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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 111-115

Prevalence of organic tricuspid valve disease and pattern of valvular involvement in rheumatic heart disease: An echocardiographic study


Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Mysore, Karnataka, India

Date of Submission01-May-2020
Date of Decision14-Jun-2020
Date of Acceptance23-Jun-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. Santhosh Krishnappa
Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, TB Sanitorium Campus, KRS Road, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_27_20

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  Abstract 


Background: Rheumatic fever and rheumatic heart disease are still a major public health problem in developing countries. There is a growing interest in tricuspid valve disease because of its clinical outcome, difficulty in treating it, and upcoming interventional therapeutic options. The aim of the present study is to assess the organic involvement of tricuspid valve and echocardiographic pattern of other valvular involvement in rheumatic heart disease in a tertiary care center located in South India. Materials and Methods: This is a prospective observational study which was carried out over a period of 1 year. Transthoracic echocardiography data of patients, diagnosed with rheumatic heart disease during the study period, were reviewed for type and degree of valvular involvement. Results: During the study period, a total of 6612 patients were found to have rheumatic heart disease, and 4129 (62.45%) were female. The average age was 33.96 ± 12.21 years. On echocardiography, organic tricuspid valve involvement was seen in 684 (10.34%) patients. Mitral valve is the most common valve involved, both in isolation and in totality. Five thousand and thirty (76.07%) patients were diagnosed with mitral regurgitation, and 4497 (68.01%) patients were diagnosed with mitral stenosis. Two thousand nine hundred and ninety-three (45.27%) patients were diagnosed with aortic regurgitation, and 1085 (16.41%) patients were diagnosed with aortic stenosis. Conclusion: Mitral valve was most commonly affected, whereas isolated aortic valve was least commonly affected valve. A considerable number of patients showed involvement of organic rheumatic tricuspid valve disease. With the growing awareness of tricuspid valve disease causing significant morbidity and mortality, and therapeutic options under research, identifying organic tricuspid valve disease is of foremost important.

Keywords: Echocardiography, organic tricuspid valve disease, rheumatic heart disease


How to cite this article:
Krishnappa S, Krishnegowda C, Rachaiah JM, Mariappa HM, Siddaramu PT, Nanjappa MC. Prevalence of organic tricuspid valve disease and pattern of valvular involvement in rheumatic heart disease: An echocardiographic study. J Indian coll cardiol 2020;10:111-5

How to cite this URL:
Krishnappa S, Krishnegowda C, Rachaiah JM, Mariappa HM, Siddaramu PT, Nanjappa MC. Prevalence of organic tricuspid valve disease and pattern of valvular involvement in rheumatic heart disease: An echocardiographic study. J Indian coll cardiol [serial online] 2020 [cited 2021 Jan 18];10:111-5. Available from: https://www.joicc.org/text.asp?2020/10/3/111/304375




  Introduction Top


Rheumatic fever and rheumatic heart disease are immunological complications of Group A streptococcal pharyngitis. Although rheumatic fever and rheumatic heart disease are rare in developed countries, they are still a major public health problem among children and young adults in developing countries such as India. Rheumatic heart disease has, in the past 50 years, still a major contributor to cardiovascular morbidity and mortality in India. Despite the paucity of clear information regarding secular trends, the few available community surveys indicate that there are at present more than 1 million patients with rheumatic heart disease in India.[1] Even a conservative estimate of the incidence of rheumatic fever suggests that at least 50,000 new episodes occur every year.[1] The prevalence of rheumatic heart disease is reported as 1–5.4/1000 in various studies and surveys in India.[2] Chronic valvular involvement is the predominant cause of morbidity and mortality in these patients. This study was conducted to assess the echocardiographic prevalence of organic tricuspid valve disease and pattern of other valvular involvement in rheumatic heart disease patients.

Objectives

  1. To assess echocardiographic prevalence of organic tricuspid valve disease in rheumatic heart disease patients using standard echocardiographic criteria[3],[4]
  2. To assess echocardiographic pattern of various valvular involvement in rheumatic heart disease patients using standard echocardiographic criteria.[3]



  Materials and Methods Top


Consecutive patients of age group of 5–85 years who come for evaluation for our tertiary care center and fulfill the echocardiographic criteria for rheumatic valvular heart disease are screened by standard two-dimensional (2D), M Mode, and Doppler echocardiography for the organic tricuspid valve involvement and other valvular involvement over 1-year period prospectively.[3],[5] We used 2–4 MHz adult probe to do echocardiography, nyquist limit of 35–50 cm/s was used to assess tricuspid valve and nyquist limit of 70 cm/s was used to assess mitral, aortic and pulmonary valves. Standard transthoracic views were used and when needed modifications of these, to define and visualize valves and various cardiac structures. Tricuspid valve was studied in multiple views, namely, apical four chamber, subcostal four chamber, parasternal long axis with medial and downward angulation (right ventricle inflow view), parasternal short axis view, and other views when needed. Other three valves were studied in all standard transthoracic views and its modification when needed.

Definitions

Rheumatic heart disease: It was diagnosed in the presence of standard echocardiographic parameters[3],[5],[6] such as valvular thickening, subvalvular apparatus involvement, restricted mobility of the leaflets, doming of the leaflets, reduced E point to F point slope ( E-F slope) (<35 mm/s), and posterior mitral leaflet restriction. Organic tricuspid valve involvement is described as the presence of one or many of the following abnormalities in tricuspid valve. Tricuspid valve thickening with restricted mobility of tricuspid valve,[3],[7],[8],[9] doming of tricuspid valve,[4],[8],[9] reduced E-F slope, commissural fusion,[8],[9],[10] subvalvular apparatus involvement,[8],[9],[10] or mean tricuspid valve gradient on continuous wave Doppler of ≥2 mmHg.[8],[9],[10] The presence of moderate or severe tricuspid regurgitation with pulmonary artery systolic pressure ≤40 mmHg.[6],[11],[12] Mitral and tricuspid valve thickening:[8],[8],[10] If the thickness measured on M mode was more than 5 mm, mitral and/or tricuspid valve is considered as thickened. Pulmonary artery systolic pressure was calculated by adding expected right atrial pressure to tricuspid valve jet velocity. Expected right atrial pressure was estimated based on inferior vena cava size and characteristic change with respiration as per the American Society of Echocardiography 2005[13] guidelines. Mitral stenosis is graded based on planimetry on 2D echo of short axis view at mitral leaflet tip level into mild if mitral valve orifice area is 1.5–2 cm2, moderate if mitral valve orifice area is 1–1.5 cm2, and severe if mitral valve orifice area is <1 cm2.[3] Mitral regurgitation is graded based on color Doppler (jet area to left atrium area): mild if <20% left atrium area, moderate if 20%–40% left atrium area, and severe if >40% left atrium area.[3],[14] Aortic stenosis is graded based on the mean aortic valve gradient, mild if mean gradient is <25 mmHg, moderate if mean gradient is 25–40 mmHg, and severe if mean gradient is >40 mmHg.[3] Aortic regurgitation is graded based on color Doppler, mild if aortic regurgitation jet occupies <25% of left ventricular outflow tract, moderate if it occupies 25%–65% of left ventricular outflow tract, and severe if it occupies >65% of left ventricular outflow tract.[3],[14]


  Results Top


Among the consecutive patients who underwent echocardiography in our institute over 1-year period, 6612 patients were diagnosed to be having rheumatic heart disease based on the standard echocardiographic criteria used. Age group of the patients was from 6 to 85 years; 4129 (62.45%) were female and 2483 (47.55%) were male among 6612. Rheumatic heart disease patients were screened, with female predominance. Mitral valve is the most common valve involved both in isolation and in totality. Five thousand and thirty (76.07%) patients were diagnosed to be having mitral regurgitation, and 4497 (68.01%) patients were diagnosed to be having mitral stenosis. Two thousand nine hundred and ninety-three (45.27%) patients were diagnosed to be having aortic regurgitation. One thousand and eighty-five (16.41%) patients were diagnosed to be having aortic stenosis. Pulmonary regurgitation without significant pulmonary arterial hypertension was not seen in our study. Pulmonary stenosis was also not seen. Six hundred and eighty-four (10.34%) patients were diagnosed to be having organic tricuspid valve disease. Organic tricuspid valve involvement was noted in 684 (10.34%) patients of rheumatic heart disease patients screened [Figure 1]. Restricted mobility of tricuspid leaflet with reduced EF slope was the most common finding, seen in 90.35% (618) of the patients. Diastolic doming of the tricuspid leaflet was seen in 17.69% (121) of the patients. Gradient across the tricuspid valve was seen in 36.7% (251) of the patients, among whom 14.33% (98) patients had severe tricuspid stenosis with tricuspid valve gradient of more than 5 mmHg. Sixty-six (1%) of the patients of total rheumatic heart disease patients had low-pressure tricuspid regurgitation, suggestive of organic tricuspid regurgitation [Table 1] and [Figure 2]. All the patients of organic tricuspid valve involvement had concomitant mitral valve disease, 25 of these patients did not have hemodynamically significant mitral valve involvement. However, they had evidence of mitral valve involvement in the form of thickening of mitral valve leaflets and thickening of submitral apparatus. Only 395 (57.75%) of these patients had concomitant aortic valve involvement. Mitral regurgitation was the most predominant lesion in our study [Figure 1]. Five thousand and thirty (76.07%) patients had various severity of mitral regurgitations. Severity of mitral regurgitation was equally distributed [Figure 3]. Mitral stenosis is the next common lesion, seen in 4497 (68.01%) of the study population. Severity of mitral stenosis was assessed based on planimetry [Figure 4]. Aortic regurgitation was seen in 2993 (45.27%) of the study population. Severity of aortic regurgitation was assessed by color Doppler quantification [Figure 5]. Aortic stenosis is the least common lesion seen in our study in agreement with previous literature. One thousand and eighty-five (16.41%) patients had various severity of aortic stenosis based on mean aortic valve gradient [Figure 6]. Mitral valve disease was the most common isolated valve disease, seen in 3103 (46.92%) of the study population. Two thousand two hundred and five (71.06%) patients of isolated mitral valve disease were females. Isolated aortic valve disease was seen in only 148 (2.24%) of the study population. In mitral valve disease, isolated mitral regurgitation was the most common and was seen in 921 (13.93%) of the study population [Figure 7]. Rheumatic heart disease was more prevalent in females, constituting 4129 (62.45%) of the patients screened [Figure 8]. Isolated mitral valve involvement (71.06%) was more prevalent in females [Figure 9] compared to isolated aortic valve involvement (62.16%), which was more prevalent in males [Figure 10].
Figure 1: Pattern of valvular involvement in rheumatic heart disease

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Table 1: Organic tricuspid valve disease

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Figure 2: Severity of tricuspid stenosis

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Figure 3: Severity of mitral regurgitation

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Figure 4: Severity of mitral stenosis

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Figure 5: Severity of aortic regurgitation

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Figure 6: Severity of aortic stenosis

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Figure 7: Isolated lesions in rheumatic heart disease

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Figure 8: Gender prevalence in rheumatic heart disease

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Figure 9: Gender prevalence in isolated mitral valve disease

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Figure 10: Gender prevalence in isolated aortic valve disease

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  Discussion Top


Rheumatic heart disease is an immunological complication of Group A streptococcal infection. In our study, we assessed the prevalence of organic tricuspid valve disease and pattern of various valvular involvement in consecutive 6612 patients over a period of 1 year in our tertiary care hospital, based on echocardiographic parameters. Rheumatic heart disease was seen in wide age group from as young as 6 years to as old as 85 years in our study. Rheumatic heart disease was more common in females as seen in other studies.[3] Mitral valve involvement was the most common in our study as seen in other studies and surveys.[15],[16],[17] Organic tricuspid valve involvement is not uncommon in rheumatic heart disease patients. It has often been pointed out that tricuspid stenosis occurs much more frequently than it is diagnosed. 15%–30% of the rheumatic heart disease patients have tricuspid valve involvement on autopsy;[18],[19] however, clinical significance was seen only in 5% of rheumatic heart disease patients.[18] Organic tricuspid valve disease is always underreported because of lack of awareness among echocardiographers, more frequent functional tricuspid valve involvement, and unclear echocardiographic criteria to differentiate organic versus functional tricuspid valve involvement. With the increasing awareness of tricuspid valve disease, morbidity and mortality associated with it, and growing therapeutic options,[20],[21] it is very essential to identify patients with organic tricuspid valve involvement and differentiate them from functional involvement in secondary conditions. In our study, we found that 10.34% of rheumatic heart disease patients had organic tricuspid valve disease. All patients of organic tricuspid valve disease had concomitant mitral valve involvement in our study. Isolated rheumatic tricuspid valve disease in the absence of mitral valve involvement is not documented neither in earlier studies[18],[22] nor in our study. Gutner[23] showed that natural history of rheumatic tricuspid valve lesions is dictated by severity of mitral and/or aortic disease, but in case of organic tricuspid valve involvement, it may not be applicable. Mitral valve is the most common valve involved in our study and it correlates with the past studies.[15],[16] Organic tricuspid valve involvement causing significant lesions has to be addressed therapeutically. Percutaneous balloon valvotomy is a proven therapeutic option for significant or severe tricuspid stenosis with gratifying results, which was seen in significant number of patients in our study [Table 1]. With the upcoming percutaneous and surgical tricuspid valve repair, possibly in the near future, significant number of these patients can be treated effectively.

Limitations

This was a single-center, tertiary care, hospital-based observational study. No clinical correlation or follow-up was done of these patients.


  Conclusion Top


Rheumatic heart disease is one of the major contributors to cardiovascular morbidity and mortality in India, especially in a lower socioeconomic stratum. Mitral valve disease is the most common valve involved. Tricuspid valve disease, even though easy to miss on clinical evaluation, is not uncommon. Around 10% of these rheumatic heart disease patients have echocardiographic involvement of organic tricuspid valve. Thorough evaluation using various echocardiographic parameters is needed. With the increasing awareness of tricuspid valve disease, morbidity and mortality associated with it, and growing therapeutic options, it is very essential to identify patients with organic tricuspid valve involvement and differentiate them from functional involvement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vijaykumar M, Narula J, Reddy KS, Kaplan EL. Incidence of rheumatic fever and prevalence of rheumatic heart disease in India. Int J Cardiol 1994;43:221-2.  Back to cited text no. 1
    
2.
Padmavati S. Rheumatic heart disease: Prevalence and preventive measures in the Indian subcontinent. Keywords: Rheumatic heart disease; rheumatic fever. Heart 2001;86:127.  Back to cited text no. 2
    
3.
American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; Bonow RO, Carabello BA, Kanu C, de Leon AC Jr., Faxon DP, Freed MD, et al. ACC/AHA 2006 guidelines for the management of patient with valvular heart disease. Circulation 2006;114:84-231.  Back to cited text no. 3
    
4.
Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA. Long-term follow-up of patients with severe rheumatic tricuspid stenosis. Am Heart J 1998;136:103-8.  Back to cited text no. 4
    
5.
World Health Organization. Rheumatic Fever and Rheumatic Heart Disease. Geneva: World Health Organization: 2001. p. TRS-923  Back to cited text no. 5
    
6.
Guidelines on the management of valvular heart disease. EHJ 2007;28:230-68.  Back to cited text no. 6
    
7.
Nanna M, Chandraratna A, Reid C, Nimalasuriya A, Rahimtoola SH. Value of 2D ECHO in detecting tricuspid stenosis. Circulation 1983;67:221-4.  Back to cited text no. 7
    
8.
Daniels SJ, Mintz GS, Kotler MN. Rheumatic tricuspid valve disease: Two-dimensional echocardiographic, hemodynamic, and angiographic correlations. Am J Cardiol 1983;51:492-6.  Back to cited text no. 8
    
9.
Shimada R, Takeshita A, Nakamura M, Tokunaga K, Hirata T. Diagnosis of tricuspid stenosis by M mode and 2 D ECHO. Am J Cardiol 1984;53:164-8.  Back to cited text no. 9
    
10.
Pearlman AS. Role of echocardiography in the diagnosis and evaluation of severity of mitral and tricuspid stenosis. Circulation 1991;84(3 Suppl):I193-7.  Back to cited text no. 10
    
11.
Fisher EA, Goldman ME. Simple, rapid method for quantification of tricuspid regurgitation by two-dimensional echocardiography. Am J Cardiol 1989;63:1375-8.  Back to cited text no. 11
    
12.
Silver MD, Lam JH, Ranganathan N, Wigle ED. Morphology of human tricuspid valve. Circulation 1971;43:333-48.  Back to cited text no. 12
    
13.
Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for Chamber Quantification. J Am Soc Echocardiogr 2005;18:1440-63.  Back to cited text no. 13
    
14.
Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003;16:777-802.  Back to cited text no. 14
    
15.
Wood P. An appreciation of mitral stenosis. I. Clinical features. Br Med J 1954;1:1051-63.  Back to cited text no. 15
    
16.
Rowe JC, Bland EF, Sprague HB, White PD. The course of mitral stenosis without surgery: Ten- and twenty-year perspectives. Ann Intern Med 1960;52:741-9.  Back to cited text no. 16
    
17.
Reddy A, Jatana SK, Nair M. Clinical evaluation versus echocardiography in the assessment of rheumatic heart disease. Med J Armed Forces India 2004;60:255-8.  Back to cited text no. 17
    
18.
Kitchin A, Turner R. Diagnosis and treatment of tricuspid stenosis. Br Heart J 1964;26:354-79.  Back to cited text no. 18
    
19.
Waller BF, Moriarty AT, Eble JN, Darvey DM, Hawley DA, Pless JE. Etiology of pure TR based on annular circumference and leaflet area: Analysis of 45 necropsy patients with clinical and morphological evidence of pure TR. J Am Coll Cardiol 1986;7:1063-74.  Back to cited text no. 19
    
20.
Tang GH, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA. Tricuspid valve repair with an annuloplasty ring results in improved long-term outcomes. Circulation 2006;114:I-577-81.  Back to cited text no. 20
    
21.
Taramasso M, Pozzoli A, Guidotti A, Nietlispach F, Inderbitzin DT, Benussi S, et al. Percutaneous tricuspid valve therapies: The new frontier. Euro Heart J 2017;38:639-47.  Back to cited text no. 21
    
22.
Guyer DE, Gillam LD, Foale RA, Clark MC, Dinsmore R, Palacios I, et al. Comparison of the echocardiographic and hemodynamic diagnosis of rheumatic tricuspid stenosis. J Am Coll Cardiol 1984;3:1135-44.  Back to cited text no. 22
    
23.
Gutner RN. Trivalvular rheumatic stenosis: Documentation of disease progession by serial cardiac catheterization. Am J Med Sci 1980;280:185.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1]



 

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