Treatment of trivalvular rheumatic heart disease: why it matters where we live

A 42-year-old woman who had recently emigrated to the UK from Ethiopia presented to her general practitioner with increasing breathlessness and palpitations. Transoesophageal echocardiogram revealed rheumatic heart disease affecting three valves, and severe aortic stenosis. ECG demonstrated atrial fibrillation. She was treated operatively with mitral and aortic valve replacement and tricuspid valve repair and put on lifelong warfarin. Four months later she remains well, with substantially increased exercise tolerance. This case report summarises treatment options for severe rheumatic heart disease and discusses differences in prevention and management between patients presenting in the UK and in the developing world.