ECHOCARDIOGRAPHIC EVALUATION OF PATIENTS WITH ACUTE RHEUMATIC-FEVER AND RHEUMATIC CARDITIS

Background Cardiac involvement is the most important component of acut e rheumatic fever. The role of echocardiography in the evaluation of r heumatic carditis has not been adequately defined. We used echocardiog raphy in a large sample of patients with acute rheumatic fever to desc ribe morphological abnormalities associated with rheumatic carditis an d to assess its role in the diagnosis of rheumatic carditis. Methods a nd Results Cross-sectional and color Doppler echocardiographic examina tion was performed in 108 consecutive patients with acute rheumatic fr yer within 24 to 48 hours of diagnosis. Twenty-eight patients had acut e rheumatic fever without clinical evidence of carditis (group 1). Thi rty-five patients had a presumed first episode of rheumatic carditis ( group 2), and 45 patients had a recurrence of carditis (group 3). Pati ents in group 1 did not demonstrate any evidence of valvular regurgita tion. Mitral regurgitation was the most common Doppler echocardiograph ic feature in groups 2 (94%) and 3 (84%). Valvular thickening with or without restriction of leaflet mobility was frequently seen in rheumat ic carditis. One of every 4 patients with rheumatic carditis demonstra ted echocardiographic presence of focal valvular nodules. These nodule s were found on the body and the tips of the mitral valve leaflets and disappeared on follow-up. Ventricular dilatation (group 2, 54%; group 3, 74%) and restriction of leaflet mobility (group 3, 37%) were commo n mechanisms of mitral regurgitation in rheumatic carditis; valve prol apse (group 2, 9%; group 3, 16%) and annular dilatation (group 2, 12%; group 3, 21%) were infrequent. The majority of patients with rheumati c carditis had normal left ventricular systolic function. Congestive h eart failure (group 2, 17%; group 3, 40%) was invariably associated wi th the presence of hemodynamically significant valve lesions. On follo w-up, no patient in group 1 developed valvular regurgitation. In group 2 patients, a progressive decrease in left ventricular dimensions was observed without any change in ventricular fractional shortening. Val vular regurgitation remained unchanged in 69% of patients, decreased i n 22%, and disappeared in 9%. Conclusions In patients with rheumatic c arditis, the mitral valve is most often involved and mitral regurgitat ion is the most common finding on color flow imaging. Mitral regurgita tion in rheumatic carditis is related to ventricular dilatation and/or restriction of leaflet mobility. Rheumatic carditis does not result i n congestive heart failure in the absence of hemodynamically significa nt valve lesions. In a quarter of patients with rheumatic carditis, we observed valve nodules that may represent echocardiographic equivalen ts of rheumatic verrucae. Our study failed to reveal any incremental d iagnostic utility of echocardiography and Doppler color flow imaging i n rheumatic fever without clinical evidence of carditis.