1. CARDITIS RHEUMATIC HEART DISEASE and CLINICAL ASPEC
Nahar Taufiq
RS DR Sardjito Yogyakarta

2. An Overview Carditis Acute Rhematic Fever (RF) and
Rhematic heart disease (RHD)
Consequences of Haemodynamic
When to Intervention?
Consequences of Anticoagulant Therapy

3. An Overview Carditis Acute Rhematic Fever (RF) and
Rhematic heart disease (RHD)
Consequences of Haemodynamic
When to Intervention?
Consequences of Anticoagulant Therapy

4. Carditis
Myocarditis is an inflammatory disorder of the myocardium with necrosis of the myocytes and associated inflammatory infiltrate.
The term of Carditis
It is caused by viral infection
Part of Acute Rheumatic Fever

5. Viral Carditis
The WHO reports that incidence of cardiovascular involvement after enteroviral infection is 1-4%.
Incidence varies greatly among countries and is related to hygiene and socioeconomic conditions.
Occasional epidemics of viral infections have been reported with an associated higher incidence of myocarditis

6. Viral Carditis
Enteroviruses, such as coxsackie virus and echovirus, and adenoviruses, particularly types 2 and 5, are the most commonly involved organisms
With suspected coxsackievirus B, the mortality rate is higher in newborns (75%) than in older infants and children (10-25%).
Complete recovery of ventricular function has been reported in as many as 50% of patients.
Some patients develop chronic myocarditis (ongoing or resolving) and/or dilated cardiomyopathy and may eventually require cardiac transplantation.

7. Viral Carditis Investigation Virus identification
1 ) Cultures from blood , stools and throat.
2 ) Acute & convalescent sera
ECG
Chest X Ray
Echocardiogram
Biopsi miocardium

8. Viral Carditis Management
Bed rest or limitation of activity in the acute phase
Management ADHF
Management of CHF

9. An Overview Carditis Acute Rhematic Fever (RF) and
Rhematic heart disease (RHD)
Consequences of Haemodynamic
When to Intervention?
Consequences of Anticoagulant Therapy

10. Rheumatic Heart Disease
Rhematic Fever (RF) and or Rhematic heart disease (RHD) is a a major health hazard in most developing countries as well as sporadically in developed economies

11. Rheumatic Heart Disease
Rheumatic fever (RF) is an acute, immunologically mediated, multisystem inflammatory disease that occurs a few weeks following an episode of group A streptococcal pharyngitis.
Major involvement of systemic connective tissue, it often violate connective tissue of heart, joint, skin, and subcutaneous and vascular connective tissue. Key pathologic features is Rheumatic Granuloma

12. Acute Rheumatic Heart Disease
Infection by GABHS
2 – 5 days intubation
URI infection
high fever, sore throat, headache, body weakness,
and increase in WBC count
3% of them develop RF after
Several weeks
Major : Carditis, Polyarthritis, Chorea,
erythema marginatum, Subcutaneus nodule
Minor : Clinis : arthralgia , fever
Lab : Erythrocyt cedimen rate, C – reactive protein
prolonged PR interval,positive throat culture,etc
2 Major or 1 major 2 minor
Evidence for recent GAS infection
Acute Rheumatic Fever
Acute Rheumatic Heart Disease

13. Chorea Sydenham.
Erthema marginatum

14. Acute Rheumatic Heart Disease
Divided into rheumatic endocarditis, rheumatic myocarditis
and rheumatic pericarditis,
often for rheumatic pancarditis.

15. Management of ARF – Acute RHD
1. Eradicate the GABHS
Benzathine Penicilin G ,
< 27 kg : U –IM (once)
> 27 kg : 1,200,000 U – IM (once)
Erythromycin estolate, 20-40mg/kg/2-4 times daily (10 days)
Erythromycin Ethylsuccinate 40mg/kg/2-4 times (max 1 g/d) (10 days)

16. Management of ARF – Acute RHD
2. Suppress the Inflamatory response
Aspirin mg/kg/day for 10 weeks and tapered in the next 2 weeks
> 20 kg: Prednison 60 mg/day three weeks and tapered in the next nine weeks
< 20 kg : prednison 40 md/day

17. Management of ARF – Acute RHD
Benzathine Penicilin G 1,200,000/ 3-4 weeks – IM
Penicilin V 25 mg twice daily – oral
Erythromycin 250 mg twice daily -oral

18. Acute R Fever – Acute RHD
Acute rheumatic endocarditis: small (diameter 1- to 2-mm) vegetations along the mitral valve margin, insufficient to cause valvular deformation.

19. Chronic Rheumatic Heart Disease

20. Stages of Progression of VHD

21. Diagnostic Testing-Diagnosis and Follow Up

22. Frequency of Echo in asymptomatic patient
with VHD and normal LV

23. An Overview Carditis Acute Rhematic Fever (RF) and
Rhematic heart disease (RHD)
Consequences of Haemodynamic
When to Intervention?
Consequences of Anticoagulant Therapy

24. Mitral Regurgitation

25. Mitral Regurgitation

26. Mitral Regurgitation

27. Mitral Regurgitation

28. Mitral Regurgitation
Porcine model, 6M

29. Indication for Surgery for Mitral Regurgitation

30. Mitral Stenosis

31. Mitral Stenosis

32. Mitral Stenosis

33. Mitral Stenosis

34. Indications for Surgery for Rheumatic Mitral Stenosis

35. Aortic Regurg – Austin Flint Murmur
Aortic Regurgitation
Aortic Regurg – Austin Flint Murmur
Due to the vibration of the anterior leaflet of the mitral valve as it is buffetted simultaneously by the blood jets from the left atrium and the aorta.

36. Aortic Regurgitation

37. Aortic Regurgitation

38. Aortic Regurgitation

39. Aortic Regurgitation

40. Indication for Surgery for Chronic aortic Regurgitation

41. Aortic Stenotic

42. Aortic Stenotic

43. Indication for Surgery for Chronic aortic Stenosis

44. An Overview Carditis Acute Rhematic Fever (RF) and
Rhematic heart disease (RHD)
Consequences of Haemodynamic
When to Intervention?
Consequences of Anticoagulant Therapy

50. Anticoagulation for Prosthetic Valve

51. Resume Carditis is an inflammation disease
Viral carditis  Chronic Myocarditis  Dilated Chamber of heart  Chronic Heart failure
Carditis part of Acute Rheumatic heart Disease  Sequele in the valve  Heart failure  Replacement of the valve  long term anticoagulant

52. TERIMA KASIH

53. Acute Rheumatic Heart Disease
Acute Rheumatic Fever
Acute Rheumatic Heart Disease
Dr. T Duckett Jones
Major Manifestation
Carditis, Arthritis, subcutaneous nodules, erythema marginatum and chorea
Minor manifestation
Fever, arthralgia
Essensial Criteria

54. Acute rheumatic endocarditis: small (diameter 1- to 2-mm) vegetations along the mitral valve margin, insufficient to cause valvular deformation.

55. Small vegetations (verruca) are visible along the line
of closure of the mitral valve leaflet (arrows).

56. Advanced: vegetations organization, recurrent organization cause chronic heart valve disease ( valvular stenosis and / or valvular insufficiency )

58. Mitral stenosis with diffuse fibrous thickening and distortion of
the valve leaflets, commissural fusion (arrows), and thickening
and shortening of the chordae tendineae.

59. Rheumatic Heart Disease
Rhematic Fever (RF) and or Rhematic heart disease (RHD) is a systemic inflamatory disease with protean manifestation primarily affecting the connective tissue and usually preceded by a group A beta hemolytic streptococcal (GABHS) infection characterized by acute exacerbation and recurrencces

68. Template
Jogja Cardiology Update

69. Jogja Cardiology Update

70. Jogja Cardiology Update