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Mr.Arokiasamy, a bank employee, developed
shortness of breath while walking when he was 32 years old. He
was surprised to know that he had a damaged mitral valve that
was not working well. He was prescribed few medicines and was
advised to take for a long period. Four years later he stopped
all the medicines as he was completely free of symptoms. Two
months after that he developed severe shortness of breath,
dropped his oxygen levels and needed emergency care. Arokiasamy
was found to have water lodgment in the lungs due to poorly
functioning mitral valve. Echocardiography showed severe leak
across the valve (regurgitation). He was stabilized with
medications and was subsequently subjected to cardiac surgery.
His mitral valve was replaced with an artificial valve.
What is rheumatic heart disease?
It is a delayed inflammatory reaction to a previous throat
infection by a bacterium called streptococcus. In the process of
eliminating the infection, body produces proteins and
specialized white cells. In some individuals, these proteins and
cells misinterpret the heart tissue as alien in view of the
resemblance with that of the streptococcus and start attacking
it. This results in valve damage. The degree of damage varies
from person to person. One can carry on without symptoms
in-spite of having serious valve disease. So the heart problem
should not be ignored or the doctor’s diagnosis should not be
doubted based on the symptoms.
How does the valve disease progress?
Once rheumatic fever or rheumatic heart disease is diagnosed,
regular penicillin injections are given every 3 weeks to prevent
another infection. If it is not taken regularly, every new
infection increases the chance of further valve damage. The
altered flow pattern across the valve can increase the wear and
tear. This mechanism can worsen the valve function even without
new infection. A third mechanism is called ‘infective
endocarditis’ where some specific bateria affect the valves in
these patients.
What type of therapy is available?
 Majority would remain well with medical therapy. When the
disease is severe or if the symptoms are significant, then
balloon procedure or surgical intervention would be advised.
Even after successful balloon or surgical procedure, one needs
to continue medical therapy indefinitely.
What kinds of medicines are available?
The medications can be divided into four groups:
1.All patients with rheumatic heart disease should take
injections or medicines to prevent another infection of
streptococcus.
2.Some people need medicines to relieve their symptoms. These
include diuretic agents, medicines that reduce the resistance to
the flow of blood and those that increase the contractility of
the heart muscle.
3.In some patients, heart beat becomes very irregular. They have
high chance of developing blood clots within the heart. These
clots can migrate to brain and other parts of the body causing
stroke and other problems. Hence medicines are given to prevent
formation of clots.
4.Patients with valve disease are prone to develop infections on
the valve (endocarditis). In order to prevent this complication,
they need to take adequate antibiotics during dental procedures
and other procedures with high chances of bacteria entering the
body. Skin and other infections need to be promptly treated.
Here, medicines need to be taken only when needed, unlike the
first three types of medicines which need to be taken
continuously.
Once the balloon treatment is done, can the patient be declared
cured?
 No. The procedure helps in relieving the symptoms. This would
allow the patient to remain nearly as active as others. However,
he should continue all the prescribed medications. As the
disease activity continues in the body, the valve can fuse and
become stenotic again. This can occur as early as 4-5 years in
some individuals while in others, it may not occur even after
12-15 years.
What is the next step if the disease recurs after a balloon
procedure?
A detailed echocardiography assessment is done to see if the
patient is suitable for repeating the balloon procedure. If not,
surgical replacement is advised.
Do we have any non-surgical correction for leaky valves?
When a valve is leaky (regurgitation), the problem is incomplete
closure. Balloon procedure does not help. Developments are
underway to stitch the leaky mitral valves by passing catheters.
Similarly, non-surgical valve replacement procedures are being
evolved for damaged aortic valves. Currently, patients with
leaky valves are subjected for surgical replacement of the
affected valve.
Kannan BRJ
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