Prevalence and follow-up of subclinical rheumatic heart disease among asymptomatic school children in a north-western district of India based on the World Heart Federation echocardiographic criteria.

BACKGROUND: The present study is based on the World Heart Federation (WHF) echocardiographic criteria to assess the prevalence of subclinical rheumatic heart disease (RHD) and elucidate evolution of the disease when the cases were placed on appropriate antibiotic prophylaxis and regular follow-up. The prevalence of subclinical RHD reported by previous active surveillance studies among asymptomatic school children is not comparable to our study because of major differences in screening methods. METHODS: A random inclusion strategy was adopted to recruit urban and rural school children of Bikaner district in the state of Rajasthan, India. The diagnosis of RHD was based on the echocardiographic criteria proposed by the WHF. All studies were reported on-site by a single experienced cardiologist and the digitally preserved studies were reported by a second cardiologist off-site. The final diagnosis was made by consensus. The second echocardiogram was performed for cases diagnosed with RHD after two years from start of study to document early evolution of the disease with ongoing antibiotic prophylaxis. RESULTS: A high prevalence of subclinical RHD was observed in the study population. Pathological mitral and/or aortic valve regurgitation was the commonest lesion, and a significant proportion of cases improved while on regular antibiotic prophylaxis. No case showed fixity of leaflets/ stenosis. CONCLUSION: The prevalence of subclinical RHD is high in the study population, and the disease seems to regress over time in the presence of appropriate antibiotic prophylaxis.

Comparison of the newer proposed diagnostic score with the World Heart Federation criteria for echocardiographic detection of rheumatic heart disease.

INTRODUCTION: Echocardiography has been found to be a much better screening tool compared to clinical examination for the detection of rheumatic heart disease (RHD) in asymptomatic school children living in the RHD endemic areas. Recently, World Heart Federation (WHF) published echocardiographic criteria for the diagnosis of RHD. The present study was done to compare the performance of the newer proposed, quantitative diagnostic score against the qualitative WHF criteria in a field survey of asymptomatic school children belonging to the district having high prevalence of RHD. METHODS: 3000 asymptomatic school children studying in rural and urban schools of Bikaner district were screened both by clinical examination and echocardiography performed in parallel. The WHF criteria and the proposed diagnostic score were applied simultaneously for the diagnosis of RHD. RESULTS: A high prevalence of subclinical RHD was found. There was complete agreement between the two sets of criteria for the diagnosis of RHD. However, there was discrepancy in grading the severity of disease. The diagnostic score proved superior to the WHF criteria in grading the disease severity accurately. CONCLUSIONS: Diagnostic score captures the disease spectrum of RHD better than WHF criteria and reduces the subjectivity in the diagnosis of RHD.

Effects of antegrade versus integrated blood cardioplegia on left ventricular function evaluated by echocardiographic real-time 3-dimensional speckle tracking.

OBJECTIVE: The objective of this study was to evaluate left ventricular free wall and interventricular septal function by 2-dimensional transthoracic echocardiography and live/real-time 3-dimensional transthoracic speckle tracking echocardiography before and after on-pump cardiac surgery and to assess the effect of mode of cardioplegia delivery. METHODS: A total of 22 patients were studied 1 day before and 4 to 5 days after surgery. Cold blood cardioplegia was delivered by intermittent antegrade infusion or by the integrated method. The latter includes a combination of intermittent antegrade and retrograde cardioplegia with a terminal warm amino acid-enriched reperfusion. RESULTS: The overall group displayed significant deterioration of septal function after surgery by 2-dimensional transthoracic echocardiography, as assessed by wall motion score index, yet subgroup analysis by 3-dimensional transthoracic speckle tracking echocardiography permitted distinction of outcomes achieved by antegrade or integrated delivery methods. Analysis after surgery showed that only the antegrade group displayed statistically significant deterioration in the strain parameters of some of the segments of the septum and free wall when strain was measured in the free wall and septum in the longitudinal, circumferential, and radial modes of deformation (P < .05). In contrast, only the integrated group displayed significant improvement in global radial, circumferential, and longitudinal strain (P < .05). CONCLUSIONS: These findings by 3-dimensional transthoracic speckle tracking echocardiography indicate that integrated cardioplegia offers superior myocardial protection of the left ventricular free wall and septum compared with the antegrade mode of cardioplegia delivery.

Live/Real time three-dimensional transesophageal echocardiography in percutaneous closure of atrial septal defects.

OBJECTIVES: This study assessed the ability of live/real time three-dimensional transesophageal echocardiography (3DTEE) in measuring (1) atrial septal defect (ASD) maximum dimension, area, and adjacent rim size, (2) ASD occluder left and right atrial disk size, (3) length of contact between the left atrial (LA) disk and the aorta, and in (4) assessing device related complications such as residual shunt, device embolization, and device encroachment upon adjacent cardiac structures. MATERIALS AND METHODS: 3DTEE images acquired during percutaneous ASD closure by the Amplatzer Septal Occluder in 15 adult patients were retrospectively analyzed. Offline analysis was done using both the Philips 5500 ultrasound system and Philips QLAB software. 3D color flow Doppler images were used to assess residual ASD shunting. RESULTS: The Philips 5500 and Philips QLAB measurements correlated well for ASD maximum dimension and area measurements. The Philips QLAB 3DTEE disk size measurements also correlated well with the manufacturer obtained sizes. The aortic rim was deficient in 7 of the 15 patients, and the mean ASD occluder device size was 4 mm greater than the mean ASD maximum dimension. The LA occluder disk was in contact with the aorta throughout the cardiac cycle in 12 of the 15 patients, and the LA occluder disk size correlated significantly with the contact length with the aorta. CONCLUSION: Most of the patients demonstrated contact between the LA occluder disk and the aorta throughout the cardiac cycle. 3DTEE may be useful in identifying patients at greater risk for aortic erosion.

Two years of follow-up validates the echocardiographic criteria for the diagnosis and screening of rheumatic heart disease in asymptomatic populations.

OBJECTIVES: Out of 1,059 school children aged 6-15 years, screened 2 years ago, 54 children were diagnosed with rheumatic heart disease (RHD) and put on penicillin prophylaxis. Significant regurgitation of mitral valves was detected in 39 cases of echocardiography diagnosed RHD, and in 15 cases significant regurgitation was detected to coexist with valve deformities. Three children had isolated mitral valve thickening without regurgitation. They were not given penicillin prophylaxis. These cases were followed up for 2 years. METHODS: After 2 years, 54 children diagnosed with RHD and three children with isolated mitral valve thickening, were evaluated again. Lot quality assurance sampling was employed to screen a selected group of school children declared normal during the earlier evaluation. Lot was to be rejected, if, one child with significant regurgitation of mitral valve was found among the first 10 screened children of each of the 10 lots. FINDINGS: No lot was rejected and thus it was inferred that the prevalence of new onset RHD was negligible in the subset declared normal 2 years ago. Isolated significant mitral regurgitation disappeared more often when present (35.9%) in comparison to when it (26.7%) was originally found coexistent with valve deformities. CONCLUSIONS: Highlight of the study is the greater reversibility of earlier lesions as compared to the later stages of RHD. Spontaneous regression of isolated mitral valve thickening in two-thirds of the cases even without antibiotic prophylaxis, undermines the value of morphological criteria for the diagnosis of RHD.

High prevalence of rheumatic heart disease detected by echocardiography in school children.

OBJECTIVES: It is fairly easy to detect advanced valve lesions of established rheumatic heart disease by echocardiography in the clinically identified cases of rheumatic heart disease. However, to diagnose a subclinical case of rheumatic heart disease, no uniform set of echocardiographic criteria exist. Moderate thickening of valve leaflets is considered an indicator of established rheumatic heart disease. World Health Organization criteria for diagnosing probable rheumatic heart disease are more sensitive and are based on the detection of significant regurgitation of mitral and/or aortic valves by color Doppler. We attempted diagnosing RHD in school children in Bikaner city by cardiac ultrasound. METHODS: The stratified cluster sampling technique was employed to identify 31 random clusters in the coeducational schools of Bikaner city. We selected 1059 school children aged 6-15 years from these schools. An experienced operator did careful cardiac auscultation and echocardiographic study. A second expert confirmed the echocardiographic findings. FINDINGS: The prevalence of lesions suggestive of rheumatic heart disease by echocardiography was 51 per 1,000 (denominator = 1059; 95% CI: 38-64 per 1,000). We were able to clinically diagnose RHD in one child. None of these children or their parents having echocardiographic evidence of RHD could provide a positive history of acute rheumatic fever. CONCLUSIONS: By echocardiographic screening, we found a high prevalence of rheumatic heart disease in the surveyed population. Clinical auscultation had much lower diagnostic efficacy.

Camphor induced myocarditis: a case report.

Availability of camphor containing products in households is not uncommon. In certain parts of the world, camphor is used in medicines intended for enteral intake and also used as a flavoring agent in edibles. Toxicity due to ingestion of camphor has been described and in severe forms it manifests as seizures, apnea, asystole, circulatory collapse and death. We report myocarditis associated with ingestion of a large dose of camphor. The electrocardiogram revealed prolonged QRS duration and QTc interval. 2D- Echo images revealed features of acute myocarditis. The changes were transient and resolved in a short time while the patient was on supportive therapy. The medicinal uses of camphor are unsupported by evidence and safer, more effective alternatives exist. Its use in household products and edibles should be discouraged.