted by experts remote from the site of acquisition. Approximately 1500 children and pregnant women will be screened across high-risk communities in Australia and Timor-Leste over an 18-month period. The study will use a type II effectiveness-implementation hybrid design. A tailored package of implementation strategies will be co-designed with communities and health services and mapped onto a Theory of Change framework. The clinical effectiveness will be assessed as the change in the proportion of the target population that are prescribed secondary prophylaxis for RHD by the end of the study compared with baseline. The implementation will be assessed as the adoption, penetration, sustainability, fidelity and cost of the programme with a mixed-methods theory-based and economic evaluation. Data will include numbers of normal, abnormal and uninterpretable SPLASH echocardiograms obtained, numbers of participants progressing through the cascade of care, interviews with staff and programme costs.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research, Darwin (HREC-2022-4479), the Western Australian Aboriginal Health Ethics Committee (HREC-1237) and the Instituto Nasional Saude Publika Timor-Leste Ethics and Technical Committee (03-UEPD/INSP-TL/V/2023). Informed consent is required to be enrolled. Study findings will be disseminated in the communities involved and submitted for publication.

TRIAL REGISTRATION NUMBER

NCT06002243.

Role of Multimodality Images to Diagnose and Follow-Up Recurrent Rheumatic Myocarditis

Rheumatic heart disease is an immune disorder that may occur as a complication of rheumatic fever. Diagnosing the reactivation of rheumatic carditis is a challenge, particularly in older individuals. We report a 43-year-old woman who experienced recurrent rheumatic myocarditis. The diagnosis, treatment, and follow-up were enabled by the use of multimodal imaging techniques.

Preintervention Wait Time and Survival in People With Rheumatic Heart Disease in Uganda

BACKGROUND

There is an unmet surgical burden among people living with rheumatic heart disease (RHD) in Uganda. Nevertheless, risk factors associated with time to first intervention and preoperative mortality are poorly understood.

METHODS

Individuals with RHD who met indications for valve surgery were identified using the Uganda National RHD Registry (January 2010-August 2022). Kaplan-Meier estimates and multivariable Cox proportional hazard models were used.

RESULTS

Of the cohort with clinical RHD, 64% (1452 of 2269) met criteria for an index operation. Of those, 13.5% obtained a surgical intervention, whereas 30.6% died before the operation. The estimated likelihood of first operation was 50% at 9.3 years of follow-up (95% CI, 8.1-upper limit not reached). Intervention was more likely in men vs women (hazard ratio [HR], 1.78; 95% CI, 1.21-2.64), those with postsecondary education vs primary school or less (HR, 3.60; 95% CI, 1.88-6.89), and those with a history of atrial fibrillation (HR, 2.78; 95% CI, 1.63-4.76). Surgical intervention was less likely for adults vs those aged <18 years (HR, 0.49; 95% CI, 0.32-0.77) and those with New York Heart Association Functional Class III/IV vs I/II (HR, 0.51; 95% CI, 0.32-0.83). The median preoperative survival time among those awaiting first operation was 4.6 years (95% CI, 3.9-5.7 years). History of infective endocarditis, right ventricular dysfunction, pericardial effusion, atrial fibrillation, and having surgical indications for multiple valves were associated with increased probability of death.

CONCLUSIONS

Our analysis revealed a prolonged time to first surgical intervention and high preintervention death for RHD in Uganda, with factors such as age, sex, and education level remaining barriers to obtaining surgery.

Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA)

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based nongovernmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Challenges and Priorities for Children With Congenital Valvar Heart Disease: The Heart Valve Collaboratory

The Heart Valve Collaboratory is a multidisciplinary, patient-centered community of stakeholders addressing complex problems and embracing innovation to help patients with heart valve disease achieve their fullest potential for health. The Scientific Council is composed of cardiologists, surgeons, ex-officio representatives of the Food and Drug Administration and Centers for Medicare and Medicaid Services, National Heart Lung Blood Institute, and representatives from industry partners. In October 2022, this group convened a workshop that included experts from stakeholder groups to address the unmet and clinical needs of patients with pediatric and congenital heart valve disease. The following document includes the discussion and summary of the current state of valve therapy and the needs being addressed for valve development.

Rheumatic heart disease manifesting as mitral stenosis and tricuspid regurgitation in a young Asian male: a case report

Background

Rheumatic heart disease (RHD) is a major global health issue because of its potential to cause heart failure. While RHD has been reported more frequently in women, this case report highlights the clinical manifestations, diagnosis, and management of rheumatic multivalvular disease in a young Asian male.

Case summary

A 46-year-old Asian man with a history of percutaneous mitral valvuloplasty (PMV) was admitted with dyspnoea and generalized oedema that severely hindered his quality of life. Transthoracic and transoesophageal echocardiography revealed severe mitral stenosis, left atrial appendage (LAA) thrombus, and severe tricuspid regurgitation due to RHD. Following a comprehensive evaluation by a multidisciplinary team, we advised mitral valve replacement, LAA thrombectomy, and tricuspid valve annuloplasty based on the detailed imaging of the valve anatomy and the patient's low surgical risk. Surgical intervention led to considerable improvement in the patient's symptoms, enabling a return to routine activities.

Discussion

This case highlights the chronic nature of RHD and its potential to cause heart failure. This report emphasizes the need for regular follow-up in patients with a history of RHD to detect potential complications and ensure timely management. The successful outcome in this case underscores the importance of a team-based approach for managing complex valvular heart disease.

Optimizing Anticoagulation in Valvular Heart Disease: Navigating NOACs and VKAs

BACKGROUND/OBJECTIVES

Non-vitamin K antagonist oral anticoagulants (NOACs) have demonstrated similar effectiveness and safety profiles to vitamin K antagonists (VKAs) in treating nonvalvular atrial fibrillation (AF). Given their favorable pharmacological profile, including the rapid onset and offset of action, fixed dosing, and predictable pharmacokinetics with a consistent dose-response relationship, reducing the need for frequent blood tests, researchers have investigated the potential of NOACs in patients with AF and valvular heart disease (VHD).

METHODS

Clinical trials, excluding patients with mechanical prosthetic valves or moderate/severe mitral stenosis, have shown the benefits of NOACs over VKAs in this population. However, there is a need for further research to determine if these findings apply to mechanical valve prostheses and NOACs.

RESULTS

Several ongoing randomized controlled trials are underway to provide more definitive evidence regarding NOAC treatment in moderate to severe rheumatic mitral stenosis. Importantly, recent trials that included patients with atrial fibrillation and bioprosthetic valves (also transcatheter heart valves) have provided evidence supporting the safety of NOACs in this specific patient population. Ongoing research aims to clearly define the specific scenarios where NOACs can be safely and effectively prescribed for various types of VHD, including moderate/severe mitral stenosis and mechanical valves.

CONCLUSIONS

The aim of this review is to accurately identify the specific situations in which NOACs can be prescribed in patients with VHD, with a focus centered on each type of valvulopathy.

Making a Difference: 5 Years of Cardiac Surgery Intersociety Alliance (CSIA)

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Socio-economic determinants influencing adherence to secondary prophylaxis in patients with rheumatic heart disease: a systematic review

Introduction

Rheumatic heart disease (RHD) poses a substantial global health challenge, especially impacting resource-limited nations, with over 40.5 million cases reported in 2019. The crucial role of Benzathine penicillin G in both primary and secondary prevention, particularly the latter, emphasizes its significance.

Method

Following PRISMA guidelines, our systematic review explored Medline, Scopus, Google Scholar, and Embase databases from 1990 to 2022. Registered with PROSPERO ), the review utilized quality appraisal tools, including the PRISMA checklist, Cochrane bias tool and Newcastle-Ottawa scale. The objective was to identify and stratify the impact of socio-economic factors on adherence to secondary prophylaxis in RHD.

Results and discussion

The impact of education on adherence has been found to be significant. Socially disadvantaged environments significantly influenced adherence, shaped by education, socio-economic status, and geographical location and access to healthcare. Surprisingly, lower education levels were associated with better adherence in certain cases. Factors contributing to decreased adherence included forgetfulness, injection-related fears, and healthcare provider-related issues. Conversely, higher adherence correlated with younger age, latent disease onset, increased healthcare resources, and easy access.

Conclusion

Patient education and awareness were crucial for improving adherence. Structured frameworks, community initiatives, and outreach healthcare programs were identified as essential in overcoming barriers to secondary prophylaxis. Taking active steps to address obstacles like long-distance commute, waiting time, injection fears, and financial issues has the potential to greatly improve adherence. This, in turn, can lead to a more effective prevention of complications associated with RHD.

Lateral medullary syndrome resulting from atrial fibrillation due to rheumatic heart disease: A case report and literature review

Lateral medullary syndrome, resulting from cerebellar/brainstem infarction, can occur due to cardioembolic stroke from atrial fibrillation caused by rheumatic heart disease. This rare association highlights the importance of strict arrhythmia management, prophylactic anticoagulation, and timely diagnosis to prevent debilitating neurological outcomes.

Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA)

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA)

SUMMARY

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, it's 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Trends in cardiovascular disease among Inuit in Greenland from 1994 to 2021

Background and aims

Cardiovascular disease (CVD) poses significant health challenges globally. While substantial data exists for most populations, the Arctic Inuit's CVD incidence rates remain understudied. This research aimed to change this by estimating CVD incidence and mortality rates in Greenland from 1994 to 2021.

Methods

Using nationwide registers, a retrospective observational study was conducted, focusing on individuals born in Greenland to Greenlandic-born parents. Data were sourced from the Greenlandic Hospital Discharge Register and the nationwide electronic medical record.

Results

A total of 65,824 individuals were included. the age- and sex-specific incidence rates (IR) of ischemic heart disease, stroke, and heart failure (HF) declined from 1994 to 2021, with the most substantial decline observed for HF among women. Conversely, the IR of atrial fibrillation/flutter increased in both men and women, while the IR of myocardial infarction rose among men. The IR for stroke was particularly elevated compared to other CVD subgroups. Mortality rates for those diagnosed with CVD were 2.4 times higher than those without. Men exhibited a 40 % elevated mortality risk relative to women.

Conclusion

The study provides pivotal insights into CVD trends within the Arctic Inuit population, highlighting both positive developments and areas of concern. Given the increasing elderly demographic in Greenland, proactive health strategies are crucial. Emphasizing primary prevention and addressing specific CVD risks, particularly the elevated stroke IR, is imperative for future public health efforts.

Precision Medicine in Congenital Heart Disease, Rheumatic Heart Disease, and Kawasaki Disease of Children: An Overview of Literature

Congenital heart disease and common acquired heart diseases like Kawasaki disease and rheumatic heart disease are prevalent cardiovascular conditions in children worldwide. Despite the availability of treatment options, they continue to be significant contributors to morbidity and mortality. Advancements in early diagnosis, improvements in treatment approaches, and overcoming resistance to available treatments are crucial to reduce morbidity. Researchers have turned to precision medicine to tackle these challenges. We aimed to analyze the existing literature concerning the utilization of precision medicine in congenital heart disease, rheumatic heart disease, and Kawasaki disease. The emphasis is placed on comprehending the key themes explored in these studies and evaluating the present state of their clinical integration. The central theme of most studies revolves around the examination of genetic factors. Despite promising research outcomes, limitations in these studies indicate that the clinical implementation of precision medicine in these conditions remains a distant prospect, necessitating additional exploration and attention to confounding factors.

Lack of awareness of secondary rheumatic prevention in preoperative candidates for mitral valve surgery - alarming situation

BACKGROUND

We conducted this study to assess the compliance with secondary rheumatic prophylaxis among preoperative patients with rheumatic mitral valve disease undergoing valvular heart surgery at a tertiary care cardiac hospital in a developing country.

METHODS

This is a descriptive cross-sectional study conducted at a tertiary care cardiac hospital in Karachi, Pakistan. The inclusion criteria encompassed patients of any sex, aged between 18 and 80 years, who had been diagnosed with rheumatic mitral valve disease through transthoracic echocardiography and had undergone valvular heart surgery. The level of compliance with secondary rheumatic prophylaxis and barriers toward noncompliance was assessed during routine preoperative interview session. This preventive measure plays a crucial role in reducing the progression of the disease and improving patient outcomes.

RESULTS

Out of the 239 patients included in the study, 125 (52.3%) were females, with a mean age of 38.8 ± 11.8 years. The majority of patients (88.7%) came from rural areas. Among the patients, 79 (33.1%) received rheumatic prophylaxis, while 160 (66.9%) did not adhere to it regularly. The common barriers for receiving rheumatic prophylaxis were non availability (41.0%) and nonaffordability (40.6%). Additionally, 28.0% of patients had lacked awareness of the importance of rheumatic prophylaxis, and 2.5% expressed fear of injection site pain and subsequent symptoms.

CONCLUSIONS

A concerning level of noncompliance with secondary rheumatic prophylaxis was observed. The barriers identified in patients who did not receive rheumatic prophylaxis were primarily related to affordability, availability, lack of awareness, and fear of injection site pain and subsequent symptoms.

Association between Mitral Valve Mean Pressure Gradient and Atrial Fibrillation in Patients with Rheumatic Mitral Stenosis: A Cross-Sectional Study

INTRODUCTION

Atrial fibrillation (AF) often occurs in patients with rheumatic mitral stenosis (RMS) and is associated with adverse clinical outcomes. Mitral valve mean pressure gradient (MVMPG) is utilized as an indicator to assess the severity of mitral stenosis and its hemodynamic implications. The aim of this study was to investigate the association between MVMPG and AF in individuals with RMS.

METHODS

We conducted a retrospective analysis of medical records from 360 consecutive patients diagnosed with RMS at the First Affiliated Hospital of Wenzhou Medical University between January 2018 and January 2023. Using both univariate and multivariate logistic regression models, the relationship between MVMPG and AF was evaluated. Restricted cubic splines were employed to test for linearity, and stratified and interaction analyses were performed to evaluate the stability of this relationship among different subgroups.

RESULTS

Based on the MVMPG levels, 360 RMS patients in total were categorized into three groups for the analysis: Q1 (<5 mm Hg), Q2 (5-10 mm Hg), and Q3 (>10 mm Hg). The average age was 60.6 years (Q1: 66.1, Q2: 61.9, Q3: 55.8), and 70.8% were female. The prevalence of AF was 39.6%, 56.5%, and 63.2% in Q1, Q2, and Q3, respectively. After adjusting for potential confounders, a significant association between MVMPG and AF was observed. In Q2, there was a 119% increase in AF (OR 2.19, 95% CI: 1.01-4.75), while in Q3, there was a 238% increase (OR 3.38, 95% CI: 1.39-8.19), compared to Q1. The relationship between MVMPG and AF was linear (p = 0.503). These results remained consistent in each subgroup analysis.

CONCLUSION

Our study reveals a significant positive association between MVMPG and AF in patients with RMS, which holds important clinical implications. It is necessary to conduct further research.

2023 World Heart Federation guidelines for the echocardiographic diagnosis of rheumatic heart disease

Rheumatic heart disease (RHD) is an important and preventable cause of morbidity and mortality among children and young adults in low-income and middle-income countries, as well as among certain at-risk populations living in high-income countries. The 2012 World Heart Federation echocardiographic criteria provided a standardized approach for the identification of RHD and facilitated an improvement in early case detection. The 2012 criteria were used to define disease burden in numerous epidemiological studies, but researchers and clinicians have since highlighted limitations that have prompted a revision. In this updated version of the guidelines, we incorporate evidence from a scoping review, an expert panel and end-user feedback and present an approach for active case finding for RHD, including the use of screening and confirmatory criteria. These guidelines also introduce a new stage-based classification for RHD to identify the risk of disease progression. They describe the latest evidence and recommendations on population-based echocardiographic active case finding and risk stratification. Secondary antibiotic prophylaxis, echocardiography equipment and task sharing for RHD active case finding are also discussed. These World Heart Federation 2023 guidelines provide a concise and updated resource for clinical and research applications in RHD-endemic regions.

Epidemiological study of pediatric rheumatic heart disease: An analysis from the Global Burden of Disease Study 2019

BACKGROUND

Rheumatic heart disease (RHD) is the most common acquired heart disease among children in developing countries. However, there is a lack of systematic studies on the epidemiology of pediatric RHD. This study aimed to report the burden of pediatric RHD at global, regional, and national levels between 1990 and 2019, which may provide some reference for policymakers.

METHODS

The numbers and age-standardized rates (ASRs) of incidence, prevalence, mortality, and disability-adjusted life years (DALYs) for childhood RHD from 1990 to 2019 were analyzed based on data obtained from the Global Burden of Disease Study 2019 (GBD 2019). In addition, Joinpoint regression analysis was used to assess temporal trends in the burden of childhood RHD.

RESULTS

Globally, the number of incidence and prevalence cases of RHD in children increased by 41.89% and 40.88%, respectively, from 1990 to 2019. Age-standardized incidence rate (ASIR) and age-standardized prevalence rate (ASPR) increased with an average annual percentage change (AAPC) of 0.75% and 0.66%, respectively. In contrast, the age-standardized DALY rate and age-standardized mortality rate (ASMR) decreased significantly since 1990 by an AAPC of -3.47% and - 2.65%, respectively. Girls had a significantly higher burden of RHD than boys during the study period. At the age level, the RHD burden was significantly highest in the age group of 10-14 years. Moreover, the ASRs of incidence, prevalence, mortality, and DALYs were negatively associated with sociodemographic index (SDI). Nationally, Fiji had the most significant increase in incidence and prevalence, and Philippines had the most remarkable rise in DALYs and mortality rates.

CONCLUSION

From 1990 to 2019, although the incidence and prevalence of childhood RHD increased globally, DALYs and mortality rates markedly reduced. Countries with lower levels of sociodemographic development shoulder a higher burden of childhood RHD. Children aged 10-14 years are critical populations for whom targeted measures are needed to reduce the RHD burden, while attention to girls cannot be neglected.

Left atrial function in patients with rheumatic mitral stenosis: addressing prognostic insights beyond atrial fibrillation prediction

Aims

Rheumatic mitral stenosis (MS) frequently leads to impaired left atrial (LA) function because of pressure overload, highlighting the underlying atrial pathology. Two-dimensional speckle tracking echocardiography (2D-STE) offers early detection of LA dysfunction, potentially improving risk assessment in patients with MS. This study aims to evaluate the predictive value of LA function assessed by 2D-STE for clinical outcomes in patients with MS.

Methods and results

Between 2011 and 2021, patients with MS underwent LA function assessment using 2D-STE, with focus on the reservoir phase (LASr). Atrial fibrillation (AF) development constituted the primary outcome, with death or valve replacement as the secondary outcome. Conditional inference trees were employed for analysis, validated through sample splitting. The study included 493 patients with MS (mean valve area 1.1 ± 0.4 cm2, 84% female). At baseline, 166 patients (34%) had AF, with 62 patients (19%) developing AF during follow-up. LASr emerged as the primary predictor for new-onset AF, with a threshold of 17.9%. Over a mean 3.8-year follow-up, 125 patients (25%) underwent mitral valve replacement, and 32 patients (6.5%) died. A decision tree analysis identified key predictors such as age, LASr, severity of tricuspid regurgitation (TR), net atrioventricular compliance (C n), and early percutaneous mitral valvuloplasty, especially in patients aged ≤49 years, where LASr, with a threshold of 12.8%, significantly predicted adverse outcomes.

Conclusion

LASr emerged as a significant predictor of cardiovascular events in this MS cohort, validated through a decision tree analysis. Patients were stratified into low- or high-risk categories for adverse outcomes, taking into account LASr, age, TR severity, and C n.

Viral cardiovascular surgical diseases: global burdens, challenges and opportunities

Globally, more than one billion people are vulnerable to neglected tropical diseases, many of which have viral origins and cardiovascular implications. Access to cardiovascular care is limited in countries where these conditions are endemic. Six billion people lack access to safe, timely and affordable cardiac surgical care, whereby over 100 countries and territories lack a single cardiac surgeon. Moreover, while clinically unique, the surgical consequences of neglected cardiovascular diseases with viral origins have been poorly described in the current literature. This review provides an overview of the global burden of viral cardiovascular disease, describes access to cardiac surgical care in regions where these conditions are endemic, and further highlights surgical consequences and considerations to manage patients requiring cardiac surgical care.

Temporal trend analysis of rheumatic heart disease burden in high-income countries between 1990 and 2019

AIMS

To assesses trends in rheumatic heart disease (RHD) burden in high-income, European Union 15+ (EU15+) countries between 1990 and 2019.

METHODS AND RESULTS

Cross-sectional analysis of the incidence and mortality of RHD was conducted using data from the Global Burden of Disease (GBD) Study database. Age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs) were extracted for EU15+ countries per sex for each of the years from 1990 to 2019, inclusive, and mortality-to-incidence indices (MII) were computed. Joinpoint regression analysis was used for the description of trends. Over 29 years, an overall declining trend in RHD incidence and mortality across EU 15+ nations were observed. There was significant variability in RHD incidence and mortality rates across high-income countries. However, both RHD incidence and mortality were higher among females compared with males across EU15+ countries over the observed period. The most recent incidence trend, starting predominantly after 2014, demonstrated a rise in RHD incidence in most countries for both sexes. The timing of this RHD resurgence corresponds temporally with an influx of migrants and refugees into Europe. The recent increasing RHD incidence rates ranged from +0.4% to +24.7% for males, and +0.6% to +11.4% for females.

CONCLUSION

More than half of EU15+ nations display a recent increase in RHD incidence rate across both sexes. Possible factors associated with this rise are discussed and include increase in global migration from nations with higher RHD prevalence, host nation factors such as migrants' housing conditions, healthcare access, and migrant health status on arrival.

Agreement between Handheld and Standard Echocardiography for Diagnosis of Latent Rheumatic Heart Disease in Brazilian Schoolchildren from High-Prevalence Settings (Agreement between Screening and Standard Echo for RHD)

Introduction: Handheld echocardiography (echo) is the tool of choice for rheumatic heart disease (RHD) screening. We aimed to assess the agreement between screening and standard echo for latent RHD diagnosis in schoolchildren from an endemic setting. Methods: Over 14 months, 3 nonphysicians used handheld machines and the 2012 WHF Criteria to determine RHD prevalence in consented schoolchildren from Brazilian low-income public schools. Studies were interpreted by telemedicine by 3 experts (Brazil, US). RHD-positive children (borderline/definite) and those with congenital heart disease (CHD) were referred for standard echo, acquired and interpreted by a cardiologist. Agreement between screening and standard echo, by WHF subgroups, was assessed. Results: 1390 students were screened in 6 schools, with 110 (7.9%, 95% CI 6.5-9.5) being screen positive (14 ± 2 years, 72% women). Among 16 cases initially diagnosed as definite RHD, 11 (69%) were confirmed, 4 (25%) reclassified to borderline, and 1 to normal. Among 79 cases flagged as borderline RHD, 19 (24%) were confirmed, 50 (63%) reclassified to normal, 8 (10%) reclassified as definite RHD, and 2 had mild CHD. Considering the 4 diagnostic categories, kappa was 0.18. In patients with borderline RHD reclassified to non-RHD, the most frequent WHF criterion was B (isolated mitral regurgitation, 64%), followed by A (2 mitral valve morphological features, 31%). In 1 patient with definite RHD reclassified to normal, the WHF criterion was D (borderline RHD in aortic and mitral valves). After standard echo, RHD prevalence was 3.2% (95% CI 2.3-4.2). Conclusions: Although practical, RHD screening with handheld devices tends to overestimate prevalence.

Temporal Trends of Age-Adjusted Mortality Rates for Rheumatic Heart Disease in Brazil From 2000 to 2021

Background Rheumatic heart disease (RHD) is a chronic cardiovascular condition stemming from an infectious origin, posing a substantial health burden, particularly in economically disadvantaged regions. It starts with acute rheumatic fever (ARF), a complication following group A Streptococcus infection, leading to heart valve damage and, over time, structural heart abnormalities. RHD contributes to premature deaths, especially in low-middle-income countries. Although the incidence and prevalence have generally reduced globally due to antibiotics and improved healthcare, it remains a significant public health concern in Brazil, echoing its prevalence in many developing nations around the world. RHD stands as a poignant testament to the intersection of socio-economic disparities and healthcare challenges within Brazil's diverse population. In Brazil, despite advancements in healthcare, RHD continues to impact communities, highlighting the urgent need for enhanced prevention strategies, access to quality healthcare services, and heightened awareness to combat this preventable, yet persistent, cardiac condition. Understanding the epidemiological landscape and socio-cultural factors influencing RHD in Brazil is crucial for developing targeted interventions aimed at mitigating its burden on individuals, families, and the healthcare system at large. Thus, our study focuses on analyzing age-related mortality rates linked to ARF and chronic RHD (ARHD) in Brazil from 2000 to 2021, particularly examining gender disparities. Materials and methods This retrospective cohort study employed a descriptive time-series approach, utilizing comprehensive nationwide data from Brazil spanning from 2000 to 2021 to assess trends in diverse age groups, among both sexes, enabling a detailed analysis of temporal patterns. Mortality data, extracted and categorized meticulously, were subjected to Joinpoint statistical analyses enabling comparative assessments, with average annual percent change (AAPC) and annual percent change (APC) serving as key metrics to quantify and interpret trends over the analyzed period. Results The acute RHD (ARHD)-related mortality declined over the analyzed years supported by AAPC, with higher mortality reduction in females. The age-adjusted mortality rate for "males and females" decreased from 78 to 67 deaths/100,000 from 2000 to 2021. Female mortality dropped from 85 to 69/100,000, and male mortality decreased from 73 to 63/100,000 over the same period. For ARHD, male age groups (20-29, 60-69, 70-79, 80+) showed declining mortality, while the 30-59 age group exhibited an upward. Females AAMR for chronic RHD (CRHD) decreased across all age groups, with significant reductions in the 80 years and above age group from 2000-2002 (APC: -11.94*) and steadily from 2002 onwards (APC: -1.33). Conclusions Our study revealed an overall decline in mortality rates for both acute and CRHD across both sexes. Females consistently exhibited higher mortality rates and a more pronounced reduction compared to males in both acute and CRHD. In ARHD, males experience the highest mortality in the 50-59 age group, while females have a peak in the 40-49 age group. The 60-69 age group had the highest mortality in CRHD for both sexes. Conversely, the 20-29 age group displayed the lowest mortality in CRHD, and the 80-89 age group had the lowest mortality in ARHD.

The Group A Streptococcal Vaccine Candidate VAX-A1 Protects against Group B Streptococcus Infection via Cross-Reactive IgG Targeting Virulence Factor C5a Peptidase

Group B Streptococcus (Streptococcus agalactiae or GBS) is the leading infectious cause of neonatal mortality, causing roughly 150,000 infant deaths and stillbirths annually across the globe. Approximately 20% of pregnant women are asymptomatically colonized by GBS, which is a major risk factor for severe fetal and neonatal infections as well as preterm birth, low birth weight, and neurodevelopmental abnormalities. Current clinical interventions for GBS infection are limited to antibiotics, and no vaccine is available. We previously described VAX-A1 as a highly effective conjugate vaccine against group A Streptococcus that is formulated with three antigens, SpyAD, streptolysin O, and C5a peptidase (ScpA). ScpA is a surface-expressed, well-characterized GAS virulence factor that shares nearly identical sequences with the lesser studied GBS homolog ScpB. Here, we show that GBS C5a peptidase ScpB cleaves human complement factor C5a and contributes to disease severity in the murine models of pneumonia and sepsis. Furthermore, antibodies elicited by GAS C5a peptidase bind to GBS in an ScpB-dependent manner, and VAX-A1 immunization protects mice against lethal GBS heterologous challenge. These findings support the contribution of ScpB to GBS virulence and underscore the importance of choosing vaccine antigens; a universal GAS vaccine such as VAX-A1 whose formulation includes GAS C5a peptidase may have additional benefits through some measure of cross-protection against GBS infections.

The Global Burden of premature cardiovascular disease, 1990-2019

Aims

Premature cardiovascular disease (pCVD) definition varies in literature, with age cut-offs ranging from 50-65 years. While there is some literature available on pCVD in North America, comprehensive data on its global burden is still lacking which hinders the development of efficient strategies for early detection and prevention. In this study we aimed to investigate the global trends in pCVD related morbidity and mortality from 1990 to 2019.

Methods

The 1990-2019 Global Burden of Disease (GBD) database was utilized to examine global trends in cardiovascular disease-related total mortality, mortality rates, and Disability-Adjusted Life Years (DALYs) within individuals aged 15-49 years. The findings were further analyzed based on factors such as age, sex, and Socio-Demographic Index (SDI).

Results

From 1990 to 2019, the number of global annual pCVD deaths increased by 25%, from 992,067 (95% UI 1,042,261 - 946,383) to 1,241,484 (95% UI 1,339,193 -1,146,252). The rate of associated mortality decreased by 13%. Metabolic conditions were the most significant risk factors for pCVD mortality. Ischemic heart disease and stroke are the leading causes of death across all age groups. pCVD mortality presented progressive widening between high and low SDI regions. Additionally, sex-specific disparities in CVD mortality were significantly greater in the premature age group as compared to all-age groups.

Conclusion

pCVD is an increasingly significant global cause of morbidity and mortality that disproportionately affects males and individuals living in less privileged regions. Furthermore, ischemic heart disease and stroke were identified as the main drivers of pCVD global burden.

Global Access to Comprehensive Care for Paediatric and Congenital Heart Disease

Paediatric and congenital heart disease (PCHD) is common but remains forgotten on the global health agenda. Congenital heart disease is the most frequent major congenital anomaly, affecting approximately 1 in every 100 live births. In high-income countries, most children now live into adulthood, whereas in low- and middle-income countries, over 90% of patients do not get the care they need. Rheumatic heart disease is the most common acquired cardiovascular disease in children and adolescents. While almost completely eradicated in high-income countries, over 30-40 million people live with rheumatic heart disease in low- and middle-income countries. Challenges exist in the care for PCHD and, increasingly, adult congenital heart disease (ACHD) worldwide. In this review, we summarize the current status of PCHD and ACHD care through the health systems lens of workforce, infrastructure, financing, service delivery, information management and technology, and governance. We further highlight gaps in knowledge and opportunities moving forward to improve access to care for all those living with PCHD or ACHD worldwide.

Rheumatic Heart Disease in the Developing World

Despite recent public policy initiatives, rheumatic heart disease (RHD) remains a major source of morbidity worldwide. Rheumatic heart disease occurs as a sequela of Streptococcus pyogenes (group A streptococcal [GAS]) infection in patients with genetic susceptibility. Strategies for prevention of RHD or progression of RHD include prevention of GAS infection with community initiatives, effective treatment of GAS infection, and secondary prophylaxis with intramuscular penicillin. The cardiac surgical community has attempted to improve the availability of surgery in RHD-endemic areas with some success, and operative techniques and outcomes of valve repair continue to improve, potentially offering patients a safer, more durable operation. Innovation offers hope for a more scalable solution with improved biomaterials and transcatheter delivery technology; however, cost remains a barrier.

Streptococcus pyogenes carriage acquisition, persistence and transmission dynamics within households in The Gambia (SpyCATS): protocol for a longitudinal household cohort study

Background

Streptococcus pyogenes (StrepA) causes a significant burden of disease globally from superficial infections to invasive disease. It is responsible for over 500,000 deaths each year, predominantly in low- and middle-income countries (LMIC). Superficial StrepA infections of the skin and pharynx can lead to rheumatic heart disease, the largest cause of StrepA-related deaths in LMIC. StrepA can also asymptomatically colonise normal skin and the pharynx (carriage), potentially increasing infection risk. Streptococcus dysgalactiae subsp. equisimilis (SDSE) carriage is also common in LMIC and may interact with StrepA. This study aims to investigate StrepA and SDSE carriage and infection epidemiology, transmission dynamics and naturally acquired immunity within households in The Gambia.

Methods

A longitudinal household observational cohort study will be conducted over one year. 45 households will be recruited from the urban area of Sukuta, The Gambia, resulting in approximately 450 participants. Households will be visited monthly, and available participants will undergo oropharyngeal and normal skin swabbing. Incident cases of pharyngitis and pyoderma will be captured via active case reporting, with swabs taken from disease sites. Swabs will be cultured for the presence of group A, C and G beta-haemolytic streptococci. Isolates will undergo whole genome sequencing. At each visit, clinical, socio-demographic and social mixing data will be collected. Blood serum will be collected at baseline and final visit. Oral fluid and dried blood spot samples will be collected at each visit. Mucosal and serum anti-StrepA antibody responses will be measured.

Outcome

This study will report StrepA and SDSE clinical epidemiology, risk factors, transmission dynamics, and serological responses to carriage and infection. Detailed social mixing behaviour will be combined with phylogenetic relatedness to model the extent of transmission occurring withing and between households. The study will provide data to help meet global strategic StrepA research goals.

Streptococcus pyogenes carriage acquisition, persistence and transmission dynamics within households in The Gambia (SpyCATS): protocol for a longitudinal household cohort study

BACKGROUND

Streptococcus pyogenes (StrepA) causes a significant burden of disease globally from superficial infections to invasive disease. It is responsible for over 500,000 deaths each year, predominantly in low- and middle-income countries (LMIC). Superficial StrepA infections of the skin and pharynx can lead to rheumatic heart disease, the largest cause of StrepA-related deaths in LMIC. StrepA can also asymptomatically colonise normal skin and the pharynx (carriage), potentially increasing infection risk. Streptococcus dysgalactiae subsp. equisimilis (SDSE) carriage is also common in LMIC and may interact with StrepA. This study aims to investigate StrepA and SDSE carriage and infection epidemiology, transmission dynamics and naturally acquired immunity within households in The Gambia.

METHODS

A longitudinal household observational cohort study will be conducted over one year. 45 households will be recruited from the urban area of Sukuta, The Gambia, resulting in approximately 450 participants. Households will be visited monthly, and available participants will undergo oropharyngeal and normal skin swabbing. Incident cases of pharyngitis and pyoderma will be captured via active case reporting, with swabs taken from disease sites. Swabs will be cultured for the presence of group A, C and G beta-haemolytic streptococci. Isolates will undergo whole genome sequencing. At each visit, clinical, socio-demographic and social mixing data will be collected. Blood serum will be collected at baseline and final visit. Oral fluid and dried blood spot samples will be collected at each visit. Mucosal and serum anti-StrepA antibody responses will be measured.

OUTCOME

This study will report StrepA and SDSE clinical epidemiology, risk factors, transmission dynamics, and serological responses to carriage and infection. Detailed social mixing behaviour will be combined with phylogenetic relatedness to model the extent of transmission occurring withing and between households. The study will provide data to help meet global strategic StrepA research goals.

Evaluating the implementation of a dynamic digital application to enable community-based decentralisation of rheumatic heart disease case management in Uganda: protocol for a hybrid type III effectiveness-implementation study

INTRODUCTION

Rheumatic heart disease (RHD) affects over 39 million people worldwide, the majority in low-income and middle-income countries. Secondary antibiotic prophylaxis (SAP), given every 3-4 weeks can improve outcomes, provided more than 80% of doses are received. Poor adherence is strongly correlated with the distance travelled to receive prophylaxis. Decentralising RHD care has the potential to bridge these gaps and at least maintain or potentially increase RHD prophylaxis uptake. A package of implementation strategies was developed with the aim of reducing barriers to optimum SAP uptake.

METHODS AND ANALYSIS

A hybrid implementation-effectiveness study type III was designed to evaluate the effectiveness of a package of implementation strategies including a digital, cloud-based application to support decentralised RHD care, integrated into the public healthcare system in Uganda. Our overarching hypothesis is that secondary prophylaxis adherence can be maintained or improved via a decentralisation strategy, compared with the centralised delivery strategy, by increasing retention in care. To evaluate this, eligible patients with RHD irrespective of their age enrolled at Lira and Gulu hospital registry sites will be consented for decentralised care at their nearest participating health centre. We estimated a sample size of 150-200 registrants. The primary outcome will be adherence to secondary prophylaxis while detailed implementation measures will be collected to understand barriers and facilitators to decentralisation, digital application tool adoption and ultimately its use and scale-up in the public healthcare system.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board (IRB) at Cincinnati Children's Hospital Medical Center (IRB 2021-0160) and Makerere University School of Medicine Research Ethics Committee (Mak-SOMREC-2021-61). Participation will be voluntary and informed consent or assent (>8 but <18) will be obtained prior to participation. At completion, study findings will be communicated to the public, key stakeholders and submitted for publication.

Analysis and comparison of the trends in burden of rheumatic heart disease in China and worldwide from 1990 to 2019

OBJECTIVES

This study aimed to describe the temporal trends in age and gender burdens of rheumatic heart disease (RHD) in China from 1990 to 2019, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs), and to compare them with the global burden of the disease.

METHODS

Using open data from the Global Burden of Disease (GBD) database from 1990 to 2019, this study analyzed the characteristics of RHD burden in China and worldwide, including changes in incidence, prevalence, mortality, and DALYs. Joinpoint was used to calculate the average annual percentage change (AAPC) and the corresponding 95% confidence interval (95% CI) to reflect the trends in the burden of RHD. A comprehensive comparative analysis of the differences in RHD burden between China and the rest of the world was conducted from multiple dimensions, including age, gender, and time periods.

RESULTS

From 1990 to 2019, the age-standardized incidence rate (ASIR) of RHD in China decreased from 29.62/100,000 to 23.95/100,000, while the global ASIR increased from 32.69/100,000 to 37.40/100,000. The age-standardized prevalence rate (ASPR) in China decreased from 446.15/100,000 to 390.24/100,000, while the global ASPR increased from 451.56/100,000 to 513.68/100,000. The age-standardized rates of mortality (ASMR) in China decreased from 18.11/100,000 to 4.04/100,000, while the global ASMR decreased from 8.94/100,000 to 3.85/100,000. The age-standardized DALY rate (ASDR) in China decreased from 431.45/100,000 to 93.73/100,000, while the global ASDR decreased from 283.30/100,000 to 132.88/100,000. The AAPC of ASIR, ASPR, ASMR, and ASDR in China was - 0.73%, -0.47%, -5.10%, and - 5.21%, respectively, while the AAPC of the global burden of RHD was 0.48%, 0.45%, -2.87%, and - 2.58%, respectively. The effects of age and gender on the burden of RHD were different. ASIR generally decreased with increasing age, while ASPR increased first and then decreased. ASMR and ASDR increased with increasing age. Women had higher incidence and mortality rates of RHD than men.

CONCLUSION

From 1990 to 2019, the incidence, prevalence, mortality, and DALYs of RHD in China decreased, indicating a relative reduction in the burden of RHD in China. The burden of RHD is age-related, with a higher prevalence observed in the younger population, a peak incidence among young adults, and a higher mortality rate among the elderly population. Women are more susceptible to RHD and have a higher risk of mortality than men. Given China's large population and aging population, RHD remains a significant public health challenge in China.

Research opportunities for the primary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report

Primary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) encompasses the timely diagnosis and adequate treatment of the superficial group A Streptococcus (GAS) infections pharyngitis and impetigo. GAS is the only known inciting agent in the pathophysiology of the disease. However, sufficient evidence indicates that the uptake and delivery of primary prevention approaches in RHD-endemic regions are significantly suboptimal. This report presents expert deliberations on priority research and implementation opportunities for primary prevention of ARF/RHD that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. The opportunities identified by the Primary Prevention Working Group encompass epidemiological, laboratory, clinical, implementation and dissemination research domains and are anchored on five pillars including: (A) to gain a better understanding of superficial GAS infection epidemiology to guide programmes and policies; (B) to improve diagnosis of superficial GAS infections in RHD endemic settings; (C) to develop scalable and sustainable models for delivery of primary prevention; (D) to understand potential downstream effects of the scale-up of primary prevention and (E) to develop and conduct economic evaluations of primary prevention strategies in RHD endemic settings. In view of the multisectoral stakeholders in primary prevention strategies, we emphasise the need for community co-design and government engagement, especially in the implementation and dissemination research arena. We present these opportunities as a reference point for research organisations and sponsors who aim to contribute to the increasing momentum towards the global control and prevention of RHD.

Research priorities for the secondary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report

Secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) involves continuous antimicrobial prophylaxis among affected individuals and is recognised as a cornerstone of public health programmes that address these conditions. However, several important scientific issues around the secondary prevention paradigm remain unresolved. This report details research priorities for secondary prevention that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. These span basic, translational, clinical and population science research disciplines and are built on four pillars. First, we need a better understanding of RHD epidemiology to guide programmes, policies, and clinical and public health practice. Second, we need better strategies to find and diagnose people affected by ARF and RHD. Third, we urgently need better tools to manage acute RF and slow the progression of RHD. Fourth, new and existing technologies for these conditions need to be better integrated into healthcare systems. We intend for this document to be a reference point for research organisations and research sponsors interested in contributing to the growing scientific community focused on RHD prevention and control.

Prevalence and Impact of HIV Infections in Patients with Rheumatic Heart Disease: A Systematic Review and Meta-Analysis

Socioeconomic factors such as poor health and poor nutrition in low- and middle-income countries (LMICs) may favour inflammatory reactions, thus contributing to the recurrence of rheumatic fever (RF) and thereby modifying trends in rheumatic heart disease (RHD). Apart from epidemiological studies, studies of HIV infections in RHD patients are limited. This systematic review synthesises data on the prevalence and impact of HIV infections or AIDS on RHD from PubMed, Scopus, Web of Science databases up to April 2021. The outcomes were managed using PRISMA guidelines. Of a total of 15 studies found, 10 were eligible for meta-analyses. Meta-analysis found that 17% (95 % CI 8-33, I2 = 91%) of adults in cardiovascular disease (CVD) cohorts in Southern Africa are HIV positive. The proportion of RHD diagnosed among people living with HIV was 4% (95% CI 2-8, I2 = 79%) for adults but lower [2% (95% CI 1-4, I2 = 87%)] among perinatally infected children. Despite limited reporting, HIV-infected patients with RHD are prone to other infections that may enhance cardiac complications due to poor immunological control. PROSPERO registration number: CRD42021237046.

Prevalence, clinical characteristics and echocardiographic parameters of arrhythmias among patients with rheumatic heart disease attending Jakaya Kikwete Cardiac Institute: a prospective cohort study

BACKGROUND

Arrhythmia is a known complication of rheumatic heart disease (RHD). It is critical to recognize arrhythmias early on so that prompt preventative actions and vigilant monitoring may be considered while treating these patients.

AIM

This study aimed at determining the prevalence, clinical characteristics and echocardiographic parameters of arrhythmias among RHD patients attending Jakaya Kikwete Cardiac Institute (JKCI).

METHODOLOGY

Hospital-based cross-sectional study was conducted among 390 patients with an echocardiographic diagnosis of RHD aged 18years and above attending JKCI. Demographic and clinical information was documented. Echocardiography, a resting electrocardiography and 24 h ambulatory Holter monitoring electrocardiography were done. Chi square test was used to determine association between variables and those with a p value ≤ 0.2 were entered in a multivariate logistic regression analysis to determine the independent factors associated with arrhythmias. P value of < 0.05 was considered statistically significant. The receiver operating curve was used to determine the critical point for left atrial size beyond which arrhythmias develop.

RESULTS

A total of 390 patients were included in the analysis. The median age was 39 years interquartile range (IQR 30-52). Females were 257/390 (65.9%). Asymptomatic patients were 208/390 (53.3%). Most patients belonged to New York heart Association (NYHA) functional class I&II 247/390 (62.1%). The most common valve lesion was mitral stenosis 228/390 (58.5%). Arrhythmias were found in 276/390 (70.77%) patients, of which 193/390 (49.5%) patients were from resting electrocardiography (ECG) and 88/197 (44.7%) patients from holter ECG. Independent factors for arrhythmias were, NYHA functional class III&IV (a0R 4.67, 95% CI 1.82-12.00 p = < 0.01) and severe left atrial diameter enlargement (aOR 7.28, 95% CI 3.17-16.70 p = < 0.01). The critical point beyond which arrhythmias develop was found to be left atrium diameter > 48 mm.

CONCLUSION

We found a high prevalence of arrhythmias among patients with RHD. The independent predictors of arrhythmias were left atrium dilatation and NYHA functional class III-IV. We recommend close monitoring for arrhythmias among RHD patients in sinus rhythm with higher NYHA functional class and dilated left atrium.

Health Related Quality of Life and Associated Factors Among Adult Patients with Rheumatic Heart Disease Patients in Ethiopia

Background

Quality of life (QOL) is defined as "individuals" perceptions of their position in life. Rheumatic heart disease (RHD) is a consequence of severe, single, or recurrent bouts of acute rheumatic fever. To improve overall patient outcomes, there is currently a greater emphasis on assessing the QOL of these patients. The purpose of this study is to assess the QOL of adult RHD patients who had followed up at St Peter and Tikur Anbessa Hospital, Ethiopia.

Methods

An institutional-based cross-sectional study done at St Peter and Tikur Anbessa Hospital, Ethiopia from March 1-June 30/2021 in adult RHD patients. The sample size was 297. Socio-demographic and clinical data were collected using a structured questionnaire. The Amharic version of Short form-36 (SF-36) was used to assess the QOL. A logistic regression model was used to identify associated factors.

Results

The study included 297 patients. The majority are female (71%), and half of them are aged between 18-30 years of age. Of the patiends, 81.1% had no comorbidity, and 15.8% had interventions. RHD affects all domains and summary scores of short form 36 QOL parameters compared to normative values. Age, marital status, place of residence, presence of comorbidity, number of medications, and whether an intervention was done are associated with the QOL of these patients.

Conclusion

RHD patients had poor QOL assessed by SF-36. It affects all domains and summary score of short form 36 QOL parameters. Old age, divorce, living in rural areas, associated comorbid conditions, and no intervention done are associated with poor QOL. Identification and treating comorbid conditions and intervention may improve QOL.

Spatiotemporal trends in global burden of rheumatic heart disease and associated risk factors from 1990 to 2019

BACKGROUND

The aim of this study was to estimate the burden of rheumatic heart disease (RHD) and its trends in different countries, regions, genders and age groups globally.

METHODS

Data were obtained from the Global Burden of Disease 2019 study. Age-standardized rates (ASRs) and the estimated annual percentage changes (EAPCs) in the ASRs were used to describe the burden of disease and its trends. Pearson's correlation was used to evaluate the correlation between sociodemographic index (SDI) values and the observed trends.

RESULTS

In 2019, the ASRs of the incidence, prevalence, mortality and disability-adjusted life years (DALYs) of RHD were 37.39/105 (95%UI, 28.59/105 to 46.74/105), 513.68/105 (95%UI, 405.01/105 to 636.25/105), 3.85/105 (95%UI, 4.29/105 to 3.29/105) and 132.88/105 (95%UI, 115.02/105 to 150.34/105), respectively. From 1990 to 2019, the incidence and prevalence of RHD showed upward trends and the mortality and DALYs showed downward trends. Countries or regions in Africa, South America and South Asia had a greater burden of RHD. The burden of RHD was greater in women, where as men showed more obvious increasing trends in the incidence and prevalence. The incidence of RHD was highest in adolescents, and the prevalence was highest in young and middle-aged. The mortality and DALYs rate associated with RHD increased with age. The EAPCs in the ASRs were negatively correlated with the SDI value.

CONCLUSION

Although the ASRs of mortality and DALYs attributable to RHD are decreasing globally, RHD remains an important public health problem that needs to be addressed urgently, especially in certain low- and middle-income countries and regions.

Myocardial fibrosis in rheumatic heart disease: emerging concepts and clinical implications

Rheumatic heart disease (RHD) remains a significant cardiovascular burden in the world even though it is no longer common in affluent countries. Centuries of history surrounding this disease provide us with a thorough understanding of its pathophysiology. Infections in the throat, skin, or mucosa are the gateway for Group A Streptococcus (GAS) to penetrate our immune system. A significant inflammatory response to the heart is caused by an immunologic cascade triggered by GAS antigen cross-reactivity. This exaggerated immune response is primarily responsible for cardiac dysfunction. Recurrent inflammatory processes damage all layers of the heart, including the endocardium, myocardium, and pericardium. A vicious immunological cycle involving inflammatory mediators, angiotensin II, and TGF-β promotes extracellular matrix remodeling, resulting in myocardial fibrosis. Myocardial fibrosis appears to be a prevalent occurrence in patients with RHD. The presence of myocardial fibrosis, which causes left ventricular dysfunction in RHD, might be utilized to determine options for treatment and might also be used to predict the outcome of interventions in patients with RHD. This emerging concept of myocardial fibrosis needs to be explored comprehensively in order to be optimally utilized in the treatment of RHD.