Contemporary Outcomes of Aortic and Mitral Valve Surgery for Rheumatic Heart Disease in Sub-Saharan Africa

Abstract

Objective: Rheumatic heart disease (RHD) is endemic in sub-Saharan Africa. There is a paucity of data on outcomes of valvular surgery for end-stage RHD in low-income countries. The objective of this study was to evaluate the outcomes of aortic and mitral valve surgery for RHD in Ethiopia. Method(s): Between 2009 and 2017, 240 consecutive patients with end-stage RHD underwent aortic and/or mitral surgery at a single center in Addis Ababa, Ethiopia. These surgeries were performed in the context of 22 international humanitarian missions. Median follow-up was 2.3 [IQR: 0.5-4.0] years and was 96% complete. Outcomes were compared between patients who underwent mechanical valve implantation (n=90, 38%), bioprosthetic valve implantation (n=58, 24%), and valve repair (n=92, 38%). Result(s): Mean age was 19+/-8 years and 136 (57%) patients were female. A total of 126 (53%) patients underwent singlevalve surgery, 94 (39%) underwent double-valve surgery, and 20 (8%) underwent triple-valve surgery. Operative mortality occurred in 5 (2%) patients, and was not significantly different between the groups. Eleven (5%) additional patients died at follow-up, and 55 (23%) suffered at least one major adverse valve-related event (MAVRE). Propensity score-adjusted Cox regression analysis demonstrated higher rates of death in the bioprosthetic group compared with the mechanical group (HR [95% CI]: 8.82 [1.64-47.39], p=0.011) (Figure 1A). Survival was not significantly different between the repair and mechanical groups (HR [95% CI]: 1.09 [0.17-7.16], p=0.93). Similarly, rates of MAVRE were higher in the bioprosthetic group compared with the mechanical group (HR [95% CI]: 2.71 [1.13-6.49], p=0.025), but not significantly different between the repair and mechanical groups (HR [95% CI]: 1.98 [0.89-4.39], p=0.092) (Figure 1B). Conclusion(s): Left-sided valve surgery for end-stage RHD in sub-Saharan Africa is associated with acceptable perioperative outcomes, but a high incidence of MAVRE at follow-up. The use of bioprosthetic valves is associated with poor outcomes in this patient population.