Portable Echo Helps Reveal Tonga’s RHD Epidemic

The prevalence of rheumatic heart disease (RHD) in Tonga, as with other South Pacific nations, is one of the highest in the world. Due to their isolation and lack of medical facilities most Pacific Islands spend between 4 – 12% of their total health budget sending RHD patients abroad for life-saving heart valve surgery.

The World Heart Federation Pacific Rheumatic Heart Disease program focuses on secondary prevention of rheumatic fever and the control of RHD. Screening of school children for early signs of rheumatic heart disease has been found to be one effective way of controlling the disease in young populations. By detecting RHD in its early stages, prophylactic antibiotics can be started to prevent further damage to the heart valves. Secondary prevention is a cheap option for the Tongan Ministry of Health when the alternative is sending patients with progressive RHD overseas for life-saving heart surgery.

Dr Toakase Fakakovikaetau , paediatrician at the Vaiola Hospital in the capital city of Nuku’alofa, has found that in Tonga approx 50 - 80 children out of every 1000, in the 10-12yr age group, have early signs of RHD. Dr Fakakovi is currently conducting a screening program of Grade 5/6 children (approx 12 yrs of age) throughout Tongan schools to determine those children who are showing early signs of RHD and to start them on prophylactic therapy. In a country consisting of so many islands the logistics of getting a medical team and equipment to many remote schools is an undertaking in itself! The screening program consists of auscultation and a modified echocardiogram to screen the child’s heart valves. Skin checks, hearing and eye tests are also carried out on the children. Dr Fakakovi was awarded the prestigious Louis Lown Heart Hero Award in 2008 for her efforts in RHD screening in Tonga.3

Echocardiography has been found to be a very effective tool in diagnosing valve damage due to RHD. Cardiac auscultation alone has been found to lack sensitivity and specificity for screening in this setting, although clinical history taking and physical examination remains the mainstay for diagnosing RF and valvular heart disease when echo is not available.2

Vaiola Hospital has only 2 ultrasound systems, an old non-portable system used in Radiology, and a Cypress portable system donated a few years ago from French Polynesia for use by the Cardiology and Paediatric departments. This system, though working, is in urgent need of repair. Also Dr Toa is unable to download the images from the Cypress to her PC in order to email the images to paediatric cardiologists in New Zealand or Australia for review/consultation.

On a recent school screening trip to Vava’u, Philips Healthcare with the support of distribution partner Lifehealthcare kindly loaned the portable CX50 system to be used for the echocardiograms. The Philips CX50 was perfect for this type of work. Its compact size and light weight enabled it to be easily transported from school to school and its quick boot up time enabled a rapid setup time. The wide broadband transducer (1 – 5 MHz) enabled all children from 20kg to 100kg (yes some of those 13 yr olds were big!) to be screened without the time-consuming need to change probes. Image acquisition was quick and easy. The abnormal studies were downloaded onto a DVD at the end of each clinic for Dr Toa to easily review the images on her laptop and for review by the overseas cardiology experts.

The battery capability of the CX50 was very useful on the days that the team traveled via boat to some villages that did not have electricity. Essential if there was no generator available! During the echo screening procedure for RHD many other incidental findings of abnormal heart pathology were detected including bicuspid aortic valves; atrial and ventricular septal defects; PDA’s and even a case of dextrocardia! These children who would have remained undiagnosed will now be followed up and consulted every few years by visiting medical teams.

In October of this year the Operation Open Heart team4 from Australia visited Tonga for 2 weeks and during that time performed 18 cardiac surgical procedures including 16 valve replacements/repairs for RHD cases; 1 PDA and 1 ASD closures.

In summary, rheumatic heart disease exists in Tongan schoolchildren at an unacceptably high rate. Currently the secondary prevention program is up and running thanks to the drive and determination of Dr Toa Fakakovi. Echocardiography, especially portable echo in these island nations, is an extremely valuable tool in the diagnosis and management of RHD.

Only through the continued work of such dedicated doctors will the focus remain to reduce the endemic of RF and RHD. Reducing RHD improves not only the health of the people leading to more productive lifestyles, but also helps improve their economy by ensuring less medical expense. To help Dr Toa Fakakovi achieve these goals she needs the help of trained staff and improved medical equipment and supplies.

For further information about the WHF Pacific RHD control programme activities or to donate equipment or funds for use in Pacific Island countries please contact: Samantha Colquhoun World Heart Federation Pacific RHD programme Coordinator cols@unimelb.edu.au

References: 1.Rheumatic fever and rheumatic heart disease. Report of a WHO Expert Consultation. Geneva, World Health Organisation, 2001 (Technical Report Series, No 923). 2.Carapetis JR et al (2008) Evaluation of a screening protocol using auscultation and portable echocardiography to detect asymptomatic rheumatic heart disease in Tongan schoolchildren. Nature: Clincal Practice Cardiovasc Med 5:411-417 3.http://www.world-heart-federation.org/publications/heart-beat-e-newsletter/heart-beat-augustseptember-2008/in-this-issue/rhd-tonga-receives-heart-hero-award/ 4.Operation Open Heart: for further information contact Russell Lee, email russell@ooh.org.au

By Dianne Bruce Email: dibruce1@gmail.com

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Live 3D TOE one year on

The Echocardiography Department at Prince of Wales Hospital, Randwick, NSW was among the first hospitals in Australia to take delivery of the Philips Live 3D TOE probe. Live 3D TOE is the newest addition to the Philips 3D Matrix Family. The X7-2T TOE probe combines PureWave crystal technology with xMatrix and Live 3D echo, miniaturised into a transoesophageal transducer.

Prince of Wales public hospital performs over one thousand transoesophageal echo’s each year; using Philips technology throughout the cardiology department, in the TOE lab, Cath lab and Cardiac Surgical Theatres. This provides physicians, surgeons and anaesthetists with more accurate information throughout the entire patient care cycle, from initial presentation and diagnosis, through planning, treatment and assessment, to follow up care.

Dr Greg Cranney, director of Cardiology at Prince of Wales Hospital, uses Live 3D TOE on a daily basis, assessing patients with a wide range of pathology.

I have been particularly impressed with the improvement in 2D image quality of the 3D matrix TOE probe. X-Plane functionality allows me to assess structures in 2 planes simultaneously, which is fantastic for sorting out complex anatomy.  The ability to steer the beam in the lateral and elevation planes, lets us interrogate structures which were otherwise difficult to visualise.

With the addition of Live 3D scanning to our lab, we are better able to appreciate the anatomical relationship of structures within the heart and convey this information to other physicians, surgeons, anaesthetists and interventional cardiologists.

Live 3D TOE has opened up a new window for cardiac imaging and I expect will become the standard in all TOE labs.

Prince of Wales Cardiology department was the first Australian site to host our Live 3D TOE demonstration and workshop event. The day was an introduction to Live 3D TOE scanning with images on actual patients beamed live to an audience of attendees.

The success of this day has prompted Philips and Lifehealthcare to run a series of these events across Australia and New Zealand. This next phase of Live 3D TOE Workshops has been expanded to include both live cases and a live quantification workshop. The upcoming Sydney event will be once again held at Prince of Wales hospital on the Wednesday 17^th June 2009.

The 3D TOE probe was released in October 2007 and is currently installed at more than 30 sites throughout Australia.

About Philips Live 3D TOE Technology

Live 3D TOE provides the clinician with visualization of pathology and function never seen before in real time. It offers more perspectives of the heart, the surgeon’s view, and the view inside the left ventricle for accurate, easy, and precise quantification of the mitral valve.

For more information on this breakthrough technology, visit the Philips website at the following link:

http://www.medical.philips.com/au/products/ultrasound/technologies/live3d_tee_echo.wpd

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Live 3D TOE Workshop, Melbourne - March 2009

Philips & Lifehealthcare recently ran a Live 3D TOE Workshop & Symposium hosted by Monash Medical Centre, Melbourne on 5^th March 2009.  The full day workshop provided a comprehensive synopsis of the current uses and limitations of Live 3D TOE in the assessment of cardiac disease in a range of clinical settings.  The meeting was moderated by Dr John Gelman (MonashHeart and Cabrini Hospital) and Dr Mark Monaghan (Kings College Hospital, London) with presentations from Dr Helen Thomson (The Alfred Hospital and John Fawkner Cardiology) and Dr Roman Kluger (St Vincent’s Hospital). 

The morning program included a technical overview, the experience of the local and international experts and was highlighted by two live cases (ASD closure and MVP) from MonashHeart. 

Quantification of cardiac disease was the focus of the afternoon session where attendees had the opportunity to gain hands-on experience with QLAB^TM at computer workstations. On real life data sets attendees learnt how to manipulate and crop 3D volumes and quantify a number of cardiac diseases including: mitral valve disease, left ventricular dysfunction and atrial septal defects. 

A similar program will be held at the Prince of Wales Hospital, Sydney on Wednesday 17^th June 2009 and later in the year in Brisbane with the date yet to be confirmed.