Rheumatic Mitral Stenosis in Ethiopian Children: Severe Disease, High Mortality

Children in Tigray, Ethiopia, who develop rheumatic mitral stenosis frequently reach tertiary care with severe valve disease, extensive complications, and a substantial risk of death, according to a retrospective cohort study published in BMC Pediatrics. Researchers at Ayder Comprehensive Specialized Hospital reviewed the records of 98 children younger than 18 years with echocardiographically confirmed rheumatic mitral stenosis diagnosed between April 2019 and April 2024, a period during which neither cardiac surgery nor catheter-based valve interventions were available in the region.

The study documented a mean age at diagnosis of 13.7 plus or minus 3.0 years, with the youngest patient aged 5 years.

The complication burden was heavy.

Malnutrition compounded the clinical picture.

Sixteen children, or 16.3 percent of the cohort, died during the study period. Because surgical commissurotomy, valve replacement, and percutaneous balloon mitral valvuloplasty were unavailable in Tigray, these children could receive only medical management for what is, in severe cases, a surgically correctable lesion. The authors frame this treatment gap as central to the observed outcomes.

To identify factors associated with documented mortality, the researchers used univariable and multivariable Firth penalized logistic regression, a statistical approach suited to small numbers of outcome events, analyzing the data with SPSS version 27 and R version 4.6.1. Complications were coded as present if documented at any time during follow-up, and valve severity was taken from the last available echocardiogram.

Two factors emerged as significantly associated with death in the adjusted model. Atrial fibrillation carried an adjusted odds ratio of 8.35 (95 percent confidence interval 1.64 to 45.78; p = 0.011), and peripheral edema carried an adjusted odds ratio of 4.77 (95 percent confidence interval 1.35 to 17.86; p = 0.016). Infective endocarditis showed a positive but non-significant association, with an adjusted odds ratio of 4.72 (95 percent confidence interval 0.91 to 22.80; p = 0.064).

The authors are careful about what these associations mean. With only 16 deaths, the regression model is exploratory, and the wide confidence intervals reflect that uncertainty. More importantly, the timing of the recorded findings relative to each death was unknown, so causal or prognostic effects cannot be inferred. With the timing of these findings relative to death unknown, the study cannot determine whether atrial fibrillation and peripheral edema are markers of severity or contributors to mortality.

The study also has structural limitations inherent to its design. As a retrospective record review at a single tertiary referral center, it captures children well enough or sick enough to reach and be assessed at the hospital, and it relies on what was documented in charts rather than standardized prospective assessments. Severity classification came from the last echocardiogram rather than serial measurements, so disease progression over time cannot be traced from these data.

Nevertheless, the findings sketch a sobering picture of pediatric rheumatic mitral stenosis where definitive treatment is out of reach: disease that is often severe by the time of last assessment, a near-universal burden of heart failure, probable pulmonary hypertension in most measured patients, widespread malnutrition, and one death for every six children in the cohort. The authors conclude that early detection, nutritional support, and access to definitive valve intervention merit attention, pointing to the broader need for rheumatic heart disease control programs that prevent valve damage before it becomes irreversible.

Subject of Research: Clinical profile, complications, and mortality factors in children with rheumatic mitral stenosis in Ethiopia

Article Title: Clinical profile, complications, and factors associated with mortality among children with rheumatic mitral stenosis in a resource-limited setting: a retrospective cohort study

Article References: Girmay, E. F., Abay, T. H., Hadush, M. Y., Mustefa Mohammedamin, M., Legese, Y. M., Arefayine, D. Y., Welegebrieal Marru, Z., & Tesfa, A. B. (2026). Clinical profile, complications, and factors associated with mortality among children with rheumatic mitral stenosis in a resource-limited setting: a retrospective cohort study. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07957-2

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07957-2

Keywords: rheumatic mitral stenosis, children, Ethiopia, retrospective cohort, pulmonary hypertension, malnutrition, atrial fibrillation, heart failure, mortality, echocardiography, rheumatic heart disease, Clinical