Valve repair a possible cure to RHD
Dr Harshbir Singh Pannu

Rheumatic heart disease (RHD) continues to be a global problem, but in India it is the commonest heart valve disease. Earlier, it was believed that its incidence is decreasing and its prevalence was believed to be 1 in 1,000 persons. But surveys carried out recently have proved that it is not so and its prevalence in India ranges from 5.5 to as high as 20.4 in 1,000 persons.

The surveys conducted in the urban areas like the one in and around Delhi by AIIMS revealed the prevalence of 20.4 and surprisingly a very high prevalence of 27 in 1,000 in females. Another one carried out in rural India in a remote area of Himachal Pradesh showed the prevalence of 5.5 in 1,000.

The World Congress in Cardiology held in Dubai in April this year published a Global Rheumatic Heart Disease registry under the aegis of the WHO and India, Africa and West Asia have been identified to be the worst hit. Thirty centres have been set up to tackle the rising prevalence of this crippling disease.

The main reason for this surge in the incidence is crowding in urban areas instead of rural areas as earlier it was the case. This urban crowded living is due to several people huddled together in small rooms because of expensive city and metropolis living conditions and growing ambition to move to bigger cities to improve the economic condition of families back home in smaller towns and villages.

RHD — an autoimmune phenomenon

It is said that rheumatic fever, which usually starts as an innocuous throat infection, “licks the throat and joints and bites the heart”. The heart valves mainly (damaged by the body’s own immune system) are the mitral and aortic valves which become either tight or leaky.

Starting in early childhood, the disease strikes and starts affecting their life by the time they are in their twenties or thirties. This leads to decreased flow in the body and increases pressure of blood in the lungs causing symptoms like breathlessness, fainting attacks and chest pain initially. If ignored, these symptoms are the harbinger of life-threatening complications like stroke, heart attacks and even sudden death. As the valve undergoes progressive damage from turbulence, survival soon becomes compromised as heart failure sets in.

Valve replacement mainstay of treatment

Once the symptoms set in, normally valve replacement is the answer and rarely so repair can be applied. Repair is only possible most often in situations where valve deformation is less and symptoms are yet to appear. Though this is the gold standard for the timing of surgery for valvular heart disease nowadays, it is very rarely seen practically in clinical practice in our country as the presentation is very late due to the lack of knowledge fact that this disease can occur even in younger people.

Heart valve replacement is carried out routinely all over the country. Since patients are young, a mechanical valve is used (metal valve) for this kind of disease. For the maintenance of these metal valves in the blood, the patient has to take lifelong anticoagulants (blood thinners) and undergo blood testing at regular intervals.

If the patient is older than 60 years, a biological valve prosthesis prepared and processed from other mammals can be a safer alternative, where anticoagulants are discontinued after three months. This certainly improves the quality of life and decreases symptoms, but anticoagulant-related complications and risk of infection on this valve prosthesis continues for life. Eventually 60 per cent of these patients may succumb to known complications, and 10-year valve-related risk to life is almost 63 per cent. Moreover, the pump function decreases by 5-20 per cent after valve replacement.

Valve repair a superior and proven option now

Dr Rankin Scot in the USA has applied the principle of biologically inert plus patients own material to valves deformed from degenerative and ischemic causes and used patients own pericardium (natural covering of the heart) for the last more than 10 years and shown 10-year risk free survival up to 85 per cent in that group of patients.

We in collaboration with him decided to use and apply the same technique in rheumatic valves severely deformed by the disease (inflammation) and turbulence in two of our patients. Both patients had severely leaking and either moderately tight or severely tight mitral valves. First we tried this technique in a lady from Gobindgarh (aged 46 years) with good pumping function (LVEF65 per cent).

As we were encouraged by good short-term results, we offered the same to a seemingly hopeless case, a young man from Uttarakhand, aged 25 years and weighing only 31 kg with poor pump function (LVEF 20 per cent) as a result of end-stage heart failure. He was refused surgery by several centres due to the fact that valve replacement carried a prohibitive risk. He may not have survived with LVEF of 10-15 per cent resulting from valve replacement.

Both patients are completely free of symptoms. After three months they are off all blood thinners with normal rhythm (NSR) of the heart returning as well which is a perplexing finding.

From an economic viewpoint, this is an advantageous situation because the cost of the prosthetic valve is avoided, the range of which is Rs 50,000 to 1,25,000. It also avoids the cost of lifelong cumbersome anticoagulants and testing to maintain the blood thinners. This type of surgery, if applied early during the disease process when the likelihood of repair is very high, has the potential to make this operation of valve repair a very economical tool in the fight against rheumatic heart disease.

The writer is Chief Consultant, Cardiovascular Surgery, Ivy group of hospitals, Mohali.

Caring for baby’s teeth
Dr Pratibha Gupta

It’s well known that healthy teeth are helpful in maintaining overall health. These tiny army of white pearls help the child to chew food, make sounds and words and hence speak well. Dental care should start even before the teeth start appearing in the baby’s mouth. Because if you can’t see teeth in the baby’s mouth it doesn’t mean that they are not there. They are present beneath the gum pads. So, care for the gum pads is also very essential as early good oral habits lead to the best lifetime habits.

The first tooth generally appears from 4th-7th month of age, although it is different in the case of every child. At this age babies are generally bottle-fed. Never let your child sleep with the milk bottle or juice in his/her mouth. Always bottle-feed your child yourself. If the child has the habit of sleeping with the bottle, give him a bottle filled with water. It is because the sugary content of milk or juice will lead to bacterial growth in the oral cavity, as it gets pooled in the mouth while the child is asleep.

Clean your child’s gum pads with clean, wet muslin cloth. Give them a cold teething ring to soothe their gum irritation. When the child has one or two teeth in the mouth, clean them with a wet gauze piece or a soft cloth to clear the plaque film formed over the teeth, which is full of bacteria.

Some important tips for good oral health of 
your baby:

Ø Wean off the bottle by one year of age.

Ø By the age of 18-24 months, start brushing your baby’s teeth with a non-fluoridated toothpaste.

Ø Check for any alarming symptoms in the oral cavity like brown spots on the teeth or redness in the gums.

Ø Visit your dentist regularly as it also helps the child to be familiar with the dental clinic environment.

The writer is a Panchkula-based dentist.

How not to suffer pain during first child-birth?
Dr Meenal Kumar

Reenee, 35, has just landed in a corporate hospital for delivering her first child. She doesn’t want to suffer pain for too long. Her mother is adamant that she will not allow caesarean section (CS) on her athlete daughter. A friend has now suggested on her mobile to get acupressure done to ‘reduce labour pains, induce contractions, resulting in an easier, safer and shorter birth’.

She is upset that the facility of acupressure is not available in this five-star hospital. “Can you induce my delivery immediately so that I don’t suffer from pains?” she asked.

The doctor smiled and told her to have patience for 12-24 hours since labour pain had just begun. “If the labour does not progress on the expected lines we will consider CS; a procedure that ensures quick, pain-free delivery and that ensures greater safety for the newborn also.”

If CS is safer for me and my newborn both and also it is pain-free, why don’t you offer it to me right away?” the patient demanded. “Pains or no pains, we will not allow CS at any cost; if you want to make more money, I will give it,” thundered the mother. The doctor was in a dilemma.

Why not caesarean section for all women?

In a study at Hammersmith Hospital, London, it was observed that CS rates had doubled in recent decades. Consequently, it has led to a sharp decline in maternal and neonatal mortality, influenced by the safety of CS under epidural anaesthesia, thrombo-prophylactic and antibiotic cover. Besides pain-free status, most women wish to prevent damage to their pelvic floor, and to prevent damage to their baby. Vaginal delivery is the major cause for stress incontinence, prolapsed uterus and anal incontinence in women that affects almost a third of all women.

A survey in the UK indicated that 92 per cent of women wanted to be delivered by the route that was safest for the baby. The same survey showed that 54 per cent of obstetricians thought that it was by CS. Should all women be offered an elective caesarean section? Clearly, the answer is no, at least in Indian conditions. Vaginal delivery is natural and should be allowed if the pelvic outlet is not narrow and the progress of labour is on the expected lines, without any danger to the mother or foetus.

Why the CS rates are destined to rise?

Firstly, women are reproducing later in life, and the rising age correlates linearly with CS rates. Reenee has been busy with her athletics-related activities and was not free for reproduction earlier! Next, babies are getting bigger, and so are their mothers. Finally, the litigation costs resulting from vaginal delivery complications are also rising. Caesarean rates in the twenty-first century will be driven up by consumer demand, and will certainly exceed 50 per cent.

However, a normal delivery will be a first choice in Indian conditions.

Who are the women at greater risk and likely to ask for CS?

Primigravida (PG), a woman who conceives for the first time, is at greater risk. Proper antenatal monitoring during first pregnancy helps in avoiding problems associated with Rh incompatibility if the baby is Rh-positive. Iron deficiency, which is observed in almost all patients ranging from mild to severe, is a major cause for premature labour, and a low-birth-weight baby. A study revealed that elderly PG were even at a greater risk — pregnancy-induced hypertension (24.35 per cent vs 6.41 per cent), diabetes, malpresentations and premature labour. More (30.76 per cent) of the elderly group were delivered by a caesarean section as compared to 16.02 per cent in the young group. Congenital malformations of the foetus were common in the elderly group (5.12 per cent vs 1.28 per ent). Cases of essential hypertension (12.82 per cent vs 1.92 per cent), fibroid uterus (9.61 per cent vs 2.56 per cent) and ovarian cyst (7.69 per cent vs 1.92 per ent) were frequent in elderly group patients. It is better to bear a child when you are young, 21-34 years.

Considering CS in the case of those where labour is not progressing or there are signs of foetal distress is in order. Give a fair chance to normal vaginal delivery before embarking upon a surgical adventure. Give freedom to your doctor to decide.

The writer is a senior gynaecologist, based in Chandigarh.