Figure 1
Central Illustration – General characteristics of surgical valve procedures in the Uganda national RHD registry and a needs assessment to increase access to surgical management of RHD in Uganda.
*: Clinical complications of RHD include heart failure, arrhythmias, stroke and systemic embolism, infective endocarditis. RHD: Rheumatic Heart Disease; SSA: sub-Saharan Africa; PVT: Prosthetic Valve Thrombosis; WOCBP: Women of Child Bearing Potential; INR: International Normalized Ratio.
Table 1
General characteristics of surgical valve procedures.
| VOLUME OF PROCEDURES | |
|---|---|
| Total number of procedures | 367 |
| Total number of patients | 359 |
| Female (n = 359 patients) | 215 (59.9%) |
| AGE AT TIME OF SURGERY, YEARS (n = 367 PROCEDURES) | |
| 5–10 | 25 (6.8%) |
| 11–20 | 180 (49.1%) |
| 21–30 | 79 (21.5%) |
| 31–40 | 44 (12.0%) |
| 41–50 | 31 (8.4%) |
| 51–60 | 5 (1.4%) |
| 61–70 | 3 (0.8%) |
| TYPE OF SURGICAL PROCEDURE (n = 367) | |
| MV Replacement | 127 (34.6%) |
| MV Replacement and TV Repair | 68 (18.5%) |
| MV and AV Replacement | 57 (15.5%) |
| MV and AV Replacement, TV Repair | 33 (9.0%) |
| AV Replacement | 33 (9.0%) |
| MV Repair | 31 (8.5%) |
| MV Repair and TV Repair | 9 (2.5%) |
| AV Replacement and MV Repair | 4 (1.1%) |
| AV Repair | 2 (0.5%) |
| Mitral Commissurotomy | 2 (0.5%) |
| MV, AV, and TV Replacement | 1 (0.3%) |
| TYPES OF PROSTHETIC VALVES USED IN VALVE REPLACEMENT PROCEDURES (n = 323 PROCEDURES) | |
| Mechanical Valve | 312 (96.6%) |
| Bioprosthetic Valve | 11 (3.4%) |
| SURVIVAL STATUS (n = 359 PATIENTS) | |
| Alive | 307 (85.5%) |
| Dead | 47 (13.1%) |
| Unknown Status‡ | 5 (1.4%) |
| SPONSORING ENTITY (n = 367 PROCEDURES) | |
| Charity Efforts | 286 (77.9%) |
| Patient/Family Out-of-Pocket Payment | 69 (18.8%) |
| Employer | 10 (2.7%) |
| Medical Insurance | 2 (0.5%) |
| COUNTRIES (AND CENTERS) WHERE SURGERY WAS PERFORMED (n = 367 PROCEDURES) | |
| Uganda (Uganda Heart Institute) | 115 (31.4%) |
| Sudan (Salaam Center) | 188 (51.2%) |
| India (multiple centers) | 46 (12.5%) |
| Other Countries | 18 (4.9%) |
[i] MV: Mitral valve; TV: Tricuspid Valve; AV: Aortic valve; ‡Unknown status was assigned to patients who had not been seen in any RHD registry clinic for more than 1 year and had been unreachable on phone for more than 6 months.
Figure 2
Number of surgical procedures by year and country where they were performed.
*Patients were operated upon before inception of the Uganda national RHD registry, but were enrolled into the registry upon its inception in 2009. They continue to receive care under the registry with all clinical outcomes registered prospectively.
Table 2
Description of known deaths following valve replacement surgery.
| MORTALITY AFTER VALVE REPLACEMENT (n = 45) | |
|---|---|
| Females, n (%) | 27 (60%) |
| Patients with mechanical valves, n (%) | 44 (98%) |
| Patients with bioprosthetic valves, n (%) | 1 (2%) |
| Time from operation to death, n (%) | |
| Surgical mortality* | 14 (31%) |
| Late mortality# | |
| • Within 12 months | 13 (29%) |
| • 13–24 months | 5 (11%) |
| • 25–36 months | 5 (11%) |
| • >36 months | 8 (18%) |
| Causes of death¶ | |
| Surgical mortality*, n (%) | 14 (31%) |
| • Post-operative hemorrhagic shock | 1 |
| • Post-operative cardiac and/or multi-organ-failure | 13 |
| Late mortality#, n (%) | 31 (69%) |
| • Heart Failure | 10 |
| • Major Bleeding (VKA-related) | 2 |
| • Confirmed prosthetic valve thrombosis | 2 |
| • Suspected prosthetic valve thrombosis | 2 |
| • Venous thrombo-embolism | 1 |
| • Acute reaction to BPG | 1 |
| • Acute Kidney Injury | 1 |
| • Severe Malaria | 1 |
| • Homicide | 1 |
| • Sudden unexpected death† | 4 |
| • Unknown (unclear or total lack of history surrounding the death)‡ | 6 |
[i] BPG: Benzyl Benzathine Penicillin; *Surgical mortality: death prior to hospital discharge OR within 30 days of surgery; #Late mortality: death after hospital discharge OR after 30 days of surgery; ¶Causes of death: most causes of death were confirmed from hospital records; †Sudden unexpected death based on verbal autopsy with a family member; ‡Verbal autopsy attempted but unfruitful or inconclusive.
Table 3
Mortality following double valve replacement and other surgical procedures by country where operations were performed.
| DOUBLE VALVE REPLACEMENT‡ | OTHER SURGICAL PROCEDURES¶ | |||||
|---|---|---|---|---|---|---|
| SURGICAL MORTALITY* | UGANDA (n = 26) | ABROAD (n = 65) | P-VALUE | UGANDA (n = 89) | ABROAD (n = 187) | P-VALUE |
| 2 (7.7%) | 2 (3.1%) | 0.686 | 7 (7.9%) | 3 (1.6%) | 0.024 | |
| Late Mortality# | UGANDA (n = 24) | ABROAD (n = 63) | P-VALUE | UGANDA (n = 82) | ABROAD (n = 184) | P-VALUE |
| 4 (16.7%) | 7 (11.1%) | 0.486 | 7 (8.5%) | 15 (8.2%) | 0.916 | |
[i] * Surgical mortality: death prior to hospital discharge OR within 30 days of surgery; #Late mortality: death after hospital discharge OR after 30 days of surgery; ‡‘Double valve replacement procedures’ included replacement of the mitral and aortic valve, with or without tricuspid valve intervention; ¶‘Other surgical procedures’ included single valve replacement procedures with or without repair, valve repair-only procedures, and surgical commissurotomy procedures.
Figure 3
Kaplan-Meier estimates of survival or freedom from re-operation in registry patients undergoing valve replacement versus valve repair.
Valve repair and mitral commissurotomy, n = 43 (41 valve repairs, 2 mitral valve commissurotomies); Valve replacement, n = 314. This analysis excluded 1 valve repair and 4 valve replacement patients who had unknown outcomes.