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

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

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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.

Original languageEnglish
Article numbere011763
Pages (from-to)1-12
Number of pages12
JournalBMJ Global Health
Volume8
Issue number3
DOIs
Publication statusPublished - 24 Mar 2023

Bibliographical note

Funding Information:
The authors would like to acknowledge the support and expert advice of Peter Horne, Spatial Data Manager, Health Surveillance, Tropical Public Health Services, Cairns and Hinterland Hospital and Health Service during the preparation of the manuscript. The authors would also like to acknowledge the support from the Northern Territory, RHD register, assisting with data related to this surgical cohort. We thank Rheumatic heart disease Australia and James Cook University clinical school for assistance with office space. This project was undertaken in part through Northern Territory general practice education and training as part of the rural generalist fellowship of the Royal Australian College of General Practice. James Doran is supported by the 2017 RACGP Foundation Indigenous Health Award.

Publisher Copyright:
© 2023 BMJ Publishing Group. All rights reserved.

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