Mean Levels of B-type Natriuretic Peptide (BNP) in Patients with Mitral Stenosis Caused by Rheumatic Heart Disease

Objective: Mitral stenosis caused by rheumatic heart disease (RHD) is the most common cause of valvular lesion in adults and prevalent in developing countries like Pakistan. Higher natriuretic peptide (BNP) levels can be observed in patients with moderate to severe untreated mitral stenosis and are associated with higher rates of morbidity and mortality. That is why this study aims to determine the association between levels of pro-BNP with severity (mild. Moderate, and severe) of mitral stenosis. Patients and Methods: This was a clinical prospective study carried out in the department of adult cardiology, national institute of cardiovascular diseases, Karachi from 8th august 2019 to 7th February 2020. Total 68 patients of either gender with age between 25-70 years had mitral stenosis of moderate to severe intensity (mitral valve area ≤1.5 cm2), diagnosed on echocardiography were included for final analysis. A simple blood sample was taken for the assessment of pro-BNP levels. Questionnaire was used for demographic & clinical data collection and analysed using SPSS version 22.0. Results: The overall mean age of study subjects was 42.21±11.50 years, ranging from 25 – 70 years. Among them, females were prevalent (n = 43, 63.2%). The overall mean serum BNP level was 1071.12±807.26 pg/ml and the mean difference of serum BNP level was not significant among groups of gender, age, and diabetes mellitus with p>0.05. Significantly raised levels of BNP were observed in patients with severe mitral stenosis as compared to moderate mitral stenosis, p<0.05 Conclusion: In conclusion, the mean BNP levels were higher in patients with severe Mitral Stenosis. Therefore, BNP may be used to complement the clinical and echocardiographic assessments in patients with Mitral Stenosis.

When Aortic Stenosis Is Not Alone: Epidemiology, Pathophysiology, Diagnosis and Management in Mixed and Combined Valvular Disease

Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.

Current Devices and Complications Related to Transcatheter Mitral Valve Replacement: The Bumpy Road to the Top

Mitral regurgitation is the most common valvular lesion in the developed world, with increasing prevalence, morbidity, and mortality. The experience with surgical mitral valve repair or replacement is very well-validated. However, more than 45% of these patients get denied surgery due to an elevated risk profile and advanced disease of the left ventricle at the time of presentation, promoting the need for less invasive transcatheter options such as transcatheter repair and transcatheter mitral valve replacement (TMVR). Early available TMVR studies have shown promising results, and several dedicated devices are under clinical evaluation. However, TMVR is still in the early developmental stages and is associated with a non-negligible risk of periprocedural and post-procedural complications. In this review, we discuss the current challenges facing TMVR and the potential TMVR-related complications, offering an overview on the measures implemented to mitigate these complications, and future implications.

Mitral valve stenosis

Mitral stenosis is an important valvular lesion that when encountered both in the developing world and the developed world requires accurate assessment. The mitral valve area is the key parameter that should be used to assess severity. Morphological assessment of the entire valve apparatus is required to identify rheumatic versus non-rheumatic aetiology as well the subgroup of patients who may benefit from percutaneous mitral commisurotomy. Three-dimensional transthoracic and transoesophageal echocardiography provide additive qualitative and quantitative data to the aforementioned key imaging requirements. Tomographic imaging (CT/MRI) are mainly utilized when echocardiography is not feasible. Imaging techniques are vital to aid diagnosis and explore therapeutic options in degenerative mitral stenosis but require further refinement with regard to accuracy of diagnosis and selection of optimal quantitative techniques.

Incidence & Pattern of Valvular Heart Disease in Patients attended in Echo Lab at a tertiary care Hospital: A single Centre Study

Background: This echocardiographic study was undertaken to establish incidence, pattern & complications in patients of valvular heart disease. Methods: A total of 97 patients were enrolled among the patients attended in echo lab at Ibrahim cardiac hospital & Research Institute over a period of 1 year. Results: Mean age was 53.8±1.5 years. Male were predominant (58.76% vs 41.23%). Most common symptom was shortness of breath (60.8%) followed by palpitation (43.3%). 39.2% of patients had normal ECG & 12.4% revealed AF. The most common complication was pulmonary hypertension (54.6%) followed by pulmonary edema (26.8%), Stroke (10.3%), Left atrial thrombus (7.3%), & infective endocarditis (6.2%). MV was most commonly involved (72.2%) followed by aortic valve (AV) (66.0%), tricuspid valve (TV) (54.6%) & pulmonary valve (PV) was (20.6%). Rheumatic involvement (52.6%) constituted the dominant cause than degenerative & congenital (24.7% in each). Mitral stenosis (MS) was predominant (52.6%) & was rheumatic in origin; then aortic stenosis (AS) (48.5%) which was mostly degenerative followed by bicuspid aortic valve (8.2%). Mitral regurgitation (MR) was the most common valvular lesion (64.9%); then aortic regurgitation (AR) (51.5%) which was also rheumatic in etiology. Multiple valve involvement was also present. The most common variety was MS+MR (43.3%). Tricuspid stenosis (TS) was in association with MR+AR (1.03%). Tricuspid regurgitation (TR) was 58.8%, mostly secondary to rheumatic involvement of other valves. Severe TR (5.2%) was due to Ebstain anomaly and prolapse (4.1% & 3.1%). ventricular systolic & diastolic functions were normal mostly. Conclusion: Among the rheumatic heart disease patients’ mitral valve was the most commonly affected valve. Mitral regurgitation was the most common valvular lesion. Rheumatic involvement remains the dominant cause of valvular heart disease in Bangladesh. Cardiovasc. j. 2021; 13(2): 144-153

Bartonella Species as a Cause of Culture-negative Endocarditis in South Africa

Background: Previous reports have highlighted the high prevalence of blood culture negative endocarditis (BCNE) in South Africa.Methods: The Tygerberg Endocarditis cohort (TEC) study is a prospective cohort study of patients with confirmed or suspected IE presenting to Tygerberg Academic Hospital, Cape Town, South Africa. Results: To date, 44 patients have been included in this ongoing study. Fourteen of the 44 patients (31.8%) had BCNE. Further analysis of the patients with BCNE identified Bartonella species as the most common causative organism (n=6; 43%). Other causes included Mycoplasma species (n=2), C. burnetii (n=1), and non-bacterial thrombotic endocarditis due to anti-phospholipid syndrome (n=1). No cause could be identified in 4 of the 44 patients (9%). Bartonella quintana was identified with PCR of valvular tissue as the causative organism in 4 of the 5 patients that underwent urgent surgery. The patients with Bartonella IE (n=6) had an average age of 39 years with equal gender distribution The common clinical features were clubbing (n=5; 83%), anemia (n=4; 66.6%), haematuria (n=3; 50%), acute on chronic severe valvular lesion (n=3; 50%) and acute severe valvular lesion (n=2; 33.3%). The aortic valve was involved in 5 of 6 patients. During a mean follow-up period of 251 days after diagnosis, no major adverse events occurred.Conclusion: Bartonella IE is an important cause of BCNE in the Western Cape of South Africa. Imaging findings of significant valvular destruction with large vegetations on the aortic valve not affected by pre-existing congenital or rheumatic valve disease, should raise the suspicion of Bartonella IE.

Maternal and perinatal outcome in cardiac disease complicating pregnancy

Background: Maternal cardiac disease associated with pregnancy is considered as a high-risk pregnancy. Various physiological and hemodynamic alterations during the course of pregnancy make these women prone for various complications and related morbidity and mortality.Methods: A prospective cross-sectional study of 105 cases of pregnancy complicated by cardiac disease, reporting to tertiary care hospital for delivery, was carried out to find out the maternal and perinatal outcome.Results: The incidence of cardiac disease in pregnancy in the present study was 0.54%. Most of the women (91%) belonged to low socioeconomic class. Rheumatic heart lesions constituted 87% of the cases. Mitral stenosis alone or in combination, was the commonest (57%) valvular lesion. Incidence of spontaneous vaginal delivery was 53 percent and for ventose or outlet forceps was 12 percent. Incidence of caesarean section was 35%. There were 2 maternal deaths, one each due to complication like pulmonary oedema and atrial fibrillation. The perinatal mortality was 36 per 1000 live births, mainly due to combination of factors like prematurity, low birth weight, neonatal sepsis and birth asphyxia.Conclusions: Early diagnosis of heart disease, regular antenatal checkup, institutional delivery, limiting family size can reduce the maternal and perinatal mortality and morbidity associated with heart disease.

Acquired heart diseases in children in Gadarif pediatrics teaching hospital, Gadarif state, Eastern Sudan

<p><strong>Background: </strong>Acquired heart diseases (AHD) are heterogeneous diseases including rheumatic heart disease (RHD) and other affecting the heart and blood vessels after birth but usually appear clinically after 5 years of age. AHD considered as major cause of morbidity and mortality. The present study was designed to document the spectrum, the affected age and clinical characteristics of AHDs in children of Gadarif state, eastern Sudan.</p><p><strong>Methods</strong>: This was a descriptive cross section study conducted in Gadarif pediatrics teaching hospital in period from June to Dec 2019.</p><p><strong>Results: </strong>A total of 46 children from Gadarif pediatrics teaching hospital with confirmed AHD were enrolled in this study. The females were 27 (58.7%), with a male-to-female ratio of 1.4:1. The mean age was 10.6±3.9 years (age’s ≤16 years old); the most common affected age group was 10-14 years accounted 18 (39.1) cases. RHD was the commonest AHD found in 38 (82.6%) patients, the commonest valvular lesion was mitral regurgitation 31 (73.9%).</p><p><strong>Conclusions: </strong>RHD was the most common AHD in the children in the present study, there is need to improve the scope of intervention facilities in the Sudan particularly in rural areas to prevent the growing and spread of these diseases.</p>

Increased Prevalence of Moderate-to-severe Mitral And Aortic Valve Dysfunction in Systemic Sclerosis: A Casecontrol Study

Objective To investigate the prevalence, severity and associated clinical factors of mitral and aortic valvular involvement in patients with systemic sclerosis (SSc). Methods This case–control study included 172 patients with SSc and 172 non-SSc adults without known cardiac disease matched by age, gender, and prevalence of cardiovascular risk factors. The screening of mitral and aortic valvular involvement was performed by transthoracic Doppler echocardiogram. The prevalence of aortic stenosis (AS) was also compared with that reported in a population-based study performed in our community during the same period. Results SSc patients showed an almost 5-fold increased prevalence of moderate-to-severe mitroaortic valve dysfunction compared to non-SSc controls (OR: 4.60, 95% CI 1.51–13.98; p=0.003). The most common lesion was mitral regurgitation (MR), which was observed in 5.2% of patients, followed by AS in 3.5%, and aortic regurgitation (AR) in 1.7%. Analyzing the different types of valvular lesion separately, we observed a significantly higher frequency of MR compared to controls (OR:4.69, 95% CI:1.12–22.04; p= 0.032), as well as a higher frequency of AS in the 65-75 (OR: 7.51, 95% CI:1.22–46.23, p=0.01) and 76-85 year-old age groups (OR:3.53, 95% CI:1.03–12.22, p=0.043) when compared to the general population in our community. Conclusion We found an increased prevalence of moderate-to-severe MR and AS in SSc compared to age-matched non-SSc controls with similar cardiovascular comorbidities. While results from this study do not allow to establish a direct causal relationship, they strongly support

Infective endocarditis complicating COVID-19 pneumonia: a case report

Background During the COVID-19 outbreak, cardiovascular imaging, especially transoesophageal echocardiography (TOE), may expose healthcare personnel to virus contamination and should be performed only if strictly necessary. On the other hand, transthoracic echocardiography (TTE) and TOE represent the first-line imaging exams for the diagnosis of infective endocarditis (IE). To date, this is the first case of COVID-19 complicated by IE. Case summary We present the case of a 57-year-old man with severe COVID-19 pneumonia requiring mechanical ventilation. During the intensive care unit (ICU) stay, he developed fever and positive haemocoltures for methicillin-resistant Staphylococcus aureus infection. TTE did not identify endocardial vegetations. TOE was then performed and outlined IE of the aortic valve on the non-coronary cusp. Antibiotic therapy was given with progressive resolution of the septic state and improvement of inflammatory signs. After 30 days of ICU stay, the patient was transferred to the Sub-ICU and then to a rehabilitation hospital. A close follow-up has been scheduled: after full recovery, a new echocardiography will be performed (TTE and TOE, if the former is non-conclusive) to consider surgical valve repair in the case of persistence/progression of the valvular lesion or deterioration of the valve function. Discussion In COVID-19 patients, echocardiography remains the leading imaging exam for the diagnosis of IE. If the suspicion of IE is high, even in this setting of patients, TTE or TOE (if TTE is non-conclusive) are mandatory. A high degree of attention must be paid and appropriate preventive measures taken to avoid contamination of healthcare personnel.