CARDIAC SURGERY FOR VALVULAR HEART DISEASE AT A REFERRAL HOSPITAL IN ETHIOPIA: A REVIEW OF CASES OPERATED IN THE LAST 30 YEARS
Background: Valvular heart disease has been a significant cause of heart disease worldwide. In Ethiopia, it particularly affects young individuals and constitutes the major cause of cardiovascular disease. Factors associated with choice of treatment for advanced valvular heart disease are variable. The objective of this study is to review surgery done for Ethiopian patients with valvular heart disease.
Methods: We analyzed data on patients who had valve surgery and follow-up at the Tikur Anbessa Specialized Hospital cardiology unit. We collected data on sociodemographic characteristics, the pre-operative status of effected valves and co-morbidities, and assessed their associations with patient management options.
Results: A total of 157 valve surgeries were done from 1983 to 2013. Mean age at time of surgery was 26.7 years and females constituted 66% of the cases. Patients with rheumatic heart disease were younger, more likely to be female and have atrial fibrillation, but less likely to have impaired left ventricular systolic function when compared to patients with non-rheumatic heart disease. More than 75% of the surgical procedures done were mechanical valve replacement. Mechanical valves, compared with bioprosthetic valves, were more likely to be used in patients with rheumatic heart disease. The median age of those receiving mechanical valves, 24 (IQR 22 – 28) years, was lower than those receiving bioprosthetic valves, 31.5 (IQR 29.9 – 37.9) years. Mechanical valve replacement was significantly higher in those under the age of 20 years (Adjusted Odds Ratio 41.0, 95% CI: 3.0-557.2) and in those between 20 and 29 years of age (Adjusted Odds Ratio 14.3, 95% CI: 2.3-88.6).
Conclusions: Valve surgery for valvular heart diseases has been more common performed for young and female patients. A great majority of the replacements done have been with mechanical valves. As many of the patients have been younger and female, the choice of valve surgery and the need for anticoagulation impacts subsequent management of rheumatic heart disease and associated morbidities, lifestyle plans and pregnancy.
Keywords: Rheumatic heart disease, valve surgery, valve choice, Ethiopia
Carapetis J, Steer A, Mulholland E, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005; 5:685-94.
Zühlke L, Watkins D, Engel ME. Incidence, prevalence and outcomes of rheumatic heart disease in South Africa: a systematic review protocol. BMJ Open. 2014 Jun 10; 4(6):e004844.
Remenyi B, Carapetis J, Wyber R, Taubert K, Mayosi BM. Position statement of the World Heart Federation on the prevention and control of rheumatic heart disease. Nat Rev Cardiol. 2013; 10:284-92.
RHDAustralia (ARF/RHD writing group), National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition). 2012.
Guteta S, Oli K, Feleke Y, Yadeta D, Makonnen D, Tafese A. Spectrum of cardiovascular diseases among Ethiopian patients. Ethiop Med J. 2014; 52(1):9-17.
Oli K, Porteous J. Prevalence of rheumatic heart disease among school children in Addis Ababa. East Afr Med J. 1999; 76:601-5.
Remenyi B, Wilson N, Steer A, Ferreira B, Kado J, Kumar K, et al. World Heart Federation criteria for echocardiographic diagnosis ofrheumatic heart disease-an evidence-based guideline. Nature reviews Cardiology. 2012;9:297-309.
Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet Infect Dis. 2009; 373:1382-94.
Bhandari S, Subramanyam K, Trehan N. Valvular heart disease: diagnosis and management. J Assoc Physicians India. 2007; 55:575-84.
Baskerville CA, Hanrahan BB, Burke AJ, Holwell AJ, Remond MG, Maguire GP. Infective endocarditis and rheumatic heart disease in the north of Australia. Heart Lung Circ. 2012; 21:36-41.
Lehman SJ, Baker RA, Aylward PE, Knight JL, Chew DP. Outcomes of cardiac surgery in Indigenous Australians. Med J Aust. 2009; 190:588-93.
Alizzi AM, Knight JL, Tully PJ. Surgical challenges in rheumatic heart disease in the Australian indigenous population. Heart Lung Circ 2010; 19:295-8.
Maguire GP, Carapetis JR, Walsh WF, Brown AD. The future of acute rheumatic fever and rheumatic heart disease in Australia. Med J Aust. 2012; 197:133-4.
Zakkar M, Amirak E, Chan KMJ, Punjabi PP. Rheumatic Mitral Valve Disease: Current Surgical Status. Prog Cardiovasc Dis. 2009; 51:478-81.
Dolgin M, editor. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels / the criteria committee of the New York Heart Association. Boston: Little, Brown, 1994.
Bernal JM, Ponton A, Diaz B, Llorca J, Garcia I, Sarralde A, et al. Surgery for rheumatic tricuspid valve disease: a 30-year experience. J Thorac Cardiovasc Surg. 2008; 136:476-81.
Choudhary SK, Talwar S, Dubey B, Chopra A, Saxena A, Kumar AS. Mitral valve repair in a predominantly rheumatic population. Long-term results. Tex Heart Inst J. 2001; 28:8-15.
Russell EA, Tran L, Baker RA, Bennetts JS, Brown A, Reid CM, et al. A review of valve surgery for rheumatic heart disease in Australia. BMC Cardiovascular Disorders. 2014; 14:134.
Wiemers P, Marney L, Muller R, Brandon M, Kuchu P, Kuhlar K, et al. Cardiac surgery in Indigenous Australians-how wide is 'the gap'? Heart Lung Circ. 2014; 23:265-72.
Essop MR, Nkomo VT. Rheumatic and Nonrheumatic Valvular Heart Disease: Epidemiology, Management, and Prevention in Africa. Circulation. 2005; 112:3584-91.
Wang A, Krasuski R, Warner J, Pieper K, Kisslo K, Bashore T, et al. Serial echocardiographic evaluation of restenosis after successful percutaneous mitral commissurotomy. J Am Coll Cardiol 2002; 39:328-34.
Fawzy ME, Fadel B, Al-Sergani H, Al Amri M, Hassan W, Abdulbaki K, et al. Long-Term Results (Up to 16.5 Years) of Mitral Balloon Valvuloplasty in a Series of 518 Patients and Predictors of Long-Term Outcome. J Interv Cardiol. 2007; 20:66-72.
Blaustein AS, Ramanathan A. Tricuspid valve disease. Clinical evaluation, physiopathology, and management. Cardiol Clin. 1998; 16:551-72.
Edwin F, Aniteye E, Tettey M, Tamatey M, Frimpong-Boateng K. Outcome of left heart mechanical valve replacement in West African children - A 15-year retrospective study. J Cardiothorac Surg. 2011; 6:57.
Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE. Mitral valve repair and replacement for rheumatic disease. J Thorac Cardiovasc Surg. 2000; 119:53-60.
Remenyi B, Webb R, Gentles T, Russell P, Finucane K, Lee M, et al. Improved Long-Term Survival for Rheumatic Mitral Valve Repair Compared to Replacement in the Young. World Journal for Pediatric and Congenital Heart Surgery. 2013; 4:155-64.
De Santo LS, Romano G, Della Corte A, Tizzano F, Petraio A, Amarelli C, et al. Mitral mechanical replacement in young rheumatic women: analysis of long-term survival, valve-related complications, and pregnancy outcomes over a 3707-patient-year follow-up. J Thorac Cardiovasc Surg. 2005; 130:13-9.
Wang Z, Zhou C, Gu H, Zheng Z, Hu S. Mitral valve repair versus replacement in patients with rheumatic heart disease. J Heart Valve Dis. 2013; 22:333-9.
Bakir I, Onan B, Onan IS, Gul M, Uslu N. Is rheumatic mitral valve repair still a feasible alternative?: indications, technique, and results. Tex Heart Inst J. 2013; 40:163-9.
Sarralde J, Bernal J, Llorca J, Ponton A, Diez-Solorzano L, Gimenez-Rico JR, et al. Repair of rheumatic tricuspid valve disease: predictors of very long-term mortality and reoperation. Ann Thorac Surg. 2010; 90:503-8.
Chaudhry F, Upadya S, Singh V, Cusik D, Izrailtyan I, Sanders J, et al. Identifying patients with degenerative mitral regurgitation for mitral valve repair and replacement: a transesophageal echocardiographic study. J Am Soc Echocardiogr. 2004; 17:988-94.