Prevalence of doppler-significant valvular regurgitation in children with subclinical rheumatic carditis and in those not fulfilling jones criteria

Abstract EN

Background: Acute rheumatic fever (ARF) is still a major public health problem in developing countries.

A significant number of patients with suspected rheumatic carditis have no clinical murmurs with documented regurgitation on echocardiography.

As there is a, risk of missing, up to three quarters of patients of rheumatic heart disease (RHD); a new category of subclinical carditis has emerged.

Aim of work: To detect the prevalence of significant Doppler valvular regurgitation in patients with rheumatic fever and no clinical evidence of carditis and in cases with rheumatic complaints not fulfilling Jones criteria of diagnosis of rheumatic fever.

Patients and methods: This case-control cross-sectional study included 161children (5-16 years) attending Assiut University Children hospital from August 2009-August 2010, 70 patients of them (Gl) [34 males, 36 females] were fulfilling Jones criteria without clinical evidence of rheumatic carditis and 91 patients (G2) [37 males, 54 females] were not completely fulfilling the criteria.

Both groups had no audible murmurs.

Control group included 161 age and sex matched normal children.

Full history, physical examination, CBC, ESR, CRP, ASOT, ECG, CXR and echocardiography were done.

Significant regurgitation was diagnosed by Doppler-echocardiography in patients when mitral (MR) and aortic (AR) regurgitation is present in at least two planes, length of the jets >lcm, peak flow velocities >2.5m/sec.

The significance of regurgitation and degree of severity was assessed according to WHO criteria.

Results: There was a significant increase in RVAW thickness, RV, LA, LVED, LVES and Ao root diameters in Gl than controls (P = 0.003, 0.002, 0.005, 0.000, 0.000, 0.000 respectively) and in LA diameter in G2 than controls (P =0.005).

Mitral leaflet thickened tips and prolapse were detected in 31.4% in Gl and 18.7 % and 17.6% respectively in G2, with no significant difference between groups.

All patients with valve abnormalities showed grade 1 or 2 regurge.

There were no morphologic abnormalities in the aortic valve.

MR was absent in 20% and 30.8% and insignificant in 7.1% aiid 11% in Gl and G2 respectively with no significant difference between groups.

Left-sided valve regurge (grade >1) was significantly higher in Gl and G2 than controls.

Conclusion: Doppler significant valve regurgitation is an important finding that denotes cardiac affection in patients with rheumatic fever and no clinical evidence of carditis and in cases with rheumatic complaints not fulfilling Jones criteria of diagnosis of rheumatic fever.

Careful Doppler Echocardiography with application of scientific criteria should be performed in these groups of children with proper prophylactic considerations.

Abbreviation: RV: right ventricle, LV: left ventricle, LA: left atrium, Ao: aorta, PA: pulmonary artery, RVAW: right ventricular anterior wall, LVED: left ventriclular end diastole, LVES: left ventriclular end systole, ARF;acute rheumatic fever