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Previous Volume 357:2088-2089 November 15, 2007 Number 20 Next

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To the Editor: Clinicians with access to echocardiography in regions in which rheumatic fever is endemic have been aware for decades that echocardiography is more sensitive and specific than auscultation in detecting acute carditis.^1,2,3 In New Zealand, an echocardiographic finding of left-sided regurgitation is accepted as evidence of carditis, and this has been formalized in recently published guidelines.⁴

On the basis of current knowledge, we agree with Dr. Marijon and colleagues (Aug. 2 issue)⁵ that morphologic valve changes, in addition to Doppler regurgitation, are necessary to define rheumatic heart disease in a setting in which most subjects are asymptomatic. More studies are needed to further define the minimal valvular morphologic characteristics of subclinical rheumatic heart disease. To this end, it would be helpful if the authors could describe in detail the specific criteria they used to determine "restricted leaflet mobility, focal or generalized valvular thickening, and abnormal subvalvular thickening."

It is also important to follow the natural history of isolated pathologic regurgitation detected by echocardiographic screening, such as that reported by Marijon et al. in 66 children in Mozambique.⁴ This will assist clinicians who must decide whether to commence prophylaxis with penicillin G benzathine in such patients.

Rachel Webb, M.B., Ch.B.
University of Auckland
Auckland 1142, New Zealand

Nigel J. Wilson, F.R.A.C.P.
Starship Children's Hospital
Auckland 1023, New Zealand

Diana Lennon, F.R.A.C.P.
University of Auckland
Auckland 1142, New Zealand

References

1. Wilson NJ, Neutze JM. Echocardiographic diagnosis of subclincal carditis in acute rheumatic fever. Int J Cardiol 1995;50:1-6. [CrossRef][Web of Science][Medline]
2. Veasy LG, Tani LY, Hill HR. Persistence of acute rheumatic fever in the intermountain area of the United States. J Pediatr 1994;124:9-16. [CrossRef][Web of Science][Medline]
3. Folger GM Jr, Hajar R. Doppler echocardiographic findings of mitral and aortic valvular regurgitation in children manifesting only rheumatic arthritis. Am J Cardiol 1989;63:1278-1280. [CrossRef][Web of Science][Medline]
4. New Zealand guidelines for rheumatic fever. 1. Diagnosis, management and secondary prevention. Auckland, New Zealand: Heart Foundation of New Zealand, 2006. (Accessed October 25, 2007, at http://www.nhf.org.nz/files/Rheumatic%20fever%20guideline%201.pdf.)
5. Marijon E, Ou P, Celermajer DS, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med 2007;357:470-476. [Free Full Text]

With regard to echocardiographic criteria for subclinical rheumatic features, the boundary between physiologic valve regurgitation and authentic but minimal rheumatic lesions remains difficult to discern in some cases.² The study of both Doppler and morphologic criteria enhances the specificity of echocardiography in this setting. Morphologic criteria in our study were based on the assessment of leaflet morphology, showing a typical marked thickening of the margins; leaflet mobility, with abnormal motion due to the posterior leaflet tip restriction; and subvalvular apparatus, displaying prominent thickening (most often just below the valve) and shortening of chordal structures. Using these criteria, we were able to document an excellent level of interobserver agreement for the detection of early rheumatic valve disease.

Eloi Marijon, M.D.
European Georges Pompidou Hospital
75908 Paris CEDEX 15, France
eloi_marijon{at}yahoo.fr

David S. Celermajer, Ph.D.
University of Sydney
Sydney, NSW 2006, Australia

Xavier Jouven, M.D., Ph.D.
INSERM Unité 780 Avenir
94804 Villejuif, France

References

1. Rheumatic fever and rheumatic heart disease. World Health Organ Tech Rep Ser 2004;923:1-122. [Medline]
2. Veasy LG. Time to take soundings in acute rheumatic fever. Lancet 2001;357:1994-1995. [CrossRef][Web of Science][Medline]

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