Evidence against a myocardial factor as the cause of left ventricular dilation in active rheumatic carditis

Division of Cardiology, Baragwanath Hospital, Johannesburg, South Africa.

OBJECTIVES. The aim of this study was to determine whether left ventricular dilation and congestive heart failure in patients with acute rheumatic fever with carditis are accompanied by left ventricular contractile dysfunction. BACKGROUND. Acute rheumatic fever with carditis involves both the myocardium and endocardium, with consequent valvular regurgitation. The relative contribution of volume overload induced by valvular regurgitation and myocardial dysfunction due to rheumatic myocarditis to the overall degree of left ventricular dilation and congestive heart failure in these patients is unknown. METHODS. To investigate this, we evaluated 32 patients (15 male, 17 female, mean age 14 +/- 3 years) with documented active carditis and congestive heart failure. All 32 patients were found to have significant isolated mitral regurgitation or combined mitral and aortic regurgitation. Echocardiographic analysis of left ventricular dimensions and systolic performance was performed before and after isolated mitral or combined mitral and aortic valve replacement and the results were compared with those in 19 control subjects matched for age, gender and body surface area. RESULTS. Both preoperative left ventricular end-diastolic diameter and percent fractional shortening were significantly increased in patients compared with control subjects (57 +/- 7 vs. 43 +/- 3 mm, p < 0.001, and 38 +/- 6% vs. 33 +/- 1%, p < 0.001, respectively). After valve replacement, left ventricular end-diastolic diameter decreased significantly (57 +/- 7 to 47 +/- 6 mm, p < 0.001). Although percent fractional shortening decreased significantly postoperatively (38 +/- 6% to 32 +/- 6%, p < 0.001), the postoperative percent fractional shortening did not differ from that in control subjects (32 +/- 6% vs. 33 +/- 1%, p = NS). CONCLUSIONS. The results of this study indicate that left ventricular dilation and heart failure in patients with acute rheumatic carditis rarely occur in the absence of hemodynamically significant regurgitant valve lesions. Furthermore, rapid reduction in left ventricular dimensions and preservation of fractional shortening after isolated mitral or combined mitral and aortic valve replacement suggest that rheumatic carditis is not accompanied by any significant degree of myocardial contractile dysfunction.

This article has been cited by other articles:

				S. Stewart, D. Wilkinson, C. Hansen, V. Vaghela, R. Mvungi, J. McMurray, and K. Sliwa Predominance of Heart Failure in the Heart of Soweto Study Cohort: Emerging Challenges for Urban African Communities Circulation, December 2, 2008; 118(23): 2360 - 2367. [Abstract] [Full Text] [PDF]

				V. T Nkomo Epidemiology and prevention of valvular heart diseases and infective endocarditis in Africa Heart, December 1, 2007; 93(12): 1510 - 1519. [Abstract] [Full Text] [PDF]

				M. R. Essop and V. T. Nkomo Rheumatic and Nonrheumatic Valvular Heart Disease: Epidemiology, Management, and Prevention in Africa Circulation, December 6, 2005; 112(23): 3584 - 3591. [Abstract] [Full Text] [PDF]

				J. Kamblock, L. Payot, B. Iung, P. Costes, T. Gillet, C. Le Goanvic, P. Lionet, B. Pagis, J. Pasche, C. Roy, et al. Does rheumatic myocarditis really exists? Systematic study with echocardiography and cardiac troponin I blood levels Eur. Heart J., May 1, 2003; 24(9): 855 - 862. [Abstract] [Full Text] [PDF]

				P. Ferrieri and for the Jones Criteria Working Group Proceedings of the Jones Criteria Workshop Circulation, November 5, 2002; 106(19): 2521 - 2523. [Full Text] [PDF]

				T. L. Gentles, S. D. Colan, N. J. Wilson, R. Biosa, and J. M. Neutze Left ventricular mechanics during and after acute rheumatic fever: contractile dysfunction is closely related to valve regurgitation J. Am. Coll. Cardiol., January 1, 2001; 37(1): 201 - 207. [Abstract] [Full Text] [PDF]

				E. A. Eltohami, H. A. Hajar, G. M. Folger, and E. A. Eltohami Acute Rheumatic Fever in an Arabian Gulf Country Effect of Climate, Advantageous Socioeconomic Conditions, and Access to Medical Care Angiology, June 1, 1997; 48(6): 481 - 489. [Abstract] [PDF]

				J. B. Barlow, S. J. Middlemost, R. H. Kinsley, B. J. Amsel, I. E. Rodrigus, L. Haenen, and A. C. Moulijn Biventricular Assist for Severe Acute Rheumatic Pancarditis Ann. Thorac. Surg., March 1, 1997; 63(3): 920 - 921. [Full Text]

				B. J. Amsel, H. De Raedt, I. E. Rodrigus, L. Haenen, P. Druwe, A. Vorlat, C. G. Colpaert, and A. C. Moulijn Biventricular Assist for Severe Acute Rheumatic Pancarditis Ann. Thorac. Surg., July 1, 1996; 62(1): 267 - 269. [Abstract] [Full Text]

				R. S. Vasan, S. Shrivastava, M. Vijayakumar, R. Narang, B. C. Lister, and J. Narula Echocardiographic Evaluation of Patients With Acute Rheumatic Fever and Rheumatic Carditis Circulation, July 1, 1996; 94(1): 73 - 82. [Abstract] [Full Text]