Cardiopathie rhumatismale : prévalence, méthodes diagnostiques, morbidité et mortalité attribuables en Nouvelle Calédonie

Rheumatic heart disease (RHD) remains the leading acquired heart disease in the young worldwide. The advent of echocardiography as a screening tool has raised new questions in the field. This thesis incorporated three studies to explore critical questions regarding the burden of asymptomatic and symptomatic RHD in New Caledonia (2011-2013): Retrospective population-based cohort study assessing the first nationwide echo-screening campaign targeting all children in 4th grade (2008-2011). Methods derived from research may not be applicable as a healthcare policy given the lack of completeness (~25%). Outcomes of children with asymptomatic RHD detected by echocardiography are benign although the majority of valve lesions persist with little clinical implications. RHD being a dynamic condition, 13% of children at high risk of RHD with normal baseline echocardiograms may present with mild echocardiographic lesions at 2 years follow-up. Prospective population-based study assessing sensitivity and specificity to detect asymptomatic RHD of a focused cardiac ultrasound (FCU) compared to echocardiography. FCU includes nurses after a short training scheme using pocket-echocardiographic machines and simplified criteria. Sensitivity and specificity for RHD detection was of ~80% and performed better (sensitivity ~90%) when restricted to definite RHD in which case treatment is recommended. Retrospective hospital-based cohort of patients admitted with symptomatic RHD. RHD remains prevalent and incident. Diagnosis if often made at an advanced stage (~25%). In patients with uncomplicated RHD, the survival rate was ~96% at 8 years with however an annual incidence of 59.05‰ (95% CI 44.35-73.75) major cardiovascular events. The severity of RHD at diagnosis (moderate vs. mild HR 3.39 (0.95 – 12.12); severe vs. mild RHD HR 10.81 (3.11 – 37.62), p<0.001), and ongoing secondary prophylaxis at follow-up (HR 0.27 (0.12-0.63), p=0.01) were the two most influential factors associated with major cardiovascular events.La cardiopathie rhumatismale (CR) demeure la première cause de cardiopathie acquise chez les enfants et les jeunes adultes à travers le Monde. L'essor de l'échographie cardiaque comme outils de dépistage dans les zones endémiques pose de nouvelles questions. Trois études indépendantes ont été menées en Nouvelle Calédonie dans le cadre de la thèse de 2011 à 2013: " L'étude de cohorte rétrospective en population a évalué une campagne de dépistage national de la CR par échocardiographie visant à inclure tous les enfants scolarisés en classe de CM1 sur l'île de 2008 à 2011. Les méthodes diagnostiques complexes utilisées en recherche ne peuvent être transposées en campagnes de dépistage écho-guidées à l'échelle nationale en raison du nombre élevé d'enfants (~25%) sans diagnostic final. Le pronostic de la CR asymptomatique dépistée par échographie est bénin à moyen terme, quoique les lésions échographiques persistent dans la majorité des cas. Environ 13% des enfants initialement sains présentent des anomalies échocardiographiques à 2 ans de suivi. " Une étude prospective en population a exploré des méthodes simplifiées de dépistage à l'aide de l'échoscopie cardiaque avec des appareils de poche par du personnel paramédical. La sensibilité et la spécificité de cette approche permet de dépister ~80% des cas, avec une sensibilité de ~90% dans le cadre de CR certaine, seul cas de figure où un traitement est nécessaire. " Une cohorte hospitalière contemporaine de patients admis à l'unique centre du pays a permis d'apporter des données épidémiologiques de la CR symptomatique, et d'identifier les facteurs associés à la survenue d'événements cardiovasculaires. Le diagnostic y est encore souvent porté à un stade tardif, révélé par des complications (~25%). Le taux de survie à 8 ans de la CR symptomatique sans complication initiale est élevé (~98%) mais l’incidence annuelle d’événements atteint 59‰ (95% CI 44.35-73.75). La sévérité de la CR au diagnostic (CR moyenne versus modérée HR 3.39 (0.95 – 12.12); CR sévère versus modérée HR 10.81 (3.11 – 37.62), p<0.001) et l’antibioprophylaxie (HR 0.27 (0.12-0.63), p=0.01) sont les deux facteurs associés à la survenue d’événements cardiovasculaires

Pocket-sized focused cardiac ultrasound: Strengths and limitations

SummaryFocused cardiac ultrasound (FCU) has emerged in recent years and has created new possibilities in the clinical assessment of patients both in and out of hospital. The increasing portability of echocardiographic devices, with some now only the size of a smartphone, has widened the spectrum of potential indications and users, from the senior cardiologist to the medical student. However, many issues still need to be addressed, especially the acknowledgment of the advantages and limitations of using such devices for FCU, and the extent of training required in this rapidly evolving field. In recent years, an increasing number of studies involving FCU have been published with variable results. This review outlines the evidence for the use of FCU with pocket-echo to address specific questions in daily clinical practice

Rheumatic heart disease in The Gambia: clinical and valvular aspects at presentation and evolution under penicillin prophylaxis

BACKGROUND: Rheumatic heart disease (RHD) remains the leading cause of cardiac-related deaths and disability in children and young adults worldwide. In The Gambia, the RHD burden is thought to be high although no data are available and no control programme is yet implemented. We conducted a pilot study to generate baseline data on the clinical and valvular characteristics of RHD patients at first presentation, adherence to penicillin prophylaxis and the evolution of lesions over time. METHODS: All patients registered with acute rheumatic fever (ARF) or RHD at two Gambian referral hospitals were invited for a clinical review that included echocardiography. In addition, patients were interviewed about potential risk factors, disease history, and treatment adherence. All clinical and echocardiography information at first presentation and during follow-up was retrieved from medical records. RESULTS: Among 255 registered RHD patients, 35 had died, 127 were examined, and 111 confirmed RHD patients were enrolled, 64% of them females. The case fatality rate in 2017 was estimated at 19.6%. At first presentation, median age was 13 years (IQR [9; 18]), 57% patients had late stage heart failure, and 84.1% a pathological heart murmur. Although 53.2% of them reported history of recurrent sore throat, only 32.2% of them had sought medical treatment. A history suggestive of ARF was reported by 48.7% patients out of whom only 15.8% were adequately treated. Two third of the patients (65.5%) to whom it was prescribed were fully adherent to penicillin prophylaxis. Progressive worsening and repeated hospitalisation was experienced by 46.8% of the patients. 17 patients had cardiac surgery, but they represented only 18.1% of the 94 patients estimated eligible for cardiac surgery. CONCLUSION: This study highlights for the first time in The Gambia the devastating consequences of RHD on the health of adolescents and young adults. Our findings suggest a high burden of disease that remains largely undetected and without appropriate secondary prophylaxis. There is a need for the urgent implementation of an effective national RHD control programto decrease the unacceptably high mortality rate, improve case detection and management, and increase community awareness of this disease

Infective endocarditis in the Lao PDR: clinical characteristics and outcomes in a developing country.

INTRODUCTION: Data on infective endocarditis (IE) in Southeast Asia are scarce. OBJECTIVES: To describe the clinical epidemiology of IE in Lao PDR, a lower middle-income country. METHODS: A single centre retrospective study at Mahosot Hospital, Vientiane. Patients aged over 1year of age admitted 2006-2012 to Mahosot Hospital with definite or possible IE by modified Duke criteria were included. RESULTS: Thirty-six patients fulfilled the inclusion criteria; 33 (91.7%) had left-sided IE. Eleven (30.6%) had definite IE and 25 (69.4%) possible left-sided IE. Median age was 25years old [IQR 18-42]. Fifteen patients (41.7%) were males. Underlying heart diseases included: rheumatic valve disease in 12 (33.3%), congenital heart disease in 7 (19.4%), degenerative valve disease in 3 (8.3%), and of unknown origin in 14 (38.9%) patients. Native valve IE was present in 30 patients (83.3%), and prosthetic valve IE in 6 patients (16.7%). The most frequent pathogens were Streptococcus spp. in 7 (19.4%). Blood cultures were negative in 22 patients (61.1%). Complications included: heart failure in 11 (30.6%), severe valve regurgitation in 7 (19.4%); neurological event in 7 (19.4%); septic shock or severe sepsis in 5 (13.9%); and cardiogenic shock in 3 patients (8.3%). No patient underwent heart surgery. Fourteen (38.9%) had died by follow-up after a median of 2.1years [IQR 1-3.2]; and 3 (8.3%) were lost to follow-up. CONCLUSIONS: Infective endocarditis, a disease especially of young adults and mainly caused by Streptococcus spp., was associated with rheumatic heart disease and had high mortality in Laos

Rheumatic Heart Disease-Attributable Mortality at Ages 5-69 Years in Fiji: A Five-Year, National, Population-Based Record-Linkage Cohort Study.

BACKGROUND: Rheumatic heart disease (RHD) is considered a major public health problem in developing countries, although scarce data are available to substantiate this. Here we quantify mortality from RHD in Fiji during 2008-2012 in people aged 5-69 years. METHODS AND FINDINGS: Using 1,773,999 records derived from multiple sources of routine clinical and administrative data, we used probabilistic record-linkage to define a cohort of 2,619 persons diagnosed with RHD, observed for all-cause mortality over 11,538 person-years. Using relative survival methods, we estimated there were 378 RHD-attributable deaths, almost half of which occurred before age 40 years. Using census data as the denominator, we calculated there were 9.9 deaths (95% CI 9.8-10.0) and 331 years of life-lost (YLL, 95% CI 330.4-331.5) due to RHD per 100,000 person-years, standardised to the portion of the WHO World Standard Population aged 0-69 years. Valuing life using Fiji's per-capita gross domestic product, we estimated these deaths cost United States Dollar $6,077,431 annually. Compared to vital registration data for 2011-2012, we calculated there were 1.6-times more RHD-attributable deaths than the number reported, and found our estimate of RHD mortality exceeded all but the five leading reported causes of premature death, based on collapsed underlying cause-of-death diagnoses. CONCLUSIONS: Rheumatic heart disease is a leading cause of premature death as well as an important economic burden in this setting. Age-standardised death rates are more than twice those reported in current global estimates. Linkage of routine data provides an efficient tool to better define the epidemiology of neglected diseases

Abnormal septal convexity into the left ventricle occurs in subclinical hypertrophic cardiomyopathy.

BACKGROUND: Sarcomeric gene mutations cause hypertrophic cardiomyopathy (HCM). In gene mutation carriers without left ventricular (LV) hypertrophy (G + LVH-), subclinical imaging biomarkers are recognized as predictors of overt HCM, consisting of anterior mitral valve leaflet elongation, myocardial crypts, hyperdynamic LV ejection fraction, and abnormal apical trabeculation. Reverse curvature of the interventricular septum (into the LV) is characteristic of overt HCM. We aimed to assess LV septal convexity in subclinical HCM. METHODS: Cardiovascular magnetic resonance was performed on 36 G + LVH- individuals (31 ± 14 years, 33 % males) with a pathogenic sarcomere mutation, and 36 sex and age-matched healthy controls (33 ± 12 years, 33 % males). Septal convexity (SCx) was measured in the apical four chamber view perpendicular to a reference line connecting the mid-septal wall at tricuspid valve insertion level and the apical right ventricular insertion point. RESULTS: Septal convexity was increased in G + LVH- compared to controls (maximal distance of endocardium to reference line: 5.0 ± 2.5 mm vs. 1.6 ± 2.4 mm, p ≤ 0.0001). Expected findings occurred in G + LVH- individuals: longer anterior mitral valve leaflet (23.5 ± 3.0 mm vs. 19.9 ± 3.1 mm, p ≤ 0.0001), higher relative wall thickness (0.31 ± 0.05 vs. 0.29 ± 0.04, p ≤ 0.05), higher LV ejection fraction (70.8 ± 4.3 % vs. 68.3 ± 4.4 %, p ≤ 0.05), and smaller LV end-systolic volume index (21.4 ± 4.4 ml/m(2) vs. 23.7 ± 5.8 ml/m(2), p ≤ 0.05). Other morphologic measurements (LV angles, sphericity index, and eccentricity index) were not different between G + LVH- and controls. CONCLUSIONS: Septal convexity is an additional previously undescribed feature of subclinical HCM

Subclinical Cardiac Dysfunction Is Associated With Extracardiac Organ Damages

Background: Several studies conducted in America or Europe have described major cardiac remodeling and diastolic dysfunction in patients with sickle cell disease (SCD). We aimed at assessing cardiac involvement in SCD in sub-Saharan Africa where SCD is the most prevalent.Methods: In Cameroon, Mali and Senegal, SCD patients and healthy controls of the CADRE study underwent transthoracic echocardiography if aged ≥10 years. The comparison of clinical and echocardiographic features between patients and controls, and the associations between echocardiographic features and the vascular complications of SCD were assessed.Results: 612 SCD patients (483 SS or Sβ0, 99 SC, and 19 Sβ+) and 149 controls were included. The prevalence of dyspnea and congestive heart failure was low and did not differ significantly between patients and controls. While left ventricular ejection fraction did not differ between controls and patients, left and right cardiac chambers were homogeneously more dilated and hypertrophic in patients compared to controls and systemic vascular resistances were lower (p &lt; 0.001 for all comparisons). Three hundred and forty nine SCD patients had extra-cardiac organ damages (stroke, leg ulcer, priapism, microalbuminuria or osteonecrosis). Increased left ventricular mass index, cardiac dilatation, cardiac output, and decreased systemic vascular resistances were associated with a history of at least one SCD-related organ damage after adjustment for confounders.Conclusions: Cardiac dilatation, cardiac output, left ventricular hypertrophy, and systemic vascular resistance are associated with extracardiac SCD complications in patients from sub-Saharan Africa despite a low prevalence of clinical heart failure. The prognostic value of cardiac subclinical involvement in SCD patients deserves further studies

Rheumatic heart disease : prevalence, diagnostic tests, and burden of disease in New Caledonia

La cardiopathie rhumatismale (CR) demeure la première cause de cardiopathie acquise chez les enfants et les jeunes adultes à travers le Monde. L'essor de l'échographie cardiaque comme outils de dépistage dans les zones endémiques pose de nouvelles questions. Trois études indépendantes ont été menées en Nouvelle Calédonie dans le cadre de la thèse de 2011 à 2013: " L'étude de cohorte rétrospective en population a évalué une campagne de dépistage national de la CR par échocardiographie visant à inclure tous les enfants scolarisés en classe de CM1 sur l'île de 2008 à 2011. Les méthodes diagnostiques complexes utilisées en recherche ne peuvent être transposées en campagnes de dépistage écho-guidées à l'échelle nationale en raison du nombre élevé d'enfants (~25%) sans diagnostic final. Le pronostic de la CR asymptomatique dépistée par échographie est bénin à moyen terme, quoique les lésions échographiques persistent dans la majorité des cas. Environ 13% des enfants initialement sains présentent des anomalies échocardiographiques à 2 ans de suivi. " Une étude prospective en population a exploré des méthodes simplifiées de dépistage à l'aide de l'échoscopie cardiaque avec des appareils de poche par du personnel paramédical. La sensibilité et la spécificité de cette approche permet de dépister ~80% des cas, avec une sensibilité de ~90% dans le cadre de CR certaine, seul cas de figure où un traitement est nécessaire. " Une cohorte hospitalière contemporaine de patients admis à l'unique centre du pays a permis d'apporter des données épidémiologiques de la CR symptomatique, et d'identifier les facteurs associés à la survenue d'événements cardiovasculaires. Le diagnostic y est encore souvent porté à un stade tardif, révélé par des complications (~25%). Le taux de survie à 8 ans de la CR symptomatique sans complication initiale est élevé (~98%) mais l’incidence annuelle d’événements atteint 59‰ (95% CI 44.35-73.75). La sévérité de la CR au diagnostic (CR moyenne versus modérée HR 3.39 (0.95 – 12.12); CR sévère versus modérée HR 10.81 (3.11 – 37.62), p<0.001) et l’antibioprophylaxie (HR 0.27 (0.12-0.63), p=0.01) sont les deux facteurs associés à la survenue d’événements cardiovasculaires.Rheumatic heart disease (RHD) remains the leading acquired heart disease in the young worldwide. The advent of echocardiography as a screening tool has raised new questions in the field. This thesis incorporated three studies to explore critical questions regarding the burden of asymptomatic and symptomatic RHD in New Caledonia (2011-2013): Retrospective population-based cohort study assessing the first nationwide echo-screening campaign targeting all children in 4th grade (2008-2011). Methods derived from research may not be applicable as a healthcare policy given the lack of completeness (~25%). Outcomes of children with asymptomatic RHD detected by echocardiography are benign although the majority of valve lesions persist with little clinical implications. RHD being a dynamic condition, 13% of children at high risk of RHD with normal baseline echocardiograms may present with mild echocardiographic lesions at 2 years follow-up. Prospective population-based study assessing sensitivity and specificity to detect asymptomatic RHD of a focused cardiac ultrasound (FCU) compared to echocardiography. FCU includes nurses after a short training scheme using pocket-echocardiographic machines and simplified criteria. Sensitivity and specificity for RHD detection was of ~80% and performed better (sensitivity ~90%) when restricted to definite RHD in which case treatment is recommended. Retrospective hospital-based cohort of patients admitted with symptomatic RHD. RHD remains prevalent and incident. Diagnosis if often made at an advanced stage (~25%). In patients with uncomplicated RHD, the survival rate was ~96% at 8 years with however an annual incidence of 59.05‰ (95% CI 44.35-73.75) major cardiovascular events. The severity of RHD at diagnosis (moderate vs. mild HR 3.39 (0.95 – 12.12); severe vs. mild RHD HR 10.81 (3.11 – 37.62), p<0.001), and ongoing secondary prophylaxis at follow-up (HR 0.27 (0.12-0.63), p=0.01) were the two most influential factors associated with major cardiovascular events