Rheumatic and nonrheumatic valvular heart disease - Epidemiology, management, and prevention in Africa

Background - Unlike the Western world, valvular disease ranks among the major cardiovascular afflictions in Africa. Acute rheumatic fever and chronic rheumatic valvular disease in their most virulent form are still commonly encountered and impose a huge burden on limited healthcare resources. Methods and Results - We performed a systematic review of the literature with PubMed using rheumatic fever, rheumatic heart disease, valvular disease, warfarin anticoagulation, and pregnancy as search items. Literature emanating from Africa was emphasized. Epidemiology, current concepts on pathogenesis, and aspects of the medical and surgical management of this disease as seen from an African perspective are presented. The association of pregnancy with mitral stenosis is common and may be fatal if not managed appropriately. A practical approach to these patients is presented to optimize maternal and fetal outcome. Pregnant patients with mechanical valves require careful attention to ensure maternal survival and prevent fetal warfarin embryopathy. Prolonged subcutaneous heparin and frequent monitoring of the partial thromboplastin time are impractical in this setting, and the merits of different anticoagulation regimens are discussed. Congenital submitral aneurysms are a unique cause of mitral regurgitation, with the vast majority of cases originating from sub-Saharan Africa. Although the precise etiology is as yet unclear, the clinical and echocardiographic features are sufficiently characteristic to allow a preoperative diagnosis to be made. Transesophageal echocardiography allows much better definition of the size and anatomic relationships of the aneurysm. Surgical resection can be difficult but is usually curative. Mitral valve prolapse and endocarditis constitute the remaining frequent causes of valvular disease and are discussed briefly. Conclusions - The spectrum and presentation of valvular disease in Africa are uniquely different from elsewhere. Together with socioeconomic issues and the HIV pandemic, this fact makes it imperative that further epidemiological and clinical studies be undertaken and guidelines developed that are appropriate to the practice of medicine on the African continent.