There is no primary rheumatic myocardial dysfunction .The LV dysfunction is related to the valvular lesion especially mitral regurgitation.While this is 100 % true in chronic RHD ,surprisingly it holds good even in acute rheumatic fever as well .(We have been thinking wrongly that acute myocarditis is responsible for most cases of cardiac failure in Acute rheumatic fever !)
( Incidence of LV dysfunction is still noted in 5% in RHD.This is may be due to chronic underfilling of LV in mitral stenosis, fibrosis secondory to hemodynmic stress as in Aortic stenosis or more commonly associated CAD.)
It is a paradox to note myocardits being a major component in acute rheumatic fever (ARF) ,still it does not persist long term .It invariably resolves and the injury to the valves goes on to result in progressive valve damage .
It is heartening to note this phenomenon in ARF as myocardial involvement behaves just like joint involvement.
Shall we modify the famous statement of the canadian Pathologist William Boyd “Rheumatic fever licks the joint but bites the heart”
Though ARF bites the vlave , it simply licks the myocardium like the joints
Is there a chronic indolent myocarditis ?
It was Initially thought there could be process of chronic myocardial inflammation.But now it is almost proven there is no entity like that .
But , it is not uncommon some patients with RHD present with significant LV dysfunction which in all probability unrelated to rheumatic activity .
Assignment for cardiology fellows .
1.Where in the heart Ascoff bodies are densely found ?
- Mainly over the valve leaflets
- Atrial muscle
- Ventricular myocardium
- Pericardium
2.Does Ascoff bodies disappear in Chronic RHD ?
Reference
Dr.S.Venkatesan MD 
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