Rheumatic heart disease

RHEUMATIC HEART DISEASE WHAT IS IT?

Rheumatic Heart Disease is the sequelae of Rheumatic fever which is an infection by a bacterium (beta hemolytic streptococcus). The fever affects children or young adults. It typically presents with fever and joint inflammations.

The common joints affected are knee, hip and elbow. The swelling and pain in joints has a characteristic ‘fleeting’ nature. They affect one joint at a time and seem to migrate from one joint to another. The joint lesions heal without any scar.

Rheumatic Valvular Disease is caused by the immunological reaction of the body which is misdirected at the valvular tissue. It causes inflammation and scarring of the heart valves and result in valve dysfunction – stenosis or regurgitation or a combination. Mitral valve is affected most. But other valves are also affected singly or along with mitral valve.

SYMPTOMS The symptoms of valvular diseases will vary depending on the type valve, nature of lesion (block or leak), severity of lesion and rapidity of progress. Dyspnea or Breathlessness

This is one of the commonest symptom of any type of valvular disease. From mild to most severe form this symptom can vary in intensity. Milder forms present only on exertion while more severe forms can be present even at rest.

In very severe types the patient may not be able to lay down comfortably (Orthopnea). He may also experience sudden bouts of severe breathlessness in the night which forces him to wake up with extreme difficulty in breathing associated with cough (Paroxysmal Nocturnal Dyspnea or PND). These extreme forms are most commonly seen in Mitral valve disease. Palpitation Awareness of one’s own heartbeats is known as Palpitation.

Valve disorders can present with various types of rhythm disturbances. Extra beats (Premature atrial / Ventricular Contractions) are quite common. Atrial Fibrillation is common in Mitral Stenosis and Mitral Regurgitation.

Atrial fibrillation (AF) is an abnormal rhythm where atrial contractions are ineffective and rapid and ventricular contractions are irregular. Often presented as palpitation. In valvular diseases this condition is caused by atrial dilatation and commonly found in Mitral disease. Atrial fibrillation causes blood to stagnate in atria and can cause clots in the atria. This can lead to Thrombo-Embolism (Migration of small clots into the circulation causing occlusion of arteries) It can embolize to legs or abdomen.

When it happens in the brain circulation, the result is a stroke! So AF is a serious condition which needs to be treated. Patient has to be on Anticoagulant medications (Blood thinning agents to prevent clots) until AF is reverted Copyright ⓒ 2017 Heart and Aorta. All right reserved.

Angina: Presentation of angina is just like that in Coronary Artery Disease. This symptom is common in Aortic Stenosis and can often be confusing Giddiness: Often the presenting symptom in Aortic lesions. In Aortic stenosis it is seen early while in Aortic regurgitation it is late symptom. Non-specific symptoms: Patients may experience extreme tiredness, nausea, loss of appetite and even weight loss.

DIAGNOSING VALVULAR HEART DISEASE Thorough clinical evaluation and routine investigations are mandatory. However the mainstay of diagnosing valvular heart diseases is an Echocardiography.

Echo provides accurate information regarding structure of valve and dimensions of the chambers. Doppler information is valuable in calculating the degree of stenosis or regurgitation. Trans-Esophageal Echocardiography or TEE can be helpful in planning valve repairs.

TREATMENT Medical Treatment Once the valve disorder is diagnosed, initial line of treatment will be medical. Depending on the type of lesion and severity of the lesion the treatment also differs. The medicines may include anti-hypertensive drugs, heart rate controlling medications, diuretics, anti-platelets and anti-coagulants.

In rheumatic valvular diseases, Penicillin prophylaxis may be given. Patients with Atrial Fibrillation (AF) should receive anticoagulants. If the symptoms are relieved by medications, the treatment can be continued until the disease progresses to the next stage. Sometimes in the course of treatment a decision may have to be taken regarding other treatment methods like surgery.

Balloon Valvotomy: In stenotic lesions of Mitral or Pulmonary valves, Dilatation of the stenosed valve by using a special balloon is a favored treatment. The valve must be soft with out calcification and pliable. Very hard valves can not be safely opened with balloon. It may cause balloon to rupture or valve may tear at an undesirable location causing severe valve leak. So the valve anatomy has to be carefully assessed by Echocardiography.

Valve Replacement: Severe valve disorders that cannot be treated by other methods may need valve replacement. Every patient has to be assessed individually and a careful decision made regarding replacement. Mitral and Aortic valves are the commonly affected valves and so the replacements are also common in these positions. Variety of valves are available for replacement. However they can be broadly divided into two categories. Mechanical Valves and Bio-prosthetic (Tissue) valves. ‘Mechanical Vs Bio-prosthetic valves’ is dealt in another section. Valve Repair: In spite of the tremendous progress made in the design and structure of mechanical and tissue valves, the ideal valve prosthesis is still far from reality. No man made valve can match the simplicity and efficiency of natural human valves. Even in partially defective condition natural valves function better than the prosthetic ones. In spite of the tremendous progress made in the design and structure of mechanical and tissue valves, the ideal valve prosthesis is still far from reality. No man made valve can match the simplicity and efficiency of natural human valves. Even in partially defective condition natural valves function better than the prosthetic ones.

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