Surgery for rheumatic heart disease in the Northern Territory, Australia, 1997-2016: what have we gained?

Doran, James;Canty, David;Dempsey, Karen;Cass, Alan;Kangaharan, Nadarajah;Remenyi, Bo;Brunsdon, Georgie;McDonald, Malcolm;Heal, Clare;Wang, Zhiqiang;Royse, Colin;Royse, Alistair;Mein, Jacqueline;Gray, Nigel;Bennetts, Jayme;Baker, Robert A.;Stewart, Maida;Sutcliffe, Steven;Reeves, Benjamin;Doran, Upasna;Rankine, Patricia;Fejo, Richard;Heenan, Elisabeth;Jalota, Ripudaman;Ilton, Marcus;Roberts-Thomson, Ross;King, Jason;Wyber, Rosemary;Doran, Jonathan;Webster, Andrew;Hanson, Joshua

Clare Heal

Abstract

Background: Between 1964 and 1996, the 10-year survival of patients having valve replacement surgery for rheumatic heart disease (RHD) in the Northern Territory, Australia, was 68%. As medical care has evolved since then, this study aimed to determine whether there has been a corresponding improvement in survival. Methods: A retrospective study of Aboriginal patients with RHD in the Northern Territory, Australia, having their first valve surgery between 1997 and 2016. Survival was examined using Kaplan-Meier and Cox regression analysis. Findings: The cohort included 281 adults and 61 children. The median (IQR) age at first surgery was 31 (18-42) years; 173/342 (51%) had a valve replacement, 113/342 (33%) had a valve repair and 56/342 (16%) had a commissurotomy. There were 93/342 (27%) deaths during a median (IQR) follow-up of 8 (4-12) years. The overall 10-year survival was 70% (95% CI: 64% to 76%). It was 62% (95% CI: 53% to 70%) in those having valve replacement. There were 204/281 (73%) adults with at least 1 preoperative comorbidity. Preoperative comorbidity was associated with earlier death, the risk of death increasing with each comorbidity (HR: 1.3 (95% CI: 1.2 to 1.5), p<0.001). Preoperative chronic kidney disease (HR 6.5 (95% CI: 3.0 to 14.0) p≤0.001)), coronary artery disease (HR 3.3 (95% CI: 1.3 to 8.4) p=0.012) and pulmonary artery systolic pressure>50 mm Hg before surgery (HR 1.9 (95% CI: 1.2 to 3.1) p=0.007) were independently associated with death. Interpretation: Survival after valve replacement for RHD in this region of Australia has not improved. Although the patients were young, many had multiple comorbidities, which influenced long-term outcomes. The increasing prevalence of complex comorbidity in the region is a barrier to achieving optimal health outcomes.

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BMJ Global Health

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2059-7908

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BMJ Publishing Group

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DOI

10.1136/bmjgh-2023-011763