Shifts in Clinical Characteristics, Treatment, and Outcome for Rheumatic Mitral Stenosis: Insights From a 20-Year Multicentre Registry Study in Korea

BACKGROUND

The rapid economic development of South Korea provides a unique model to study changes in the clinical characteristics, treatment approaches, and clinical outcomes of patients with rheumatic mitral stenosis (MS) relative to socioeconomic growth.

METHODS

From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, 2,337 patients diagnosed with moderate or severe rheumatic MS between January 2001 and December 2020 were analyzed. Patients were grouped into consecutive 5-year intervals based on their year of diagnosis. Clinical characteristics, echocardiographic data, and clinical outcomes were assessed.

RESULTS

Over 20 years, the severity of mitral stenosis increased from 79.1% to 90.2%; similarly, the average age at diagnosis increased from 54.3 to 63.0 years (all P < 0.001). Comorbidities such as hypertension and atrial fibrillation increased (6.3% to 29.5% and 41.4% to 46.9%, respectively; all P for trend < 0.05). The rate of mitral intervention within five years after diagnosis increased from 31.2% to 47.4% (P for trend < 0.001). However, clinical outcomes of rheumatic mitral stenosis deteriorated over time in the composite outcomes (log-rank test, P < 0.001). Conversely, the incidence of stroke remained stable (60.6-73.7%; P < 0.001), which might be attributed to the increased use of anticoagulation therapy.

CONCLUSION

This study observed an increase in patient age, comorbidities, and valve disease severity as the country transitioned from a developing to developed status. Despite a rise in mitral valve interventions, clinical outcomes deteriorated over 20 years, highlighting the need for modified treatment approaches to improve patient outcomes.

Clinical Outcome of Rheumatic Mitral Valve Repair and Replacement Surgery in Indonesia; A Comparison with Non-Rheumatic Aetiology

Introduction

Mitral valve repair (MVr) has been shown to achieve better outcomes than mitral valve replacement (MVR) in degenerative aetiology. However, that cannot be applied in rheumatic mitral valve disease. Therefore, this study aims to evaluate early and late clinical outcomes and mid-term survival in RHD compared to the non-RHD group and whether mitral valve repair is a better surgical approach in RHD patients.

Methods

Patients who underwent mitral valve surgery with or without coronary artery bypass grafting were included in this study. All patients were divided into the RHD and non-RHD group by the type of mitral surgery performed. Early and late outcomes were evaluated, and mid-term cumulative survival was reported.

Results

A total of 1382 patients post MV surgeries were included. The 30-day mortality was significantly higher in the RHD group compared to the non-RHD group (8.7% vs. 4.4%, p = 0.003). There was no difference in 30-day mortality between repair and replacement in each respective group. During follow-up (12-54 months), all-cause mortality between RHD and non-RHD groups (16.7% vs. 16.2%) was not different. In the RHD group, the survival of MVr was 85.6% (95% CI 82.0%-88.5%), and MVR was 78.3% (95% CI 75.8%-80.6%), p-value log rank 0.26 However, in the non-RHD group, patients who underwent MVr had better survival than MVR, with cumulative survival of 81.7% (95% CI 72.3%-88.2%) vs. 71.1% (95% CI 56.3%-81.7%) p-value log rank 0.007.

Conclusion

Early mortality rate in rheumatic mitral valve surgery was higher than in non-rheumatic valve surgery. Although in rheumatic MV disease MV repair did not show a significant survival advantage over MV replacement, a trend towards more favourable survival in the repair group was observed.

Segmental and global longitudinal strain measurement by 2-dimensional speckle tracking echocardiography in severe rheumatic mitral stenosis

BACKGROUND

The present study aimed to detect subtle left ventricular (LV) dysfunction in patients with severe rheumatic mitral stenosis (MS) by measuring global and segmental longitudinal strain with a two-dimensional speckle tracking echocardiography (2D-STE) method.

METHODS

In this case-control study, 65 patients with severe rheumatic MS and preserved ejection fraction (EF ≥ 50% measured by conventional echocardiographic methods) were compared with 31 otherwise healthy control subjects. All patients underwent LV strain measurement by the 2D-STE method in addition to conventional echocardiography using a VIVID S60 echocardiography device.

RESULTS

Absolute strain values in myocardial segments 1-8, 10, and 12 (all basal, mid anterior, mid anteroseptal, mid inferior, and mid anterolateral segments) were significantly lower in patients with severe MS compared with the control group (P < 0.05 for all). The absolute global longitudinal strain (GLS) value was higher in the control group (-19.56 vs. -18.25; P = 0.006). After adjustment for age, gender, and systolic blood pressure, the difference in GLS between the two groups was as follows: mean difference=-1.16; 95% CI: -2.58-0.25; P = 0.110.

CONCLUSION

In patients with severe rheumatic MS and preserved EF, the absolute GLS tended to be lower than healthy controls. Furthermore, the segmental strain values of LV were significantly lower in most of the basal and some mid-myocardial segments. Further studies are warranted to investigate the underlying pathophysiology and clinical implications of this subclinical dysfunction in certain segments of patients with severe rheumatic MS.

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.

Long-term Results of the Ross Operation in Rheumatic Valve Disease

AIMS

To evaluate the impact of rheumatic heart disease on the long-term outcomes of the Ross Operation when compared to patients with bicuspid aortic valves.

METHODS AND RESULTS

We analyzed patients with rheumatic disease and bicuspid aortic valves who underwent a Ross Operation between 1995 and 2020. The primary outcomes were late survival and reoperations on the pulmonary autograft and the right ventricular allograft. We also performed a propensity score analysis to adjust for differences in baseline characteristics. The cumulative incidence of the events in the matched cohorts was compared using the Fine-Gray model.There were 147 patients with rheumatic disease and 314 with bicuspid valves. In the unmatched population, patients with rheumatic disease were younger, more symptomatic, had worse left ventricular function and were more likely to present a preoperative diagnosis of aortic insufficiency. Propensity matching resulted in 86 pairs with similar baseline characteristics. Compared with those with bicuspid valves, rheumatic patients had similar 20-years survival both in the unmatched (RHD = 67.8% vs BAV = 79.7%, p = 0.27) and matched cohorts (RHD = 72.5% vs BAV = 82.9%, p = 0.46). Cumulative incidence of reoperations on the pulmonary autograft after 20 years was also comparable between them in the unmatched (RHD 13.4% vs BAV 14.4%, p = 0.67) and matched patients (RHD 11.6% vs BAV p 21.1%, p = 0.47). Pulmonary autograft dysfunction due to rheumatic involvement was detected in only three occasions. Cumulative incidence of reoperations on the right sided allograft was higher in the unmatched cohort (RHD = 5.5% vs BAV = 16.7%, p = 0.035), but became non-significant after propensity score matching (RHD = 9.9% vs BAV = 32.3%, p = 0.051). The cumulative incidence of all Ross-related reoperations was similar in both groups.

CONCLUSIONS

Among patients undergoing Ross Operation, patients with rheumatic heart disease had similar long-term survival and rates of reoperations, when compared to patients with bicuspid aortic valves.

[Rheumatic mitral aggression. Usefulness of 3d transesophageal echocardiography]

Rheumatic heart disease is the leading cause of cardiovascular disease in children under 25 years of age worldwide, with the highest prevalence in low-income countries. The usual and distinctive finding of rheumatic aggression is mitral stenosis, which leads to serious cardiovascular consequences. International guidelines establish transthoracic echocardiography (TTE) as the diagnostic test for rheumatic heart disease; however, it has limitations in the measurement of planimetry and those inherent to Doppler. Transesophageal 3D echocardiography (TTE-3D) is a new modality that shows realistic images of the mitral valve and has the added value of accurately locating the plane of maximum stenosis and better determining commissural involvement.

Caring for Pregnant Women with Rheumatic Heart Disease: A Qualitative Study of Health Service Provider Perspectives

Background

Rheumatic heart disease (RHD) persists in low-middle-income countries and in high-income countries where there are health inequities. RHD in pregnancy (RHD-P) is associated with poorer maternal and perinatal outcomes. Our study examines models of care for women with RHD-P from the perspectives of health care providers.

Methods

A descriptive qualitative study exploring Australian health professionals' perspectives of care pathways for women with RHD-P. Thematic analysis of semi-structured interviews with nineteen participants from maternal health and other clinical and non-clinical domains related to RHD-P.

Results

A constellation of factors challenged the provision of integrated women-centred care, related to health systems, workforces and culture. Themes that impacted on the provision of quality woman-centred care included conduits of care - helping to break down silos of information, processes and access; 'layers on layers' - reflecting the complexity of care issues; and shared understandings - factors that contributed to improved understandings of disease and informed decision-making.

Conclusions

Pregnancy for women with RHD provides an opportunity to strengthen health system responses, improve care pathways and address whole-of-life health. To respond effectively, structural and cultural changes are required including enhanced investment in education and capacity building - particularly in maternal health - to support a better informed and skilled workforce. Aboriginal Mothers and Babies programs provide useful exemplars to guide respectful effective models of care for women with RHD, with relevance for non-Indigenous women in high-risk RHD communities.For key goals to be met in the context of RHD, maternal health must be better integrated into RHD strategies and RHD better addressed in maternal health.

Right Atrial Thrombus in a Patient of Rheumatic Heart Disease with Severe Mitral Regurgitation: A Rare Association

BACKGROUND

Right atrial thrombus is a rare phenomenon, and its incidence is not well-defined. It usually occurs in the presence of predisposing factors like tricuspid stenosis or following central venous catheterization. Isolated right atrial thrombus without any predisposing factors occurs rarely.

CASE PRESENTATION

We herein report a 30-year-old male patient, a known case of rheumatic heart disease with mitral regurgitation, presented with severe breathlessness and orthopnea. He was diagnosed with acute pulmonary oedema with biventricular dysfunction and congestive symptoms. On transthoracic 2D echocardiography, he was found to have severe mitral and severe tricuspid regurgitation. All cardiac chambers were dilated, and an incidental finding of right atrial thrombus was noted. The patient was managed conservatively, but he succumbed to his worsening heart failure.

CONCLUSION

Treating physicians should be aware of the possibility of right atrial thrombus in rheumatic mitral valve disease because of its clinical implications, like life-threatening pulmonary embolization and need of surgical management.

Clinical Outcomes, Echocardiographic Findings, and Care Quality Metrics for People Living with HIV and Rheumatic Heart Disease in Uganda

BACKGROUND

Rheumatic Heart Disease (RHD) affects 41 million people worldwide, mostly in low- and middle-income countries, where it is co-endemic with HIV. HIV is also a chronic inflammatory disorder associated with cardiovascular complications, yet the epidemiology of patients affected by both diseases is poorly understood.

METHODS

Utilizing the Uganda National RHD Registry, we described the echocardiographic findings, clinical characteristics, medication prescription rates, and outcomes of all 73 people carrying concurrent diagnoses of HIV and RHD between 2009 and 2018. These individuals were compared to an age- and sex-matched cohort of 365 subjects with RHD only.

RESULTS

The median age of the HIV-RHD group was 36 years (IQR 15) and 86% were women. The HIV-RHD cohort had higher rates of prior stroke/transient ischemic attack (12% vs 5%, p=0.02) than the RHD-only group, with this association persisting following multivariable adjustment (OR 3.08, p=0.03). Prevalence of other comorbidities, echocardiographic findings, prophylactic penicillin prescription rates, retention in clinical care, and mortality were similar between the two groups.

CONCLUSIONS

Patients living with RHD and HIV in Uganda are a relatively young, predominantly female group. Although RHD-HIV comorbid individuals have higher rates of stroke, their similar all-cause mortality and RHD care quality metrics (such as retention in care) compared to those with RHD alone suggest rheumatic heart disease defines their clinical outcome more than HIV does. We believe this study to be one of the first reports of the epidemiologic profile and longitudinal outcomes of patients who carry diagnoses of both conditions.

Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review protocol

BACKGROUND

Rheumatic heart disease is preventable, yet associated with significant health burden, mostly in low-resourced settings. It is prevalent among children and young adults living in impoverished areas. Primordial, primary, and secondary preventive measures have been recommended through health interventions and comprehensive programmes, although most implemented interventions are the high-resourced settings. The proposed review aims to synthesise the evidence of prevention effectiveness of implemented health interventions for the prevention of rheumatic heart disease.

METHODS AND DESIGN

This article describes a protocol for a systematic review. A predefined search strategy will be used to search for relevant literature published from the year 2000 to present. Electronic databases Medline, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials will be searched for the studies, as well as reference lists of relevant studies included. Risk of bias and quality appraisal will be done for the included studies using ROBINS-I tool and Cochrane tool for assessing risk of bias in randomised control trials. Findings will be analysed in subgroups based on the level of intervention and prevention strategy implemented. We will present the findings in descriptive formats with tables and flow diagrams.

DISCUSSION

This review will provide evidence on the prevention effectiveness of interventions or strategies implemented for the prevention of RHD. The findings of this will be significant for policy, practice, and research in countries planning to implement interventions.

REGISTRATION

PROSPERO ID: CRD42020170503.

Non-infectious thrombotic endocarditis associated with chronic rheumatic heart disease and disseminated tuberculosis

Rheumatic heart disease is still common in developing countries and requires prompt intervention to prevent chronic complications. Vegetations in rheumatic heart disease might be due to acute episodes of rheumatic fever itself or due to either infective endocarditis (IE) or Non-infectious thrombotic endocarditis (NITE). Each form of vegetations has specific pathological characteristics on gross and microscopic examination. However, clinically IE and NITE may have overlapping signs and symptoms. A chance of misdiagnosis of NITE as culture-negative infective endocarditis is higher if the former present with infective symptoms like fever. NITE of valves can be due to underlying associated malignant neoplasm, particularly mucinous adenocarcinoma, pneumonia, cirrhosis, autoimmune disorders, and hypercoagulable state. The coexistence of tuberculosis, non-infectious thrombotic endocarditis and rheumatic valvular heart disease was rarely documented in medical literature. We describe a case of chronic rheumatic heart disease with vegetations in the posterior mitral valve leaflet, treated as culture-negative infective endocarditis, which, at autopsy, reveals the presence of Nonbacterial thrombotic endocarditis vegetation over calcified, fibrosed mitral valve leaflets and associated disseminated tuberculosis along with classic pathological sequela findings of chronic rheumatic mitral valvular heart disease in lungs and liver.

Outcome of thrombolysis with streptokinase in patients with prosthetic valve thrombosis

Objective

To evaluate the outcome of thrombolysis in patients of prosthetic valve thrombosis.

Methods

This retrospective analysis was conducted on data of 84 patients of prosthetic valve thrombosis who presented to emergency room of Faisalabad Institute of Cardiology between July 2017 to December 2019. The diagnosis of prosthetic valve thrombosis was based on clinical suspicion and bed side transthoracic echocardiography done by a consultant cardiologist. Fluoroscopy was done to confirm the diagnosis by observing immobile valve leaflet. The confirmed patients were then treated in emergency with streptokinase after taking an informed consent. Quantitative variables like age were summarized by mean and standard deviation. Qualitative variables like gender, successful thrombolysis, stroke, major bleeding, mortality or re-do surgery were summarized by frequency and percentage.

Results

Mean age was 29 ± 6.36, years and there were more female patients (n=43, 51.25%) as compared to males (n=41, 48.8%). Among the 66 surviving patients thrombolysis was successful without any complications in 56 patients (66.7%). Thrombolysis was successful with minor complications in six patients (7.1%) and it failed to produce desired results in four patients (4.8%). In this study 18 (21.4%) patients died. The common complications included minor bleeding in four patients (4.8%) and major bleeding in 10 patients (12.0 %).

Conclusion

Thrombolysis produces reasonable success rate in cases of prosthetic valve thrombosis who are in functional class I or II. However, it has very high mortality rate in patients presenting with functional class III and IV.

The Global Burden of Rheumatic Heart Disease: Population-Related Differences (It is Not All the Same!)

Rheumatic heart disease (RHD) remains the most common cardiovascular disease in young adults and adolescents in need of heart surgery in low- and middle-income countries (LMICs). The mean age of patients is 20-25 years, often much younger. By contrast, the few patients with chronic RHD in developed countries present a mean age of around 55 years. It is absolutely fundamental to differentiate these two types of population. Pathology, lesions and surgical methods are different, and the results should not be compared. It is not all the same! A certain enthusiasm for mitral repair has recently surged, with several reports showing excellent results in children and young adults, resulting from the renewed interest of cardiac surgeons, also based on new and modified techniques developed in the meantime. While surgery is easily accessible to patients in developed countries, the situation in LMICs is often dramatic, with countries where there is a complete absence of or few surgical facilities absolutely unable to meet gigantic demands. Many foreign surgical teams conduct humanitarian missions in several of these countries. They are just a "drop of water in the ocean" of needs. In some cases, however, these missions led to the establishment of local teams that now work independently and, in some cases, outperform the foreign teams still visiting.

Lutembacher syndrome variant: Rheumatic heart disease involving all four valves and associated with an atrial septal defect in a child

Rheumatic heart disease (RHD) is the most common cause of acquired heart disease in children and young adults in developing countries. It results from throat infection with group A beta hemolytic streptococcus that proceeds to acute rheumatic fever (ARF). We report a 13 years old girl from Darfur presenting with recurrent acute rheumatic fever for 4 years that led to affection of all her heart valves with severe mitral and tricuspid regurgitation together with moderate pulmonary and mild aortic valve regurgitation. There was an associated atrial septal defect (Lutembacher syndrome variant). The disease was severe and led to cardiogenic shock and death while awaiting surgery. The case highlights the impact of RHD on young people and the need to implement control programs for RHD in Sudan.

Rationale and design of the African group A streptococcal infection registry: the AFROStrep study

INTRODUCTION

Group A β-haemolytic Streptococcus (GAS), a Gram-positive bacterium, also known as Streptococcus pyogenes, causes pyoderma, pharyngitis and invasive disease. Repeated GAS infections may lead to autoimmune diseases such as acute post-streptococcal glomerulonephritis, acute rheumatic fever (ARF) and rheumatic heart disease (RHD). Invasive GAS (iGAS) disease is an important cause of mortality and morbidity worldwide. The burden of GAS infections is, however, unknown in Africa because of lack of surveillance systems.

METHODS AND ANALYSIS

The African group A streptococcal infection registry (the AFROStrep study) is a collaborative multicentre study of clinical, microbiological, epidemiological and molecular characteristics for GAS infection in Africa. The AFROStrep registry comprises two components: (1) active surveillance of GAS pharyngitis cases from sentinel primary care centres (non-iGAS) and (2) passive surveillance of iGAS disease from microbiology laboratories. Isolates will also be subjected to DNA isolation to allow for characterisation by molecular methods and cryopreservation for long-term storage. The AFROStrep study seeks to collect comprehensive data on GAS isolates in Africa. The biorepository will serve as a platform for vaccine development in Africa.

ETHICS AND DISSEMINATION

Ethics approval for the AFROStrep registry has been obtained from the Human Research Ethics Committee at the University of Cape Town (HREC/REF: R006/2015). Each recruiting site will seek ethics approval from their local ethics' committee. All participants will be required to provide consent for inclusion into the registry as well as for the storage of isolates and molecular investigations to be conducted thereon. Strict confidentiality will be applied throughout. Findings and updates will be disseminated to collaborators, researchers, health planners and colleagues through peer-reviewed journal articles, conference publications and proceedings.

Proportion of patients in the Uganda rheumatic heart disease registry with advanced disease requiring urgent surgical interventions

INTRODUCTION

Since the establishment of the Uganda Rheumatic Heart Registry, over 900 patients have been enrolled. We sought to stratify the patients in the registry according to disease severity and optimal management strategy.

METHODS

We reviewed data of 618 patients who had enrolled in the Registry between March 2010 and February 2013. The 67 patients who had died were excluded leaving 551 patients who were recruited. The optimum management strategy was determined according to the 2012 European Society of Cardiology guidelines on the management of valvular heart disease.

RESULTS

Out of the 551 patient's records evaluated, 398 (72.3%) required invasive intervention, with 332(60.3%) patients requiring surgery and 66 (12.0%) requiring percutaneous mitral commissurotomy (PMC). This leaves only 27.7% of patients who required only medical management. Currently, majority of the patients (498, 90.4%) in the registry are on medical treatment. Of the 60.3% requiring surgical intervention, only 8.0% (44 patients) underwent valvular surgery and 5(1.0%) patients of the 66 (12.0%) underwent PMC successfully.

CONCLUSION

There is a high proportion of patients with severe disease that require surgical treatment yet they cannot access this therapy due to absence of local expertise.

The HLA Class II Associations with Rheumatic Heart Disease in South Indian Patients: A Preliminary Study

INTRODUCTION

Rheumatic heart disease (RHD) occurs in 30-45% of the patients with rheumatic fever (RF) and it leads to chronic valvular lesions. The human leukocyte antigen (HLA) might confer a susceptibility to RHD. The aim of the present study was to determine the prevalent HLA class II DR/DQ allelic types which were associated with rheumatic heart disease (RHD) in a small group of south Indian patients and to compare them with those in the control subjects.

METHODS

A total of 23 patients who were diagnosed with RHD and 6 control samples were included in this study. A low resolution HLA Class II DR/DQ typing was performed on the blood samples by the PCR-SSP method.

RESULTS AND CONCLUSION

The DRB3*01:01:02:01 allele showed a positive association with RHD, whereas the DQB1 loci alleles did not show any significant association.

Rheumatic fever in children

Rheumatic fever (RF) and rheumatic heart disease (RHD) are major public health problems in developing countries. A prospective study carried out in a large general hospital showed that carditis was the predominant feature in first attack and also the recurrence of RF but that recurrence was associated with more severe manifestations. Echocardiography picked up cases of subclinical carditis. Presence of congestive cardiac failure in association with carditis always led to chronic RHD. Recurrence occurred only when patient defaulted penicillin prophylaxis. The overall recurrence rate was 0.026 per patient.

Integrated community-based screening for cardiovascular diseases of childhood

A screening programme in northern India, principally aimed at detecting and controlling rheumatic fever and rheumatic heart disease (RF/RHD) in children, also picks up individuals with congenital heart disease and other cardiovascular conditions, who are then referred for consultation and treatment. This strategy is clearly more ethical and cost-effective than screening programmes concerned exclusively with the control of RF/RHD.

Obstetric deaths in Menoufia Governorate, Egypt

A survey of all registered deaths which occurred during 1981-1983 in women of reproductive age was carried out in Menoufia Governorate, Egypt. Surviving family members were interviewed by trained social workers, and information was collected on symptoms of the disease that led to death. The completed questionnaires were reviewed by a panel of local physicians and a cause of death was assigned by the panel. Maternal mortality was a leading cause of death, second only to heart disease. There were 190 maternal deaths per 100,000 livebirths and 45 maternal deaths per 100,000 married women aged between 15 and 49 years. Most of the maternal deaths (63%) were due to direct obstetric causes of which haemorrhage was the main cause. Another 27% of the maternal deaths were due to indirect obstetric causes of which rheumatic heart disease was the main cause.