Surgery for Valvular Heart Disease: A Population-Based Study in a Brazilian Urban Center

BACKGROUND: In middle income countries, the burden of rheumatic heart disease (RHD) remains high, but the prevalence of other heart valve diseases may rise as the population life expectancy increases. Here, we compared population-based data on surgical procedures to assess the relative importance of causes of heart valve disease in Salvador, Brazil. METHODOLOGY/PRINCIPAL FINDINGS: Medical charts of patients who underwent surgery for valvular heart disease from January 2002-December 2005 were reviewed. Incidence of surgery for valvular heart disease was calculated. Logistic regression was used to identify factors associated with in-hospital death following surgery. The most common etiologies for valvular dysfunction in 491 valvular heart surgery patients were RHD (60.3%), degenerative valve disease (15.3%), and endocarditis (4.5%). Mean annual incidence for surgeries due to any valvular heart diseases, RHD, and degenerative valvular disease were 5.02, 3.03, and 0.77 per 100,000 population, respectively. Incidence of surgery due to RHD was highest in young adults; procedures were predominantly paid by the public health sector. In contrast, the incidence of surgery due to degenerative valvular disease was highest among those older than 60 years of age; procedures were mostly paid by the private sector. The overall in-hospital case-fatality ratio was 11.9%. Independent factors associated with death included increase in age (odds ratio: 1.04 per year of age; 95% confidence interval: 1.02-1.06), endocarditis (6.35; 1.92-21.04), multiple valve operative procedures (4.35; 2.12-8.95), and prior heart valve surgery (2.49; 1.05-5.87). CONCLUSIONS/SIGNIFICANCE: RHD remains the main cause for valvular heart surgery in Salvador, which primarily affects young adults without private health insurance. In contrast, surgery due to degenerative valvular disease primarily impacts the elderly with private health insurance. Strategies to reduce the burden of valvular heart disease will need to address the disparate factors that contribute to RHD as well as degenerative valve disease

Characteristics associated with in-hospital death among patients who underwent valvular heart surgery in Salvador, Brazil, 2002–2005.

*<p>Number of responses used in the multivariable model = 464.</p>†<p>Odds ratio per one year increase in age.</p><p>RHD = Rheumatic heart disease.</p

Mean annual incidence of open valvular heart surgery according to underlying etiology for valve dysfunction in Salvador, Brazil, 2002–2005.

*<p>Mean annual incidence of open valvular heart surgery per 100,000 population.</p>†<p>Includes 19 patients with rheumatic heart disease associated with endocarditis.</p>‡<p>Includes patients with calcific aortic stenosis and mitral annular calcification related to aging.</p>§<p>Includes one patient each with the following etiologies: mitral valve prolapse, systemic lupus erythematosus, Wegener’s granulomatosis, Marfan syndrome, alcoholic cardiomyopathy and traumatic injury.</p

Characteristics of patients who underwent open valvular heart surgery (VHS), according to the underlying etiology for valve dysfunction, Salvador, Brazil, 2002–2005.

*<p>Percents were calculated based on the number of available responses. Sum of percents may be different than 100% due to rounding.</p>†<p>Sum of percents is less than 100% because some patients have undergone surgery in other heart valves, including combined surgery for mitral, aortic and tricuspid valves (7 cases), surgery for tricuspid only valve (5) and combined surgery for aortic and tricuspid valves (1).</p>‡<p>Sum may be greater than 100% because patients may have undergone more than one procedure.</p>§<p>Data distribution for patients undergoing valve surgery for RHD as the underlying etiology differed significantly from those of patients undergoing valve surgery for any of the other underlying etiologies (P value <0.05).</p>¶<p>Data distribution for patients undergoing valve surgery for degenerative valve disease as the underlying etiology differed significantly from those of patients undergoing valve surgery for any of the other underlying etiologies (P value <0.05).</p>∥<p>Data distribution for patients undergoing valve surgery for endocarditis unrelated to RHD differed significantly from those of patients undergoing valve surgery for any of the other underlying etiologies (P value <0.05).</p><p>VHS = Valvular heart surgery.</p><p>RHD = Rheumatic heart disease.</p><p>ICU = Intensive care unit.</p

Mean annual incidence of valvular surgery for rheumatic heart disease (RHD) and degenerative valvular disease as the underlying etiology of the valve dysfunction per 100,000 population, according to age and payment source.

<p><b>A.</b> Incidence calculated for all surgeries. <b>B.</b> Incidence calculated for surgeries paid by the public health sector. <b>C.</b> Incidence calculated for surgeries paid by the private sector.</p