Rheumatic heart disease

Arumugam S*

Physician Assistant, CTVS, Kauvery Hospital, Hosur, Tamil Nadu

*Correspondence

Abstract

Rheumatic Heart Disease (RHD) is the only preventable cardiovascular disease which causes significant morbidity and mortality particularly in low- and middle-income countries. Early clinical diagnosis is key, the updated Jones criteria increases the likelihood of diagnosis in endemic settings, including the echo diagnosis of sub-clinical carditis, polyarthralgia and monoarthritis as well as amended thresholds of minor criteria. The mainstay of Rheumatic Heart Valve Disease (RHVD) is a thorough clinical and echocardiographic investigation while severe disease is managed with medical, interventional and surgical treatment. In this case report, will give insight of Rheumatic Heart Disease symptoms, Investigation, on time Diagnosis and surgical intervention.

Key words: Rheumatic Heart Disease (RHD); Acute rheumatic fever; Rheumatic Heart Valve Disease (RHVD)

Introduction

Acute rheumatic fever is a multi-system, autoimmune inflammatory disease occurring 2 to 4 weeks after a group A streptococcal throat infection. Driven by molecular mimicry, it affects children aged 5 to 18 years. Diagnosis relies on the modified Jones criteria, Major criteria (Pericarditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules) and Minor Criteria (Fever, arthralgia, elevated acute-phase reactants (ESR, CRP), leukocytosis and prolonged PR interval on ECG). Management focusing on antibiotics and anti-inflammatory medications.

Case presentation

A 17 years’ young patient known complaints of Rheumatic fever for 5yrs, presented with history of shortness of breath and headache for past 1 month worsened for 1 week, which was associated with giddiness and dry cough and also noted history chronic polyarthralgia was admitted in hosur kauvery hospital on 08/08/26.

Image Source: Cleveland Clinic; Rheumatic Heart Disease; 05/02/2026

Past history

Rheumatoid arthritis since past 6 years on regular siddha medicine, No co-morbidities

On examination

Conscious, oriented, afebrile

BP	110/80mmHg
Pulse rate	78bpm
Spo2	98% In RA
Respiratory rate	20 b/min
Temperature	98.6 F

Systemic examination

CVS	Pan systolic murmur on mitral area
RS	B/L AE (+)
P/A	Soft, Non tenderness
CNS	NFND

Preoperative assessment

The patient underwent comprehensive preoperative evaluation:

Echocardiography

Revealed Rheumatic heart disease, Severe aortic regurgitation / No aortic stenosis, moderate mitral regurgitation (Eccentric jet), Dilated left atrium and left ventricle, Mild tricuspid regurgitation, No regional wall motion abnormality, No pulmonary artery hypertension, Adequate LV function (LVEF-55%). Aortic valve: Mildly thickened aortic leaflet AV Max (cm/s)-216, Mitral valve: AML& PML Thickened with restricted PML mobility.

Ultrasound abdomen and pelvis: Mild diffuse bladder wall thickening, No any obvious abnormalities.

Chest x-Ray: Normal x-ray findings.

Laboratory Investigations

Investigations	Values
CBC	HB - 14.6 g/dL WBC - 12,210 cells/cumm Platelets - 339,000/cumm
ESR	30 mm/1 hr
RFT	Creatinine - 0.8 mg/dL Urea - 32.1 mg/dL
Blood group	O positive
LFT	Total bilirubin - 0.4 mg/dL Total protein - 8.9 g/dL Albumin - 4.9 g/dL S. globulin - 4.0 g/dL SGOT - 21 U/L SGPT - 16 U/L ALP - 118 U/L
Electrolytes	Sodium - 136 mmol/L Potassium - 3.9 mmol/L Chloride - 97 mmol/L
PT/INR	1.03
CRP	<5.0
TFT	TSH - 2.603 mIU/mL T4 - 9.10 mcg/dL T3 - 1.27 ng/mL
Lipid profile	Total cholesterol - 154 mg/dL Triglycerides - 216 mg/dL HDL - 27 mg/dL LDL - 84 mg/dL
Urine Routine	Colour - Pale yellow pH - 5.0 Urine albumin and sugar - Nil RBC - Nil Pus cells - 02-03/HPF

Preoperative Medications

Digoxin 0.25mg
Dytor plus 20/50mg
HCQS 200mg
Etova ER 400mg and Tab.Pan 40mg

Final diagnosis:

Rheumatic heart disease
Severe aortic regurgitation
Severe mitral regurgitation
Rheumatoid arthritis

Surgery Intervention

AVR (using 21mm TTK chitra valve) + MV repair (using 28mm profile 3D ring annuloplasty)

Anesthesia and Monitoring

The patient was sedated and intubated with a 7.0 size endotracheal tube. The following lines were established:

16 Fr Ryle’s tube
Right Internal Jugular Vein central line
Left radial arterial line
14 Fr Foley’s catheter

Procedure

Median sternotomy & thymus dissected, pericardium marsupialised. Patient heparinised and went on bypass using aortic and bicaval cannulation technique.
Core cooling started, heart fibrillated, aorta cross clamped, aortotomy done and aorotomy edges retracted and direct ostial cardioplegia given to achieve diastolic arrest of the heart. Aortic valve excised and sized.
Intra atrial groove developed and LA entered. LA size was small, hence superior trans septal approach used to expose mitral valve. LA appendage inspected for clots. Open Mitral valvotomy done. Mitral valve repair done with 28mm profile 3D ring using 2-0 ethibond interrupted pledgeted stitches. Aorotomy closed in two layers using 5-0 prolene.
Rewarming started, LA closure done in two layer using 4-0 prolene, RA closure done in two layers using 6-0 prolene, de-airing done and cross clamp released. Heart picked up in sinus rhythm.
Patient came off bypass in first attempt at 37 degrees centigrade with elective Adrenaline and Dobutamine support. Protamine given and decannulation done. Hemostasis checked and chest closed in layers with two mediastinal and right pleural drains and 1 RV pacing wire in situ.
Sternum repaired using stainless steel wires and chest closed in layers using vicryl sutures and dressing done.
At the end of the procedure the swab and instrument count was correct.

Findings: Thickened aortic value leaflets Dilated mitral annulus with thickened mitral leaflets

Postoperative course

Patient was shifted to ICU on ventilator support, gradual weaning of mechanical ventilation after extubated same day of surgery.
Drain were removed on POD -1.
Maintaining hemodynamic stability with inotropes
Inotropes were gradually tapered and stopped. After stabilization Foleys catheter, artery line removed POD- 2.
Patient shifted to ward in stable condition. Surgical Site was healthy. Regular physiotherapy and Incentive spirometry was given.
Aggressive management of fluid balance (maintaining negative balance) and early mobilization and rehabilitation
Currently patient is hemodynamically stable and is also ambulating. Hence Patient is being discharged with following advice.

Post-Operative Management & Recovery

Anticoagulant Therapy: patient receives a mechanical MVR, long-term anticoagulation (e.g., Acitrom) is required to prevent valve thrombosis. must monitor International Normalized Ratio (INR) levels closely.
Hospital Stay: Patient spend 2 to 3 days in the Intensive Care Unit (ICU) followed by 4 to 7 days in a standard hospital ward.
Medication: Post-surgery, educated patient for required medications to manage heart rhythm, prevent blood clots (anticoagulants), and manage blood pressure.
Recovery Timeline: Full recovery typically takes 4 to 8 weeks, though it may take longer for a full return to normal activity. Cardiac rehabilitation is standard practice to safely rebuild strength.
Cardiac Rehabilitation: Doctors highly recommend entering a monitored cardiac rehab program to safely regain your strength, endurance, and cardiovascular health.

Critical Medication Warning

The Vitamin K Rule

Educated patient for low intake of Vitamin K rich foods

Avoid intake of dark green leafy vegetables (spinach, kale, cauliflower, cabbage, broccoli).
Fluid restriction for 1.5 liters per day.

Conclusion

Rheumatic heart disease is acquired cardiovascular disease does not spread person to person. Primary and secondary prevention of RHD ensuring a consistent supply of quality assured antibiotics, it successfully reduce aortic regurgitation and mitral regurgitation post-op AVR and MV repair without significantly increase operative risk, post-operative complications or mortality.

Rheumatic heart disease

Rheumatic heart disease

Arumugam S*

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