Rheumatic heart disease in Tanzania
Authors:   , Mutagaywa Reuben Kato 
Published: August 2023

Chapter 1 is the general introduction and an outline of this thesis.
Part 1 of the thesis assessed RHD in special populations.
In the first part of chapter 2, we reported on the influence of gender in the management of rheumatic MS. We found that females present late in hospital. Diagnostic and management approaches do not differ between males and females. We obtained inconclusive results on the differences in mitral valve anatomy and the amount of leaflet calcium by sex, a subject that have been debatable in literature.
In response to address the inadequacy of data on infective endocarditis (IE), chapter 3 reviewed IE in LMICs. It shows a scarcity of studies on IE in developing countries especially SSA. Of the compared studies published before 2015 (group 1) and studies  2015 (group 2), RHD was higher in group 1 than in group 2. Streptococci and Staphylococcus aureus infections were lower in group 1 than group 2. Negative blood culture was higher in group 1 than in group 2. Patients in group 1 received more surgery than in group 2. Mortality did not change over time.
Chapter 4 determined the prevalence of sub-clinical RHD detected by hand-held echocardiogram in school children in Tanzania. In total, 4436 children were screened and sub-clinical RHD was found in 95 children, which is a prevalence of 2.1%. Independent factors associated sub-clinical RHD were female sex, older age, and presence of a cardiac murmur.
Part 2 of this thesis discusses the clinical presentation of patients with rheumatic MS
In chapter 5, we provided contemporary data on the clinical profile, treatment and follow-up of patients with rheumatic MS in Tanzania. We found that the disease affects young people, females, and with low income. Patients present late in the hospital and there is a low uptake of secondary prophylaxis. Interventions were done in half of the patients. There were more deaths in medical than surgical treatment arm. Predictors of mortality were: being on medical and having arrhythmias.
In chapter 6 we studied the histopathological changes in surgically excised rheumatic MS valves and corroborated them with clinical presentation, pathogenesis, and management. We confirmed that high mitral valve calcium is found in older patients, males, and in patients with severe MS. More than two-thirds of valves showed evidence of on-going inflammation with fibrinoid degeneration, polymorphonuclear leucocytes and fibrosis on haematoxylin-eosin. About a half of the specimens showed evidence of calcification and one-tenth had Aschoff nodules. A majority of the specimens were positive for markers of inflammatory cells.
Chapter 7 examined the clinical practice of patients with rheumatic MS that were evaluated for PBMV and defined the role of imaging, heart team, training/skill transfer in PBMV interventions in a Tanzania teaching hospital. We demonstrated that transoesophageal echocardiogram (TEE) is important for pre-PBMV. We showed that patients with Wilkins score of up to 11 underwent successful PBMV.
Part 3 focuses on progress in the management of RHD
In chapter 8, we retrospectively investigated 212 RHD patients who underwent cardiac surgery in Tanzania between the year 2008 – 2012. The mortality rate dropped in 4 years to 14.1% compared to the 24% reported after 1-year of establishing RHD cardiac surgery at MNH. In patients with RHD, double valve replacement is associated with increased early mortality. Chapter 9 prospectively assessed the Health-Related Quality of Life (HRQoL) of patients operated on due to rheumatic MS. We showed that six months after surgery the overall MacNew HRQoL scores improved. This improvement was regardless of the presence of comorbidities. The mortality was 4% showing significant improvement in surgery compared to the previously reported 14.1%.