Characteristics of patients with rheumatic heart disease in a national referral hospital in Indonesia

  • Estu Rudiktyo Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
  • Annemieke Wind Department of Cardiology, Diakonessen Hospital, Utrecht, The Netherlands; Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
  • Pieter Doevendans Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands; Central Military Hospital Utrecht, Utrecht, The Netherlands; Netherlands Heart Institute Utrecht, Utrecht, The Netherlands
  • Bambang Budi Siswanto Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia - National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
  • Maarten-Jan Cramer Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
  • Amiliana Mardiani Soesanto Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
Keywords: echocardiography, pathology, rheumatic heart disease, right ventricular dysfunction
Abstract viewed: 572 times
PDF downloaded: 390 times
HTML downloaded: 198 times
EPUB downloaded: 78 times


BACKGROUND Rheumatic heart disease (RHD) is one of the most common cardiovascular problems in Indonesia. Comprehensive data regarding patient characteristics are critical in planning optimal treatment strategies to relieve the burden of RHD. This study aimed to describe the clinical and echocardiographic characteristics of patients across several types of valvular lesions in RHD in the Indonesian population.

METHODS This retrospective study was performed between January 2016 and June 2019 at the National Cardiovascular Center Harapan Kita, Jakarta, Indonesia. The study population comprised all patients with significant valve disease aged ≥18 years. Patient characteristics and echocardiographic parameters were collected retrospectively from medical records and hospital information systems. Patients were classified into several groups based on etiologies of valve disease.

RESULTS Of 5,482 patients with significant valve lesions, 2,333 (42.6%) were RHD patients. They were predominantly female (64.1%) and younger (mean [standard deviation] age 42.61 [12.01] years). Atrial fibrillation (AF) was the most frequent rhythm disorder observed in RHD (65.4%). Isolated mitral stenosis was the most common valve lesion in RHD patients (46.5%). Most patients with RHD had preserved left ventricular (LV) ejection fraction. Half of the patients with mitral stenosis had reduced right ventricular (RV) contractility (tricuspid annular plane systolic excursion <17 mm).

CONCLUSIONS Isolated mitral stenosis was the most observed condition of valve lesions in RHD. Characteristics of RHD patients in this study were predominantly female, younger age, had preserved LV function, reduced RV function, and high prevalence of AF.


  1. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1459-544.

  2. Harding E. WHO global progress report on tuberculosis elimination. Lancet Respir Med. 2020;8(1):19.

  3. Watkins DA, Johnson CO, Colquhoun SM, Karthikeyan G, Beaton A, Bukhman G, et al. Global, regional, and national burden of rheumatic heart disease, 1990-2015. N Engl J Med. 2017;377(8):713-22.

  4. Okello E, Longenecker CT, Beaton A, Kamya MR, Lwabi P. Rheumatic heart disease in Uganda: predictors of morbidity and mortality one year after presentation. BMC Cardiovasc Disord. 2017;17(20).

  5. Ghamari SH, Abbasi‐Kangevari M, Moghaddam SS, Aminorroaya A, Rezaei N, Shobeiri P, et al. Rheumatic heart disease is a neglected disease relative to its burden worldwide: findings from global burden of disease 2019. J Am Heart Assoc. 2022;11(13):e025284.

  6. Laudari S, Subramanyam G. A study of spectrum of rheumatic heart disease in a tertiary care hospital in Central Nepal. Int J Cardiol Heart Vasc. 2017;15:26-30.

  7. Chockalingam A, Gnanavelu G, Elangovan S, Chockalingam V. Clinical spectrum of chronic rheumatic heart disease in India. J Heart Valve Dis. 2003;12(5):577-81.

  8. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14.

  9. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, et al. [Guidelines on the management of valvular heart disease (version 2012). The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)]. G Ital Cardiol (Rome). 2013;14(3):167-214. Italian.

  10. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739-91.

  11. Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IF. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988;60(4):299-308.

  12. Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, et al. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67-119.

  13. Rwebembera J, Manyilirah W, Zhu ZW, Nabbaale J, Namuyonga J, Ssinabulya I, et al. Prevalence and characteristics of primary left-sided valve disease in a cohort of 15,000 patients undergoing echocardiography studies in a tertiary hospital in Uganda. BMC Cardiovasc Disord. 2018;18(1):82.

  14. Sani MU, Karaye KM, Borodo MM. Prevalence and pattern of rheumatic heart disease in the Nigerian savannah: an echocardiographic study. Cardiovasc J Afr. 2007;18(5):295-9.

  15. Kingué S, Ba SA, Balde D, Diarra MB, Anzouan-Kacou JB, Anisubia B, et al. The VALVAFRIC study: a registry of rheumatic heart disease in Western and Central Africa. Arch Cardiovasc Dis. 2016;109(5):321-9.

  16. Butt HI, Shahbaz A, Nawaz H, Butt K. Comparative clinical characteristics of rheumatic heart disease patients undergoing surgical valve replacement. Cureus. 2019;11(6):e4889.

  17. Triki F, Jdidi J, Abid D, Tabbabi N, Charfeddine S, Ben Kahla S, et al. Characteristics, aetiological spectrum and management of valvular heart disease in a Tunisian cardiovascular centre. Arch Cardiovasc Dis. 2017;110(8-9):439-46.

  18. Sanyal SK, Berry AM, Duggal S, Hooja V, Ghosh S. Sequelae of the initial attack of acute rheumatic fever in children from north India. A prospective 5-year follow-up study. Circulation. 1982;65(2):375-9.

  19. Shaikh MA, Ghori RA, Devrajani BR. Sequelae of chronic rheumatic heart disease among patients at two teaching hospitals in Sindh, Pakistan. J Liaquat Univ Med Heal Sci. 2006;5(3):114-8.

  20. Faheem M, Hafizullah M, Gul A, Jan HU, Khan MA. Pattern of valvular lesions in rheumatic heart disease. J Postgrad Med Inst. 2007;21(2):99-103.

  21. Manjunath CN, Srinivas P, Ravindranath KS, Dhanalakshmi C. Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: a single center experience. Indian Heart J. 2014;66(3):320-6.

  22. Maurer G. Aortic regurgitation. Heart. 2006;92(7):994-1000.

  23. Haddad F, Denault AY, Couture P, Cartier R, Pellerin M, Levesque S, et al. Right ventricular myocardial performance index predicts perioperative mortality or circulatory failure in high-risk valvular surgery. J Am Soc Echocardiogr. 2007;20(9):1065-72.

  24. Haddad F, Couture P, Tousignant C, Denault AY. The right ventricle in cardiac surgery, a perioperative perspective: II. Pathophysiology, clinical importance, and management. Anesth Analg. 2009;108(2):422-33.

  25. Del Rio JM, Grecu L, Nicoara A. Right ventricular function in left heart disease. Semin Cardiothorac Vasc Anesth. 2019;23(1):88-107.

  26. Nagel E, Stuber M, Hess OM. Importance of the right ventricle in valvular heart disease. Eur Heart J. 1996;17(6):829-36.

  27. Ahmed MK, Reda AA, Ibrahim MH. Right ventricular function and symptomatology in patients with isolated mitral stenosis: a Doppler tissue imaging study. Egyptian Heart J. 2015;67(1):41-6.

  28. Tsang TS, Abhayaratna WP, Barnes ME, Miyasaka Y, Gersh BJ, Bailey KR, et al. Prediction of cardiovascular outcomes with left atrial size: is volume superior to area or diameter? J Am Coll Cardiol. 2006;47(5):1018-23.

  29. Gupta A, Bhatia R, Sharma G, Prasad K, Singh MB, Vibha D. Predictors of ischemic stroke in rheumatic heart disease. J Stroke Cerebrovasc Dis. 2015;24(12):2810-5.

  30. Pande S, Agarwal SK, Dhir U, Chaudhary A, Kumar S, Agarwal V. Pulmonary arterial hypertension in rheumatic mitral stenosis: does it affect right ventricular function and outcome after mitral valve replacement? Interact Cardiovasc Thorac Surg. 2009;9(3):421-5.

  31. Shiran A, Sagie A. Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J Am Coll Cardiol. 2009;53(5):401-8.

  32. Unger P, Clavel MA, Lindman BR, Mathieu P, Pibarot P. Pathophysiology and management of multivalvular disease. Nat Rev Cardiol. 2016;13(7):429-40.

  33. Galli E, Lancellotti P, Sengupta PP, Donal E. LV mechanics in mitral and aortic valve diseases: value of functional assessment beyond ejection fraction. JACC Cardiovasc Imaging. 2014;7(11):1151-66.

  34. Fraser AG. Inge Edler and the origins of clinical echocardiography. Eur J Echocardiogr. 2001;2(1):3-5.

  35. Putra TMH, Sukmawan R, Elen E, Atmadikoesoemah CA, Desandri DR, Kasim M. Prognostic value of late gadolinium enhancement in postoperative morbidity following mitral valve surgery in rheumatic mitral stenosis. Int J Angiol. 2019;28(4):237-44.

  36. Fraser WJ, Haffejee Z, Cooper K. Rheumatic Aschoff nodules revisited: an immunohistological reappraisal of the cellular component. Histopathology. 1995;27(5):457-61.

  37. Singh AD, Mian A, Devasenapathy N, Guyatt G, Karthikeyan G. Percutaneous mitral commissurotomy versus surgical commissurotomy for rheumatic mitral stenosis: a systematic review and meta-analysis of randomised controlled trials. Heart. 2020;106(14):1094-101.

  38. Aurakzai HA, Hameed S, Shahbaz A, Gohar S, Qureshi M, Khan H, et al. Echocardiographic profile of rheumatic heart disease at a tertiary cardiac centre. J Ayub Med Coll Abbottabad. 2009;21(3):122-6.

How to Cite
Rudiktyo E, Wind A, Doevendans P, Siswanto BB, Cramer M-J, Soesanto AM. Characteristics of patients with rheumatic heart disease in a national referral hospital in Indonesia. Med J Indones [Internet]. 2022Dec.23 [cited 2024May29];31(3):178-85. Available from:
Clinical Research