Andersons pediatric cardiology 1465

Cardiac Magnetic Resonance Imaging in Rheumatic Heart Disease The potential strengths of cardiac MRI in the assessment of patients with RHD are increased accuracy in assessment of ventricular volumes in comparison to echocardiography, the ability to measure the volume of regurgitant flow, and to characterize the tissue properties of the myocardium when the diagnosis of RHD is in doubt The first two applications may be of use in determining the timing of surgery with greater precision.39 The ability to detect and quantify the degree of carditis using techniques such as T1/T2 sequences and T1 mapping may be of use in determining the diagnosis or monitoring therapy over and above blood markers of systemic inflammation.40 Clearly poor access to highly specialized equipment and technology such as cardiac MRI in the population of patients most affected by RHD is its greatest limitation Therefore echocardiography is likely to remain the main imaging technique used to diagnose and monitor cardiac changes in the majority of patients affected Complications of Rheumatic Heart Disease Once established, RHD is associated with substantial morbidity and mortality Heart failure, infective endocarditis, atrial fibrillation (AF), pregnancy-related complications, and stroke are key complications of RHD.2,15,41 There is little in the contemporary literature relating to morbidity associated with RHD The REMEDY study15 reported that 33% patients had heart failure, 22% had AF, 7% had previously had a stroke, and 4% had infective endocarditis In resource-poor settings, the management of pregnant women with RHD is challenging Maternal morbidity in the setting of severe RHD has been reported to be 3.3% in South Africa42 and 33% in Senegal.43 Atrial Fibrillation AF is a relatively rare complication of RHD in the pediatric population; it is most commonly seen in the setting of MS Age and left atrial dimension are the most important risk factors for the development of AF in the setting of MS.44 Other risk factors include left atrial strain as well as elevated right atrial pressure and ejection fraction.44 Initially AF may be paroxysmal, but as MS and left atrial dilatation progresses, it eventually becomes chronic.45 AF has very serious complications, including systemic embolism or stroke The risk of AF and its complications persists even after the specific structural disease has been treated with use of either percutaneous or surgical techniques.46 Even episodes of transient AF shorter than 30 seconds detected by Holter monitoring predict the primary composite end point of stroke, transient ischemic attack, or non–central nervous system systemic embolization.47 Stroke In pediatric populations, the incidence of cerebrovascular accidents in the setting of RHD is not well defined It may be ischemic or hemorrhagic in nature and can be associated with the specific native valvar abnormality, such as MS, mechanical/bioprosthetic valve replacements, and/or atrial arrhythmias such as AF/flutter However, factors other than AF—including regional (left atrial) hypercoagulability, increased prothrombotic biomarkers, and reduced fibrinolytic activity—may contribute to stroke.48,49 Mechanical valve replacements in the pediatric population pose an extreme risk of cerebrovascular events.50 This is especially so in resource-poor settings, where the majority of RHD patients reside.15 Heart Failure Advanced valvar dysfunction eventually leads to congestive cardiac failure An Australian study showed that 27% of patients developed heart failure within 5 years from the time of diagnosis of RHD.51 Those who develop heart failure require surgical or percutaneous intervention or they will succumb In South Africa the 60-day mortality after admission with acute heart failure due to RHD was 25% and 180-day mortality was 35%.30 Infective Endocarditis RHD is a risk factor for infective endocarditis,52 which can be minimized by exercising meticulous dental hygiene It is unclear whether RHD, compared with other valve diseases, poses an incrementally increased risk due to rheumatic valve pathology itself or to confounding factors (such as poor dentition, low level of education, and other social determinates of health) common in patients with this disease With RHD, the need for infective endocarditis prophylaxis before dental and surgical procedures is controversial; it is recommended by the Australian53 and New Zealand authorities54 but not by the American College of Cardiology (ACC) and the American Heart Association (AHA) 2017 guidelines.55 ... Africa42 and 33% in Senegal.43 Atrial Fibrillation AF is a relatively rare complication of RHD in the pediatric population; it is most commonly seen in the setting of MS Age and left atrial dimension are the... primary composite end point of stroke, transient ischemic attack, or non–central nervous system systemic embolization.47 Stroke In pediatric populations, the incidence of cerebrovascular accidents in the setting of RHD is not well defined... hypercoagulability, increased prothrombotic biomarkers, and reduced fibrinolytic activity—may contribute to stroke.48,49 Mechanical valve replacements in the pediatric population pose an extreme risk of cerebrovascular events.50 This is especially so in resource-poor settings, where the majority of