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Contemporary outcomes of rheumatic mitral valve surgery in the mid‐Atlantic region

Rheumatic mitral valve disease is now rare in high‐income countries, except for migrant and older residents, it remains an important and ongoing cause of preventable heart disease in Indigenous populations. Despite our major advances in medical technology and understanding, rheumatic fever (RF) remains a serious public health problem throughout the world. Population‐based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic mitral valve disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Mitral valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. The challenges in providing tertiary care, including access to mitral valve surgery and balloon mitral valvuloplasty in low‐resource environments, will be examined, with a view to developing pragmatic strategies toward addressing the challenges faced by those with established rheumatic mitral valve disease. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. In the current issue of the Journal, Hawkins et al. report the results of a multicenter, retrospective analysis of patients undergoing mitral valve surgery from 2011 to 2019. In this study, the clinical data submitted by 19 member hospitals in the mid‐Atlantic region is derived from the Society of Thoracic Surgeons (STS) adult cardiac surgery database data forms. The study is an important piece because it highlights rheumatic heart disease remains a significant contributor to the burden of surgical mitral valve disease in the United States, despite the low prevalence of acute RF in the United States. The authors hypothesized that rheumatic heart disease remains a significant contributor to the burden of mitral valve disease in the United States, and is a predictor of increased resource utilization and worse short‐term outcomes among patients undergoing mitral valve surgery. Also, they hypothesize that this may be in part due to migration from areas where acute RF remains endemic. Because an increasing number of patients travel internationally to seek medical care, some countries offer comprehensive and outstanding services under extraordinary conditions as a neighboring country to countries that have been at war for long periods. Refugees and displaced persons from settings affected by crisis often have complex needs and an increased risk of health problems related to their journeys. Many migrants experience lack of access to and continuity of health care. This makes particularly challenging to detect and manage asymptomatic, early stage rheumatic heart disease. The authors performed a multicenter retrospective cohort study, rheumatic mitral valve disease was identified to be a significant, and increasing, contributor to mitral valve surgery in the mid‐Atlantic region of the United States. Patients undergoing mitral valve surgery for rheumatic valve disease have comparatively high resource utilization relative to those with nonrheumatic mitral valve disease. Importantly, however, morbidity and major mortality were not significantly increased among patients undergoing mitral valve surgery for rheumatic valve disease. According to their cohort, patients undergoing mitral valve surgery for rheumatic heart disease has significantly longer intensive care unit and total lengths of stay, relative to patients with nonrheumatic valve disease. Patients with rheumatic mitral valve disease were more likely to have comorbid conditions and concomitant valvular disease, which may explain this finding. The results of the study published by Hawkins et al. confirm that rheumatic heart disease remains a significant and increasing driver of mitral valve surgery. Rheumatic heart disease was associated with