Dilemmas in the management of rheumatic heart disease.

Rheumatic heart disease (RHD) is a major health care problem in India and will continue to be so for few more decades. As there is no vaccine against RHD, it is difficult to control the disease. Besides RHD, most children have other preventable ailments as well. Hence the schools, specially for the poor, must act as primary and preventive health care centres. Prevention of RHD starts with school prophylaxis. Primary, secondary and tertiary prophylaxis play their roles afterwords. After the heart valves have been damaged, tertiary prevention might minimise further damage. For mitral stenosis, closed mitral valvotomy (CMV), open mitral valvotomy (OMV) and interventional mitral valvotomy (IMV) are the different options but none is curative. Valve replacement poses many problems and therefore valvotomy is deferred as far as possible. Mild or moderate mitral regurgitation (MR) is best treated medically. For more advanced disease repair or replacement is the option. For aortic stenosis (AS), valvotomy may be preferred to replacement wherever feasible and for aortic regurgitation (AR) repair is not yet well established. In combined mitral and aortic valve disease it is important to assess both the valves carefully and try to repair one or both the valves and to avoid double valve replacement as far as possible. Once the heart valve is damaged any treatment is palliative, hence all efforts should be directed towards prevention of RHD. Indian Medical Association can play a major role in this endeavour and help children in India to grow up free from RHD.