Elsevier

International Journal of Cardiology

Volume 318, 1 November 2020, Pages 104-114
International Journal of Cardiology

Poorly suited heart valve prostheses heighten the plight of patients with rheumatic heart disease

https://doi.org/10.1016/j.ijcard.2020.05.073Get rights and content

Highlights

  • RHD affects more patients globally than degenerative valve disease.

  • Heart valve replacement is often required in these young patients.

  • Western guidelines and available HV-prostheses are often ill-suited.

  • For the time being mechanical valves may be detrimentally over-prescribed.

  • Head-to-head studies of tissue valves versus mechanical valves are overdue.

Abstract

Rheumatic heart disease (RHD) still affects more patients globally than degenerative valve disease. The vast majority of these patients live in low- to middle-income countries. Once symptomatic, they will need heart valve surgery. Unfortunately, prosthetic valves perform poorly in these patients given their young age, the high incidence of multi-valve disease, late diagnoses and often challenging socio-economic circumstances.

Notwithstanding the fact that better valve designs would ideally be available, ill-informed decision making processes between bioprosthetic and mechanical valves are contributing to the poor results. In the absence of multicentred, randomised clinical trials, comparing the current generations of bioprostheses with mechanical valves across all age groups Western guidelines tend to be uncritically applied. As a consequence, mechanical valves are being implanted into patients who are often not able to deal with anticoagulation while bioprosthetic valves may be overly shunned for fear of reoperations.

Almost sixty years after the advent of cardiac surgery heart valve prostheses have eventually undergone improvements and several potentially disruptive developments are on the horizon. Until they materialise, however, choices between contemporary valve prostheses need to be made on the basis of individual risk and life-expectancy rather than an uncritical implementation of guidelines that were derived for very different patients and under distinctly different conditions.

Given the fast expansion of cardiac surgery in middle-income countries and a growing number of independently operating centres in low-income countries a critical appraisal of facts underlying the choice of heart valve prostheses for patients with RHD seems opportune.

Introduction

Contemporary replacement heart valves were developed for the patients of industrialised countries with their advanced medical systems. To keep complication rates within an acceptable range mechanical valves need reliable anti-coagulation monitoring and bioprosthetic valves should preferentially go into older patients. Both these preconditions are insufficiently met in low- to middle-income countries (LMICs) where the dominant valve pathology is rheumatic rather than degenerative [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]] (Fig. 1).Typically, these patients are young, poor, uneducated, and often have difficulty in accessing medical care [11,14,15]. Unsurprisingly, even if they have access to cardiac surgery, clinical results are disappointing. Low anticoagulation compliance due to socioeconomic and cultural circumstances leads to a high incidence of lethal or debilitating thromboembolic complications in patients with mechanical valves [[16], [17], [18], [19], [20], [21]]. Alternatively, many patients have no choice but receiving a bioprosthetic valve at a relatively young age notwithstanding the possibility of needing several re-operations over their life span [22] (Fig. 2).

Section snippets

Heart valve surgery for RHD

Rheumatic heart disease (RHD) is not limited to developing countries. Contrary to perceptions, RHD still claims a large proportion of its global burden of deaths in middle-income countries (MICs) [23]. While these countries increasingly have access to open heart surgery, they share many of the specific challenges associated with RHD in low-income countries (LICs) foremost the poor suitability of replacement heart valves for a significant proportion of patients.

Locally produced valves continue

Valve failures

As much as valve sparing operations even in the presence of severe fibrosis [84] have significantly expanded the spectrum of mitral repairs [6,44,[85], [86], [87], [88]] and aortic valve repairs [89] including the Ross operation [90] are beginning to be applied to patients with RHD [91] a significant proportion of patients will continue to rely on valve replacements. The lack of repair skills in frontline low-volume centres [11] and the high incidences of endocarditis [32] are only two of the

In summary

In the absence of large, multicentred, randomised clinical trials, using the current generations of bioprostheses and mechanical valves across all age groups [143] valve choices will be least harmful if sensible and appropriate criteria rather than Western guidelines are being uncritically applied.

At the outset of such an approach must be an assessment of a patient's life expectancy taking his/her geographic, socioeconomic and medical background into consideration. Assessment criteria must be

Glimmers of hope

The quest for longer lasting tissue valves and anticoagulation-free mechanical valves of young patients of HICs who are eager to live an active life may add weight to the efforts of middle-income countries addressing the needs of their patients with RHD.

Low-thrombogenicity designs of mechanical valves have been a holy grail for decades but with tri-leaflet concepts [154] they may eventually be within reach. A novel design that placed the hinges of a tri-leaflet valve distinctly into the central

Declaration of Competing Interest

PZ is a shareholder in the University of Cape Town start-up company 'Strait Access technologies'

References (179)

  • M.J. Antunes et al.

    Valvuloplasty for rheumatic mitral valve disease. a surgical challenge

    J. Thorac. Cardiovasc. Surg.

    (1987)
  • L. Kontozis et al.

    Long-term follow-up of St. Jude Medical prosthesis in a young rheumatic population using low-level warfarin anticoagulation: an analysis of the temporal distribution of causes of death

    Am. J. Cardiol.

    (1998)
  • R.O. Bonow et al.

    ACC/AATS/AHA/ASE/EACTS/HVS/SCA/SCAI/SCCT/SCMR/STS 2017 appropriate use criteria for the treatment of patients with severe aortic stenosis a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons

    J. Am. Coll. Cardiol.

    (2017)
  • R. Bhardwaj

    Atrial fibrillation in a tertiary care institute - a prospective study

    Indian Heart J.

    (2012)
  • E.A. Russell et al.

    The burden and implications of preoperative atrial fibrillation in Australian heart valve surgery patients

    Int. J. Cardiol.

    (2017)
  • R.P. Whitlock et al.

    Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines

    Chest

    (2012)
  • J.R. Carapetis et al.

    The global burden of group a streptococcal diseases

    Lancet Infect. Dis.

    (2005)
  • L.S. Wann et al.

    2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline): a report of the American college of cardiology foundation/American heart association task force on practice guidelines

    Heart Rhythm.

    (2011)
  • P. Kvidal et al.

    Observed and relative survival after aortic valve replacement

    J. Am. Coll. Cardiol.

    (2000)
  • D. McGurty et al.

    Outcomes following rheumatic mitral valve repair in children

    Ann. Thorac. Surg.

    (2019)
  • S. Ozaki et al.

    Midterm outcomes after aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium

    J. Thorac. Cardiovasc. Surg.

    (2018)
  • S. John et al.

    Valve replacement in the young patient with rheumatic heart disease. review of a twenty-year experience

    J. Thorac. Cardiovasc. Surg.

    (1990)
  • U.K. Chowdhury et al.

    Mitral valve replacement using Carpentier-Edwards pericardial bioprosthesis in patients with rheumatic heart disease aged below 40 years: 17-year results

    Heart Lung Circ.

    (2018)
  • K. Sliwa et al.

    Rheumatic heart disease: the tip of the iceberg

    Circulation

    (2012)
  • A.O. Mocumbi

    Lack of focus on cardiovascular disease in sub-Saharan Africa

    Cardiovasc. Diagn. Ther.

    (2012)
  • A. ElSayed et al.

    The rebirth of cardiac surgery in Sudan

    Cardiovasc. Diagn. Ther.

    (2016)
  • S.G. Little

    The challenges of managing rheumatic disease of the mitral valve in Jamaica

    Cardiol. Young

    (2014)
  • C. Mve Mvondo et al.

    Mechanical heart valve replacement in a low-middle income region in the modern era: midterm results from a sub-Saharan center

    Thorac. Cardiovasc. Surg.

    (2020)
  • Pezzella AT. On Location-Vietnam.CTSNET 2017. CTSNET...
  • M.D. Seckeler et al.

    The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease

    Clin Epidemiol.

    (2011)
  • K.H. Yangni-Angate et al.

    Cardiac surgery in Africa: a thirty-five year experience on open heart surgery in cote d’Ivoire

    Cardiovasc. Diagn. Ther.

    (2016)
  • Q.Q. Han et al.

    Primary triple valve surgery for advanced rheumatic heart disease in mainland China: a single-center experience with 871 clinical cases

    Eur. J. Cardiothorac. Surg.

    (2007)
  • P. Zilla et al.

    Cardiac surgery in low- to middle-income countries (LMICS): a glimpse of hope

    Cardiac. Diagn. Ther.

    (2020)
  • R.K. Kumar et al.

    Rheumatic fever & rheumatic heart disease: the last 50 years

    Indian J. Med. Res.

    (2013)
  • G. Watson et al.

    Acute rheumatic fever and rheumatic heart disease in resource-limited settings

    Arch. Dis. Child.

    (2015)
  • M.J. Antunes

    Challenges in rheumatic valvular disease: surgical strategies for mitral valve preservation

    Glob Cardiol Sci Pract.

    (2015)
  • W. Zhang et al.

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

    Afr. Health Sci.

    (2015)
  • J. Scherman et al.

    Isolated mechanical aortic valve replacement in rheumatic patients in a low- to middle-income country

    J. Thorac. Cardiovasc. Surg.

    (2018)
  • S.W. Ogendo

    Long term valve-related morbidity following open-heart surgery at the Kenyatta National Hospital

    East Afr. Med. J.

    (2000)
  • T. Chalachew et al.

    Factors associated with sub-optimal control of anticoagulation in patients with prosthetic heart valves taking oral anticoagulants in a sub-Saharan African setting

    Cardiovasc. J. Afr.

    (2019)
  • A.D. Bowry et al.

    A systematic review of adherence to cardiovascular medications in resource-limited settings

    J. Gen. Intern. Med.

    (2011)
  • E.K. Rusingiza et al.

    Outcomes for patients with rheumatic heart disease after cardiac surgery followed at rural district hospitals in Rwanda

    Heart

    (2018)
  • D.A. Watkins et al.

    Global, regional, and national burden of rheumatic heart disease, 1990-2015

    N. Engl. J. Med.

    (2017)
  • R. Sankarkumar et al.

    Chitra heart valve: results of a multicenter clinical study

    J Heart Valve Dis.

    (2001)
  • L.G. Azeredo et al.

    Late outcome analysis of the Braile Biomedica(R) pericardial valve in the aortic position

    Rev. Bras. Cir. Cardiovasc.

    (2014)
  • V.M.P.M.R. Azevedo et al.

    Migowski a is rheumatic fever in Brazilian young adults an alrady controlled disease?

    Glob. Heart

    (2014)
  • R.M. de Aquino Xavier et al.

    Medium-term outcomes of 78,808 patients after heart valve surgery in a middle-income country: a nationwide population-based study

    BMC Cardiovasc. Disord.

    (2017)
  • A.S. Kumar et al.

    Results of mitral valve repair in rheumatic mitral regurgitation

    Interact. Cardiovasc. Thorac. Surg.

    (2006)
  • G.F. Coutinho et al.

    Preservation of the subvalvular apparatus during mitral valve replacement of rheumatic valves does not affect long-term survival

    Eur. J. Cardiothorac. Surg.

    (2015)
  • M.C. De Villiers et al.

    The changing landscape of infective endocarditis in South Africa

    S. Afr. Med. J.

    (2019)
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