Tadele et al.
BMC Cardiovascular Disorders 2013, 13:95
http://www.biomedcentral.com/1471-2261/13/95
R E S EAR CH A R TIC L E Open Access
Rheumatic mitral stenosis in Children:
more accelerated course in
sub-Saharan Patients
Henok Tadele1*, Wubegzier Mekonnen2 and Endale Tefera3
Abstract
Background: Mitral stenosis, one of the grave consequences of rheumatic heart disease, was generally
considered to take decades to evolve. However, several studies from the developing countries have
shown that mitral stenosis follows a different course from that seen in the developed countries. This study
reports the prevalence, severity and common complications of mitral stenosis in the first and early second
decades of life among children referred to a tertiary center for intervention.
Methods: Medical records of 365 patients aged less than 16 and diagnosed with rheumatic heart disease
were reviewed. Mitral stenosis was graded as severe (mitral valve area < 1.0 cm2), moderate (mitral
valve area 1.0-1.5 cm2) and mild (mitral valve area > 1.5 cm2).
Results: Mean age at diagnosis was 10.1 ± 2.5 (range 3–15) years. Of the 365 patients, 126 (34.5%)
were found to have mitral stenosis by echocardiographic criteria. Among children between 6–10 years,
the prevalence of mitral stenosis was 26.5%. Mean mitral valve area (n = 126) was 1.1 ± 0.5 cm2 (range
0.4-2.0 cm2). Pure mitral stenosis was present in 35 children. Overall, multi-valvular involvement was
present in 330 (90.4%). NYHA functional class was II in 76% and class III or IV in 22%. Only 25% of
patients remember having symptoms of acute rheumatic fever. Complications at the time of referral
include 16 cases of atrial fibrillation, 8 cases of spontaneous echo contrast in the left atrium, 2 cases of
left atrial thrombus, 4 cases of thrombo-embolic events, 2 cases of septic emboli and 3 cases of airway
compression by a giant left atrium.
Conclusion: Rheumatic mitral stenosis is common in the first and early second decades of life in
Ethiopia. The course appeared to be accelerated resulting in complications and disability early in life.
Echocardiography-based screening programs are needed to estimate the prevalence and to provide
support for strengthening primary and secondary prevention programs.
Keywords: Mitral stenosis, Valve area, Rheumatic heart disease, Sub-Saharan Africa
* Correspondence: henny_2007@yahoo.com
Background 1
Department of Pediatrics & Child Health, School of Medicine,
Though rare in developed countries [1-3], Rheumatic Hawassa University, Hawassa, Ethiopia
Full list of author information is available at the end of the article
Heart Disease (RHD) continues to be a serious health
exclusively attributed to RHD [11,12]. Congenital
problem in the developing countries [4,5]. RHD in
mitral stenosis is an exceedingly rare form of mitral
these much of the world has not declined [6]. Recent
stenosis that is associated with serious circulatory
echocardiography-based surveys in some developing
disturbance and high mortality within the first few
countries have estimated the prevalence of RHD to
years of life [13-15].
be 3–10 times compared to previous estimates based
The severity of rheumatic mitral valve disease in the
on clinical examination alone [7-10].
developing countries differs in many ways from that in
Unlike other valvular lesions, which might be attrib
the industrialized countries [16]. In studies from
uted to multiple etiologies, mitral stenosis alone or in
developed countries mitral stenosis was considered a
combination with other valvular lesions is almost
delayed manifestation [17] and less common
especially in the first decade of life suggesting that it decline in valve area to be as low as 0.09 cm2/year
takes several decades to evolve [11,18,19]. This [20,21].
inference was supported by echocardiography-based
longitudinal studies that have estimated the average
© 2013 Tadele et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Tadele et al. BMC Cardiovascular Disorders 2013, 13:95 Page 2 of 6 http://www.biomedcentral.com/1471-2261/13/95
health of the School of Medicine approved the study.
were referred to the cardiac center for possible
surgical or percutaneous intervention. Mean age at
In contrast, studies from developing countries diagnosis for all patents was 10.1 ± 2.5 (range 3–15)
document rapid progression of mitral stenosis leading years. Mean body weight for all patients was 26.2 ±
to serious disability early in life that requires treatment 8.2 kg (range 12- 48 kg). Of the 365 patients with
[22-27]. In developing regions, predisposing factors to chronic rheumatic heart disease, 126 (34.5%) had
recurrent rheumatic fever persist, prophylactic mitral stenosis (Figure 1). Mean mitral valve area for
penicillin is often not available and disease patients with mitral stenosis (n = 126) was 1.1 ± 0.5
progression is not detected [24,28]. Patients in most cm2 (range 0.4-2.0 cm2). Their demographic, clinical
areas of the developing world, including those who and echocardiographic character istics are shown in
know their diagnosis, do not receive the secondary Table 1.
prophylaxis [6,29]. Two patients with severe mitral stenosis had
Sub-Saharan Africa (where illiteracy is rampant, thrombus in the left atrium. Eight patients with severe
access to medical care is scarce and mitral sten osis had spontaneous echo contrast in the
echocardiography based screening practices are less left atrium (Figure 2). One patient with combined
feasible) would be expected to have a high mitral stenosis and regurgitation and two patients with
prevalence of RHD. Ethiopia has one of the highest severe mitral regurgitation had evidence of bronchial
estimated prevalence of RHD in the world [30], but compression from giant left atrium (GLA) (Figure 3).
echocardiography-based studies in children are not Pulmonary complications included complete
available. This study reports the prevalence and atelectasis of the left lung in one patient with mitral
severity of mitral stenosis in children aged <16 years stenosis and a second with severe mitral
who were referred to a tertiary academic center for regurgitation. A third patient had right middle lobe
treatment. collapse.
Structural tricuspid valve stenosis was present in 19
Methods (5.2%) patients. All patients with tricuspid valve
Medical records of all patients with rheumatic heart stenosis had severe mitral stenosis.
disease who were referred to the cardiac center in Electrocardiographic evidence of atrial fibrillation was
Addis Ababa, between its opening in January 2009 to present in 16 (4.4%) of patients. Thrombo-embolic
December 2012 were reviewed. Patients were events occurred in 4 patients with severe mitral
included in the study if their age was less than16 stenosis, leading to presumed hemiparetic embolic
years and they had echocardiographic diagnosis of strokes in two patients and gangrene and subse
chronic rheumatic valvular heart disease. Patients quent amputation of one leg in two patients. Two
were excluded if valve area meas urement was other patients without mitral stenosis had loss of
performed using other methods than area tracing pulses result ing from presumed septic emboli. Only
technique (like mean transmitral diastolic pressure 91 (24.9%) of the patients remembered having
gradient technique or pressure-half-time technique) in symptoms suggestive of acute rheumatic fever.
a setting of associated mitral regurgitation.
Demographic, clinical, electrocardiogram,
roentgenogram and echocardiographic data were Discussion
collected from the patient’s records. Severity of mitral In this case series of Ethiopian pediatric patients with
stenosis was graded as mild (valve area > 1.5 cm2), RHD, the overall prevalence of mitral stenosis in our
moderate (valve area 1.0- 1.5 cm2) and severe (valve patients was 34.5% and the prevalence of severe
area < 1.0 cm2). Functional status of the patients was mitral stenosis, defined as a valve area of less than
graded according to the New York Heart Association 1.0 cm2, was
(NYHA) based on the clinical symptoms and signs
documented at the time of referral. The ethics
committee of the department of pediatrics and child 180
160 Statistical methods
140
Data were first entered into Excel r
60
spread sheet. SPSS e
line variables. Continuous variables
s
were calculated as
t
120
n
e
i
software version 20 for Windows 23
was used for data 0
22
b 44 12
m 11
40 21
u
18
t
mean ± SD (range).
100
a
p
125
88
analysis. Descriptive statistics were Severe MS Moderate MS
analyzed for base Mild MS
No MS
0
1
N
f
80 20
o
aged <16 years
<5 6-10 11-15
Results Age in years
During the period of January 2009 to December Figure 1 Distribution of mitral stenosis at different ages in
children with chronic rheumatic heart disease (n = 365).
2012, a total of 365 children with echocardiographic
diagnosis of chronic rheumatic heart disease, and
Tadele et al. BMC Cardiovascular Disorders 2013, 13:95 Page 3 of 6 http://www.biomedcentral.com/1471-2261/13/95
for grading severity of mitral stenosis as most patients
had significant associated mitral valve regurgitation
that may exaggerate the trans-mitral diastolic
Table 1 Demographic, clinical and echocardiographic gradient.
characteristics for patients with chronic rheumatic A striking observation was the high prevalence of
valvular heart disease (n = 365) mitral stenosis in patients between ages 6–10 years
Variables Frequency (percentage) Gender (females) 212 (58.1) (26.5%). In studies from developed countries mitral
Age at diagnosis (years): sten osis in this age group is rare [11]. Our study
≤ 5 24 (6.6) confirms those from other developing countries
[16,22,23,31,32] suggesting that mitral stenosis can
6–10 170 (46.6)
progress rapidly and may lead to severe disability at
11-15 171 (46.8) an early age.
Residence (urban or semi-urban): 178 (48.8) Mitral Several reasons could account for the differing
valve disease 359 (98.4) Pure mitral stenosis (all course of RHD in underdeveloped countries
grades) 35 (10.0) compared to
108 patients. However, this parameter was not used
Mitral stenosis with regurgitation (all grades)
lack access or fail to adhere to
secondary prophylaxis [6,29].
Mitral regurgitation, no stenosis (all grades)
257 (70.4) 299 (81.9) Patients in developing countries,
Multi-valvular involvement (mitral valve who adhere to secondary
disease included): prophylaxis [33,34] have a course
developed countries. First,
Aortic valve disease (regurgitation and/or predisposing factors to acute similar to those in the developed
stenosis) rheumatic fever persist and world. Furthermore, decline in
Tricuspid valve disease prophylactic penicillin therapy is prevalence of rheumatic heart
(regurgitation and/or stenosis) often inadequate [24]. Second, while disease itself and even severity of
Mean transmitral diastolic pressure gradient secondary prophy laxis can prevent mitral stenosis has paralleled
(n = 108): or significantly reduce the changes in socio-economic factors in
91 (24.9) 233 (63.8) development of mitral or aortic valve some of fastest developing
stenosis [33], many RHD patients
<10 mmHg 4 (3.5)
21 – 30 mmHg 61 (54.5)
10 – 20 mmHg 40 (35.7)
>30 mmHg 3 (2.7)
Mitral valve score for severe mitral Though the role of anti-inflammatory treatment in an
stenosis (n = 19) acute rheumatic carditis is not well-substantiated, lack
≤8 2 (10.5) of penicillin treatment or bed rest significantly contribute
to ongoing carditis [38]. These observations suggest
>8 17 (89.5)
that raising public awareness and improving adherence
Functional class (New York Heart
to primary and secondary prophylaxis could reduce the
Association):
rates of rheumatic heart disease and its complications.
I 10 (2.7)
The low rate of recall of symptomatic episodes
II 276 (75.6) consistent with acute RF (24.9%) is consistent with
III 27 (7.4) other studies [11,18,39]. The most likely explanation is
IV 52 (14.2) that acute rheumatic fever escapes attention if it is not
nations in South East Asia [35-37]. The fact most of the associated with migratory polyarthritis or Sydenham’s
patients didn’t remember an attack of rheumatic fever in chorea, espe
the past may also contribute to ongoing carditis.
On secondary prophylaxis against recurrence
regions. another study in the united states
of rheumatic fever (at the time of referral) Our finding that all patients with [40]. Atrial fibrillation was present in
tricuspid stenosis have severe mitral 4.4% of our patients. Other studies
272 (74.5)
stenosis has also been found by have
cially in medically unsophisticated
18.1%. This figure appears to be high but was difficult found higher rates ranging between 5.9% and 40%
to make comparison with other studies, as the study [11,41]. However, considering the younger age of our
setting and methodology were importantly different patients, this percentage is alarming. Rare
from our study. The prevalence of pure mitral complications such as airway compression by a giant
stenosis in our series was 9.5%, a rate almost left atrium (GLA) occurred in one patient with
four-fold greater than a similar study reported by combined mitral stenosis and regur gitation and two
Yuko-Jowi et al. from Kenya [31]. The mean other patients with severe mitral regurgitation. The
trans-mitral diastolic pressure gradient (n = 108) was compression has led to complete atelectasis of the
≥10 mmHg in 104 (96.5%) of patients and it was left lung in two patients and right middle lobe collapse
greater than 20 mmHg in 64 (57.2%) of the in the third. This complication
Tadele et al. BMC Cardiovascular Disorders 2013, 13:95 Page 4 of 6 http://www.biomedcentral.com/1471-2261/13/95
Figure 2 Echocardiographic frames from a 10-year-old-girl with rheumatic heart disease and severe mitral stenosis (MVA 0.51
cm2), showing enlarged left atrium and spontaneous echo contrast in the left atrium, A. Apical four chamber view (diastole), B.
Parasternal long axis view (diastole); LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; MV, mitral valve; AV,
aortic valve.
Conclusion
has been reported in many case reports, generally, in Our study showed that in our population, rheumatic
adults [42-44]. mitral stenosis is common in the first and early
Our patients appeared to have a high rate of second decades of life, with a rapid clinical
secondary prophylaxis against recurrence of progression to symptoms and disability.
rheumatic fever, but most of the patients were Echocardiography-based screening programs are
diagnosed few months before their referral and had needed to determine the true prevalence of
taken only one or two doses. rheumatic valvular disease amongst our childhood
population, and in course, strengthen the the proverbial tip of a very great iceberg. Our patients
commitment to primary and sec ondary prevention are not likely to be representative of the full extent of
programs. the disease burden at the community level.
Our study has a number of limitations. This is a Additionally, our study is a retrospective in design,
hospital-based study. It is likely that only advanced and many important variables were incomplete,
symptomatic cases are referred to us, representing making comprehensive analysis
Figure 3 Echocardiographic frames in the parasternal long axis (A) and apical four chamber (B) views from a 13 year-old-girl with
severe mitral stenosis (MVA = 0.84 cm2) and mild regurgitation, showing Giant Left Atrium (GLA). MV, mitral valve; LV, left
ventricle; RV, right ventricle; RA, right atrium.
Tadele et al. BMC Cardiovascular Disorders 2013, 13:95 Page 5 of 6 http://www.biomedcentral.com/1471-2261/13/95
Acknowledgements
We thank the department of Pediatrics & Child Health for enabling
us to conduct the study. We are also grateful to the record office of
of risk factors difficult. Nevertheless, this study the cardiac center for retrieving the medical records. Our heartfelt
provides new insights into the severity, complexity, gratitude goes to Professor J. Allen McCutchan of UCSD and Dr
Joseph Knapp of Montana Heart Institute for revising and editing
and rapid progression of rheumatic valvular heart the final version of the manuscript. Last but not least, we thank Dr
disease amongst young Ethiopians, and begs for a Maria Rosario Araneta of UCSD for assisting us in retrieving some
more comprehensive population analysis. of the literature.
Author details
Abbreviations 1
RHD: Rheumatic heart disease; NYHA: New York Heart Association; Department of Pediatrics & Child Health, School of Medicine,
WHO: World Health Organization; MVA: Mitral valve area; MS: Mitral Hawassa University, Hawassa, Ethiopia. 2Department of Reproductive
stenosis; GLA: Giant left atrium. Health and Health Service Management, School of Public Health,
Addis Ababa University, Addis Ababa, Ethiopia. 3Department of
Competing interests Pediatrics & Child Health, Addis Ababa University and Cardiac Center
The authors have no conflict of interest to declare. Ethiopia, Addis Ababa, Ethiopia.
Authors’ contributions Received: 2 July 2013 Accepted: 28 October 2013
HT reviewed literature, prepared the proposal, collected data and Published: 1 November 2013
wrote the draft manuscript. WM participated in the design of the
study and assisted in statistical analysis of the data. ET assisted in References
formulating the study question, 1. Carabello BA: Modern management of mitral stenosis. Circulation
reviewed literature and wrote the final version of the manuscript in 2005, 112:432–437.
its current form. All authors have read and approved the final 2. Madden S, Kelly L: Update on acute rheumatic fever: It still
version of the manuscript. exists in remote communities. Can Fam Physician 2009,
55:475–478.
Authors’ information 3. Miyake CY, Gauvreau K, Tani LY, Sundel RP, Newburger JW:
HT is a pediatrician working in the department of Pediatrics & Child Characteristics of children discharged from hospitals in USA in
Health of the School of Medicine of Hawassa University. He was a 2000 with the diagnosis of acute rheumatic fever. Pediatrics 2007,
resident in the department of Pediatrics & Child Health of the School 120:503–508.
of Medicine, Addis Ababa University from November 4. Thakur JS, Negi PC, Ahluwalia SK, Vaidya NK: Epidemiological
2009-December 2012. WM is a Statistician at the School of Public survey of rheumatic heart disease among school children in the
Health, Addis Ababa University. ET is a Consultant Pediatric shimla hills of Northern India: prevalence and risk factors. J
Cardiologist at the School of Medicine of Addis Ababa University and Epidemiol Commun Health 1996, 50:62–67.
the Cardiac Center in Addis Ababa. 5. Carapetis JR, Steer AC, Mulholland EK: The Current Evidence for
the Burden of Group A Streptococcal Diseases 19:968–973.
(WHO/FCH/CAH/05.07). Geneva: World Health Organization; 21. Sagie A, Freitas N, Padial LR, et al: Doppler echocardiographic
2004. assessment of long-term progression of mitral stenosis in 103
6. Rizvi SF, Khan MA, Kundi A, Marsh DR, Samad A, Pasha O: patients: valve area and right heart disease. J Am Coll Cardiol
Status of rheumatic heart disease in rural Pakistan. Heart 2004, 1996, 28:472–479.
90:394–399. 7. Marijon E, Ou P, Celermajer DS, et al: Prevalence of 22. Borman JB, Stern S, Shapira T, Milvidsky H, Braun K: Mitral
rheumatic heart disease detected by echocardiographic screening. valvotomy in children. Amer Heart J 1961, 61:763.
N Engl J Med 2007, 357:470–476. 23. Al-Bahrani IR, Thamer MA, Al-Omeri MM, Al-Namaan YD:
8. Zuhlke L, Mirabel M, Marijon E: Congenital heart disease and Rheumatic heart disease in the young in Iraq. Brit Heart J 1966,
rheumatic heart disease in Africa: recent advances and current 28:824.
priorities. Heart 2013, 99(21):1554–1561. 24. Marcus RH, Sareli P, Pocock WA, et al: Functional anatomy of
9. Bhaya M, Panwar RB: Echocardiography in school severe mitral regurgitation in active rheumatic carditis. Am J Cardiol
children. Echocardiography 2010, 27(4):448–453. 1989, 63:577–584. 25. Tandon HD, Kasturi J: Pulmonary vascular
10. Beaton A, Okello E, Lwabi P, Mondo C, McCarter R, Craig S: changes associated with isolated mitral stenosis in India. Br Heart J
Echocardiography screening for rheumatic heart disease in 1975, 37:26–36.
Ugandan schoolchildren: Clinical perspective. Circulation 2012, 26. Shrivastava S, Tandon R: Severity of rheumatic mitral stenosis in
125:3127–3132. children. Int J Cardiol 1991, 30:163–167.
11. Padamavati S: Rheumatic fever and rheumatic heart disease 27. Reale A, Colella C, Bruno AM: Mitral stenosis in childhood:
in developing countries. Bull World Health Org Suppl 1978, clinical and therapeutic aspects. Amer Heart J 1963, 66:15–28.
56:543–550. 12. Rick AR, Gregory JE: Experimental evidence 28. Ahmad S, Hayat U, Naz H: Frequency of severe mitral stenosis in
that lesions with basic characteristics of rheumatic carditis can young female patients having pure mitral stenosis secondary to
result from anaphylactic hypersensitivity. Bull Johns Hopkins rheumatic heart disease. J Ayub Med Coll Abbottabad 2010,
Hosp 1943, 73:239. 22(4):19–22.
13. Ferencz C, Johnson AL, Wiglesworth FW: Congenital mitral 29. Oli K, Tekle-Haimanot R, Forsgren L, Ekstedt J: Rheumatic heart
stenosis. Circulation 1954, 9:161. disease prevalence among school children of an Ethiopian rural
14. Ruckman RN, Van Praagh R: Anatomic types of congenital mitral town. Cardiolgy 1992, 80:152–155.
stenosis: report of 49 autopsy cases in consideration of diagnosis 30. Oli K, Porteous J: Prevalence of rheumatic heart disease among
and surgical implications. Am J Cardiol 1978, 42:592–601. school children in Addis Ababa. East Afr Med J 1999, 76:601–605.
15. Moore P, Adatia I, Spevak PJ, et al: Severe congenital mitral 31. Yuko-Jowi C, Bakari M: Echocardiographic patterns of juvenile
stenosis in infants. Circulation 1994, 89:2099–2106. rheumatic heart disease at the Kenyatta National Hospital,
16. Marcus RH, Sareli P, Pocock WA, Barlow JB: The spectrum of Nairobi. East Afr Med J 2005, 82:514–519.
severe rheumatic mitral valve disease in a developing country. 32. Barlow JB, Marcus RH, Pocock WA, Barlow CWER, Sareli P:
Correlations among clinical presentation, surgical pathologic Mechanisms and management of heart failure in rheumatic
findings, and hemodynamic sequelae. Ann Intern Med 1994, carditis. S Afr Med J 1990, 78:181–186.
120:177–183. 33. Majeed HA, Batnager S, Yousof AM, Khuffash F, Yusuf AR: Acute
17. Carapetis JR, McDonald M, Wilson NJ: Acute rheumatic fever. rheumatic fever and the evolution of rheumatic heart disease: a
Lancet 2005, 366:155–168. prospective 12-year follow-up report. J Clin Epidemiol 1992,
18. Selzer A, Cohn KE: Natural history of mitral stenosis: a review. 45:871–875.
Circulation 1972, 45:878–890. 34. Sanyal SKBA, Duggal S, Hooja V, Ghosh S: Sequelae of the initial
19. Horstkotte D, Niehues R, Strauer BE: Pathomorphological aspects, attack of acute rheumatic fever in children from north India.
aetiology and natural history of acquired mitral stenosis. Eur Heart J Circulation 1982, 65(2):375–379.
1991, 12:55–60. 20. Gordon SPF, Douglas PS, Come PC, Manning 35. Stephen SJ: Changing patterns of mitral stenosis in childhood
WJ: Two-dimensional and doppler echocardiographic determinants of and pregnancy in Sri Lanka. J Am Coll Cardiol 1992,
the natural history of mitral valve narrowing in patients with rheumatic 19:1276–1284.
mitral stenosis: implications for follow-up. J Am Coll Cardiol 1992,
Tadele et al. BMC Cardiovascular Disorders 2013, 13:95 Page 6 of 6 http://www.biomedcentral.com/1471-2261/13/95
36. Jose VJ, Gomathi M: Declining prevalence of rheumatic heart disease in
rural school children in India: 2001–2002. Indian Heart J 2003, 55:158–160.
37. Misra M, Mittal M, Singh R, et al: Prevalence of rheumatic heart disease in
school-going children of eastern Uttar Pradesh. Indian Heart J 2007,
59:42–43.
38. Barlow JB, Marcus RH, Pocock WA, Barlow CW, Essop R, Sareu P:
Mechanisms and management of heart failure In active rheumatic
carditis. SAMJ 1990, 18:181–186.
39. Morton WE, Huhn LA, Litchy JA: Rheumatic heart disease epidemiology:
observations in 17,366 Denver School Children. JAMA 1967, 199:879–884.
40. Sagie A, Freitas N, Chen MH, Marshall JE, Weyman AE, Levine RA:
Echocardiographic assessment of mitral stenosis and its associated
valvular lesions in 205 patients and lack of association with mitral valve
prolapse. J Am Soc Echocardiogr 1997, 10:141–148.
41. Chockalingam A, Gnanavelu G, Chockalingam V: Clinical spectrum of chronic
rheumatic heart disease in India. J Heart Valve Dis 2003, 12:577–581.
42. El Maghraby A, Hajar R: Giant left atrium: a review. Heart Views 2012, 13:46–52.
43. Kawazoe K, Takahara Z, Tanaka K, et al: Giant left atrium in mitral valve
disease: a new plication procedure to relieve the compressions of left
ventricular wall left bronchus and right lung (abstract). Nihon Geka Gakkai
Zasshi 1983, 84:31–39.
44. Phua GC, Eng PCT, Lim SL, Chua YL: Beyond Ortner’s Syndrome-unusual
complications of the Giant Left Atrium. Ann Acad Med Singapore 2005,
34:642–645.
doi:10.1186/1471-2261-13-95
Cite this article as: Tadele et al.: Rheumatic mitral stenosis in Children:
more accelerated course in sub-Saharan Patients. BMC Cardiovascular Dis
orders 2013 13:95.
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