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Global Voices

Open AccessPublished:March 22, 2022DOI:https://doi.org/10.1016/j.hroo.2022.03.002
      “Pathologists have long known that rheumatic fever (RF) licks at the joints but bites at the heart,” Ernst-Charles Lasègue, a French physician, famously said in 1884. True to that statement, even in the 21st century, heart disease and morbidity related to RF remains an enigma, particularly in the developing countries.
      We are excited to share with you a new Heart Rhythm O2 (HRO2) initiative, Global Voices. Global Voices seeks to represent physicians practicing electrophysiology and arrhythmia management in diverse global regions. We welcome authors to submit articles containing original research that reflect health care disparities and challenges to health care delivery in developed, underdeveloped, and developing countries. In December 2022, we will publish a Special Issue to showcase these articles.
      An important component of Global Voices is a series of video interviews featuring physicians practicing or partnering with those practicing arrhythmia care around the globe. You can find the link to our first interview with Dr Jayaprakash Shenthar, cardiac electrophysiologist at Jayadeva Hospital, Bengaluru, India, on YouTube (https://youtu.be/gDWk1b50Zag). Here we summarize this interview, which also is available as Supplemental Video 1.
      Dr Shenthar related that although the incidence of severe mitral disease requiring interventions is decreasing, atrial fibrillation (AF) related to rheumatic heart disease remains a problem in countries such as India, especially in young women in the child-bearing age group. Frequently this is due to lack of awareness, limited access to care, and inadequate early management during childhood. Although the mitral valve is the most commonly affected valve, the atria are inflamed from the autoimmune reaction to infection with group A streptococci. The study by Shenthar et al
      • Shenthar J.
      • Kalpana S.R.
      • Prabhu M.A.
      • Rai M.K.
      • Nagashetty R.K.
      • Kamlapurkar G.
      Histopathological study of left and right atria in isolated rheumatic mitral stenosis with and without atrial fibrillation.
      of myocardial tissue from surgical patients indicates that myocytolysis is associated with AF and that the interstitial fibrosis is uniformly distributed throughout both atria regardless of the rhythm. The unique pathology of rheumatic valve disease underpins the reasons why AF ablation may be more challenging and why stroke rates are higher. AF-related strokes are particularly debilitating, and anticoagulation with warfarin remains the cornerstone for prevention of stroke. Compliance with anticoagulation and adequate medication monitoring remains a challenge, especially during pregnancy.
      Finding practical ways to implement AF management is important. As an example, Dr Shenthar stated that, in his own experience, ibutilide had a 77% conversion rate for patients presenting with rheumatic valvular-related AF and was a practical tool in his practice.
      • Shenthar J.
      • Banavalikar B.
      • Valappil S.P.
      • et al.
      Safety and efficacy of ibutilide for acute pharmacological cardioversion of rheumatic atrial fibrillation.
      Dr Shenthar notes that large contemporary clinical trials, which might address a comprehensive management strategy for these patients, are lacking. He calls for more support from international societies and the industry for clinical studies that will enable formulation of guidelines practical for the unique challenges that physicians in many countries face when managing AF in this patient population.
      We hope you enjoy this interview and invite you to view upcoming HRO2 Global Voices interviews.

      Funding Sources

      The authors have no funding sources to disclose.

      Disclosures

      The authors have no conflicts of interest to disclose.

      Authorship

      All authors attest they meet the current ICMJE criteria for authorship.

      Appendix. Supplementary data

      References

        • Shenthar J.
        • Kalpana S.R.
        • Prabhu M.A.
        • Rai M.K.
        • Nagashetty R.K.
        • Kamlapurkar G.
        Histopathological study of left and right atria in isolated rheumatic mitral stenosis with and without atrial fibrillation.
        J Cardiovasc Electrophysiol. 2016; 27: 1047-1054
        • Shenthar J.
        • Banavalikar B.
        • Valappil S.P.
        • et al.
        Safety and efficacy of ibutilide for acute pharmacological cardioversion of rheumatic atrial fibrillation.
        Cardiology. 2021; 46: 624-632