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View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector indian heart journal 66 (2014) 320e326 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/ihj Original Article Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: A single center experience C.N. Manjunath a, P. Srinivas b,*, K.S. Ravindranath a, C. Dhanalakshmi a a Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India b PG, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jaya Nagar 9th Block, Bannerghatta Road, Bangalore 560069, Karnataka, India article info abstract Article history: Background: Diseases of the heart valves constitute a major cause of cardiovascular Received 4 April 2013 morbidity and mortality worldwide with rheumatic heart disease (RHD) being the domi- Accepted 23 March 2014 nant form of valvular heart disease (VHD) in developing nations. The current study was Available online 14 April 2014 undertaken at a tertiary care cardiac center with the objective of establishing the incidence and patterns of VHD by Echocardiography (Echo). Keywords: Methods: Among the 136,098 first-time Echocardiograms performed between January 2010 Valvular heart disease and December 2012, an exclusion criterion of trivial and functional regurgitant lesions Incidence yielded a total of 13,289 cases of organic valvular heart disease as the study cohort. Echocardiography Results: In RHD, the order of involvement of valves was mitral (60.2%), followed by aortic, Rheumatic heart disease tricuspid and pulmonary valves. Mitral stenosis, predominantly seen in females, was almost exclusively of rheumatic etiology (97.4%). The predominant form of isolated MR was rheumatic (41.1%) followed closely by myxomatous or mitral valve prolapse (40.8%). Iso- lated AS, more common in males, was the third most common valve lesion seen in 7.3% of cases. Degenerative calcification was the commonest cause of isolated AS (65.0%) followed by bicuspid aortic valve (BAV) (33.9%) and RHD (1.1%). Multiple valves were involved in more than a third of all cases (36.8%). The order of involvement was MS þ MR > MS þ AR > MR þ AR > AS þ AR > MR þ AS > MS þ AS. Overall, 9.7% of cases had organic tricuspid valve disease. Conclusion: RHD contributed most to the burden of VHD in the present study with calcific degeneration, myxomatous disease and BAV being the other major forms of VHD. Multiple valves were affected in more than a third of all cases. Copyright ª 2014, Cardiological Society of India. All rights reserved. * Corresponding author. Tel./fax: þ91 080 22977444. E-mail address: [email protected] (P. Srinivas). http://dx.doi.org/10.1016/j.ihj.2014.03.010 0019-4832/Copyright ª 2014, Cardiological Society of India. All rights reserved. indian heart journal 66 (2014) 320e326 321 Study Period: 1.1.2010-31.12.2012 1. Introduction Total number of Echocardiograms: 409468 Diseases of the heart valves constitute a major cause of cardiovascular morbidity and mortality worldwide with an Exclusion: repeat Echo enormous burden on healthcare resources. Rheumatic heart disease (RHD) continues to be the dominant form of heart 1 valve disease in developing nations. The prevalence of RHD Study database-Entry or first Echo has greatly decreased in developed nations; however, of the study cohort: 136098 increasing life expectancy and atherosclerotic risk factors have increased the risk of acquiring age-related degenera- tive valvular heart disease (VHD). Although the patterns of Exclusion: valve disease differ among these nations, the burden of Trivial, Functional, Unspecified MR: 18199 valvular heart disease continues unabated across the globe. With RHD affecting predominantly the young population in Sclerotic aortic valve, unspecified, trivial their productive years, the socio-economic impact on the to mild AR: 3955 society is enormous. Little data exists on the prevalence of Trivial, functional TR: 25092 valvular heart disease as studied by Echocardiography e (Echo), although several autopsy2 4 and surgical patho- e logy5 8 series form a rich source of literature on the patterns Primary, native valve disease, n=13289 of valvular heart disease. The current study was undertaken to establish the incidence and patterns of heart valve dis- e ease as studied by Echo. While pathological examination of Fig. 1 Algorithm showing the inclusion and exclusion [ valves obtained at surgery or autopsy remains the gold criteria of cases for the present study (AR Aortic [ [ standard in morphological analysis, with the current ad- Regurgitation, MR Mitral Regurgitation, TR Tricuspid vancesintechniques,comparableinformationonthe Regurgitation). anatomy and hemodynamic effects of valve disease can be obtained by Echo. 3. Results The Echocardiograms were analyzed in two parts: all the iso- 2. Methods lated valve lesions were analyzed first followed by various combinations of valve lesions. The data is presented in tables The current study was undertaken at Sri Jayadeva Institute and charts. Data is expressed in numbers, percentages and of Cardiovascular Sciences and Research, a tertiary care ratios. An overview of the patterns of valve disease is presented high-volume cardiac center located at Bangalore, South in Fig. 2. India, where more than 100,000 Echocardiograms are per- Mitral valve was the most common involved valve in the formed annually. All the Echocardiograms done over a rheumatic group, seen in 60.2% of the cases. Another 24.5% of period of 3 years from January 2010 through December 2012 cases had involvement of aortic valve as well, making the were analyzed for the present study. Among the 409,468 overall involvement of mitral valve in RHD to be 84.7%. When Echocardiograms performed during the period, only the first-time Echo of each patient was included for the study to avoid repetition bias. Hence, a total of 136,098 discrete Echo OVERVIEW OF PATTERNS OF VALVE LESIONS reports were available for inclusion. From the total database 4000 of 60,535 cases for any valvular heart disease, the following 3500 were excluded from the study: trivial, functional or un- 3000 specified mechanisms of mitral regurgitation (MR), trivial to 2500 mild aortic regurgitation (AR) due to sclerotic aortic valve or 2000 unspecified causes and trivial or functional tricuspid 1500 regurgitation (TR), with the remaining 13,289 cases of 1000 500 organic valvular heart disease forming the study cohort for 0 the present analysis (Fig. 1). Trace to small degrees of MR PS TS AS TR AR MS MR and TR can be detected in up to 80e90% of individuals on AS+AR MS+AS MS+AR MR+AS MR+AR careful Doppler Echo and can confound the estimates of MS+MR OVERALL RHEUMATIC disease prevalence.9,10 Also, the study was designed to determine the patterns of primary or organic valve disease; Fig. 2 e Overview of patterns of valvular heart disease hence trivial, functional or insignificant regurgitation was (AR [ Aortic Regurgitation, AS [ Aortic Stenosis, excluded from the analysis to avoid erroneous estimates MR [ Mitral Regurgitation, MS [ Mitral Stenosis, that can be produced by these large numbers of insignificant PS [ Pulmonary Stenosis, TR [ Tricuspid Regurgitation, lesions. TS [ Tricuspid Stenosis). 322 indian heart journal 66 (2014) 320e326 the overall cohort was considered, the corresponding figures 400 356 were 54.4%, 18% and 72.4% respectively; thus making mitral 350 the most common involved valve in VHD. Among patients 294 300 283 with isolated mitral valve involvement, pure mitral stenosis (MS) was the dominant lesion (37.1%). Another 35.7% of cases 250 had MR in addition to MS; thus, MS was seen in a total of 72.8% 199 200 177 FEMALE of patients with isolated rheumatic mitral valve disease with 157 MALE 150 the remaining patients having pure MR (27.2%). Aortic valve 128 100 (AV) was involved in 29.1% of cases making it the second most 100 64 45 41 common valve to be involved in RHD; most cases had asso- 50 31 17 11 ciated mitral valve involvement. Isolated involvement of AV 1 3 0 2 0 was rare in the rheumatic group. In the overall cohort, aortic 0-9y 10-19y 20-29y 30-39y 40-49y 50-59y 60-69y 70-79y 80-89y valve was involved in 35.8% of patients. Next most common to e be involved was Tricuspid valve (10.7% and 9.7% of rheumatic Fig. 3 Age and Sex-wise distribution of Rheumatic Mitral and overall cohorts respectively). Most of the lesions were TR Stenosis cases. (10.4%). Tricuspid stenosis (TS) was rare (0.3%). Pulmonary was the least common valve to be involved in RHD (0.04%); all cases had associated MS. was diagnosed were women. It can be seen from the figure that the incidence of pulmonary hypertension was in pro- portion to the severity of MS (10.4% of mild MS, 27.9% of 3.1. Isolated MS moderate MS, and 61.7% of severe MS respectively). The distribution of cases according to etiology and gender is shown in Table 1. Age- and Sex-wise distribution of rheumatic 3.2. Isolated MR MS cases is shown in Fig. 3. A steady increase in the incidence of rheumatic MS can be seen with each decade with a peak MR occurred as an isolated lesion in 25.6% of all the cases occurring at 30e39 years. This trend was seen in both female making it the most common isolated valve lesion. The pre- and male patients. Nearly two-thirds (65.9%) of MS patients dominant form of MR was rheumatic (41.1%) followed closely were females. Interestingly, MS was seen as an isolated lesion by myxomatous or mitral valve prolapse (40.8%) (Fig. 6). Iso- even in elderly patients (60 years).
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