The Global Burden of Rheumatic Heart Disease: Population-Related Differences (It is Not All the Same!)

Abstract

Rheumatic heart disease (RHD) remains the most common cardiovascular disease in young adults and adolescents in need of heart surgery in low- and middle-income countries (LMICs). The mean age of patients is 20-25 years, often much younger. By contrast, the few patients with chronic RHD in developed countries present a mean age of around 55 years. It is absolutely fundamental to differentiate these two types of population. Pathology, lesions and surgical methods are different, and the results should not be compared. It is not all the same! A certain enthusiasm for mitral repair has recently surged, with several reports showing excellent results in children and young adults, resulting from the renewed interest of cardiac surgeons, also based on new and modified techniques developed in the meantime. While surgery is easily accessible to patients in developed countries, the situation in LMICs is often dramatic, with countries where there is a complete absence of or few surgical facilities absolutely unable to meet gigantic demands. Many foreign surgical teams conduct humanitarian missions in several of these countries. They are just a "drop of water in the ocean" of needs. In some cases, however, these missions led to the establishment of local teams that now work independently and, in some cases, outperform the foreign teams still visiting.

Keywords: Altruism; Developing Countries; Mitral Valve; Mitral Valve Repair; Rheumatic Heart Disease.

Fig. 1

Prevalence of rheumatic heart disease in children aged 5 to 14 years (adapted from Carapetis et al.^[2]).

Fig. 2

Typical acute rheumatic mitral valve of a 10-year old child, with inflamed and thickened leaflets and partially fused commissures, submitted to repair.

Fig. 3

Rheumatic mitral valve repaired by PTFE chordae in the anterior leaflet (note the jet lesions behind the posterior annulus, hallmark of anterior leaflet prolapse) and complete rigid ring annuloplasty.

Fig. 4

Number of cardiac operations (no. per million) performed in “rheumatic countries” (adapted from Zilla et al.^[4]).