Smit JPJ, Joubert G, Du Toit J
… +1 more, Burger MC
S Afr Med J
· 2025 Jun · PMID 41378611
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BACKGROUND: Outreach, as a component of health service delivery in South Africa (SA), increases diagnostic and treatment capacity for populations living in remote areas. It further allows for close population surveillanc...BACKGROUND: Outreach, as a component of health service delivery in South Africa (SA), increases diagnostic and treatment capacity for populations living in remote areas. It further allows for close population surveillance of specific health-related conditions. Paediatric orthopaedic outreach for central SA provides a unique opportunity to provide insight into the incidence rates of common paediatric orthopaedic-related conditions. OBJECTIVE: To investigate the absolute numbers and incidence rates of orthopaedic-related pathological conditions in the paediatric population presenting at outreach in central SA between 1997 and 2016. METHODS: A retrospective investigation was conducted, which included all paediatric patients residing in the Northern Cape and Free State provinces accessing public healthcare for orthopaedic-related conditions during outreach services. Patient demographic and clinical data were collected and divided into (i) periods; (ii) age groups; (iii) geographical location; and (iv) presenting pathology. Age group-specific incidence rates (ASIR) and paediatric incidence rates (PIR) were calculated using census data from 2001, 2006 and 2011, and estimated values were adjusted to reflect the percentage of the population expected to use public health facilities per 10 000 paediatric population per year. RESULTS: A total of 3 418 patients were included, with the largest number of patients seen in the Central Free State (n=985). The ASIR for all age groups varied considerably between geographic regions and periods, with the highest rates (2005 - 2008, 21.8 per 10 000 per year) observed in the neonate/infant age group in the northern Free State region. The PIR for pathological groups also varied considerably, with high incidences of congenital talipes equinovarus observed in the northern and eastern Free State regions and a high incidence of cerebral palsy in the central (2001 - 2004, 0.79 per 10 000 per year) and Eastern Free State (2001 - 2004, 0.62 per 10 000 per year). CONCLUSION: This information can provide a unique context for planning healthcare service delivery and pathology-orientated scientific research.
S Afr Med J
· 2025 Jun · PMID 41378610
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BACKGROUND: Retinopathy of prematurity (ROP) is a significant cause of preventable blindness in premature infants. The prevalence of ROP is increasing, particularly in resource-constrained settings. Low birthweight (BW),...BACKGROUND: Retinopathy of prematurity (ROP) is a significant cause of preventable blindness in premature infants. The prevalence of ROP is increasing, particularly in resource-constrained settings. Low birthweight (BW), low gestational age (GA) and other neonatal risk factors are identified as key contributors. In South Africa (SA), intravitreal bevacizumab (IVB) is commonly used for treating type 1 ROP due to its accessibility and cost-effectiveness. OBJECTIVES: To evaluate the prevalence, risk factors and outcomes of ROP in a tertiary hospital in SA infants, with a focus on the use of IVB for type 1 ROP. METHODS: This retrospective file audit, conducted at Rob Ferreira Hospital, reviewed ROP referrals from January 2020 to December 2023. Infants were screened by a specialist ophthalmologist, and treatment with IVB was administered to those diagnosed with type 1 ROP according to the Early Treatment for Retinopathy of Prematurity study protocol. Follow-up was conducted until full vascularisation, or 60 weeks post menstrual age for the respective groups. RESULTS: A total of 267 infants were referred, with an ROP prevalence of 27.0%. Type 1 and type 2 ROP accounted for 31.9% and 68.1% of diagnoses, respectively. Of screened infants, 8.6% (n=23/267) required treatment with IVB, with no reported complications. Of the 72 infants diagnosed with any ROP, 40.3% did not return for follow-up until discharge was indicated. CONCLUSION: This study highlights a similar ROP prevalence rate to other SA studies, but yields a markedly higher ROP treatment rate. IVB proved to be a safe and effective treatment option, with no observed complications. However, a 40.3% attrition rate underscores the need for strengthened follow-up systems and improved care pathways. Addressing follow-up challenges and exploring alternative treatment modalities, such as laser photocoagulation, may help to improve long-term outcomes for at-risk infants.
Barron P, Mahomed H, Masilela TC
… +4 more, Vallabhjee K, Ndlovu N, Goliath C, Schneider H
S Afr Med J
· 2025 Jun · PMID 41378609
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Effective monitoring and evaluation (M&E) systems are central to ensuring the performance and accountability of the district health system (DHS). Current systems in South Africa are suboptimal and poorly oriented to the...Effective monitoring and evaluation (M&E) systems are central to ensuring the performance and accountability of the district health system (DHS). Current systems in South Africa are suboptimal and poorly oriented to the decision-making needs of district managers. Drawing on a WHO measurement framework for the performance of primary healthcare, and as a follow-up to a first article describing the challenges of M&E systems in the DHS, this article proposes a DHS performance monitoring dashboard that is both practical and pragmatic. The dashboard was constructed in an iterative and consultative process, and consists of 20 indicators for quarterly monitoring. A set of general criteria underpinning the choice of indicators is spelled out (e.g. the data are readily available and reliable). Indicators that do not have much variability, or are better suited to annual evaluation (e.g. number of community health workers per 1 000 population) are not included. The dashboard includes the name or description of the indicator, the definition of the indicator, why it is useful, challenges and pitfalls to be considered when analysing the indicator and how it can be used for decision-making. We propose that these indicators be assessed, tracked and monitored on a quarterly basis by relevant managers at the facility subdistrict and district levels. We emphasise that the purpose of this dashboard is not external compliance, but rather to support district managerial decision-making and accountability.
Prinsloo M, Roomaney RA, Neethling I
… +4 more, Basera NW, Groenewald P, Matzopoulos R, Bradshaw D
S Afr Med J
· 2025 Jun · PMID 41378608
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The President of South Africa addressed the nation on 15 November 2024 regarding the rise in food-borne illnesses and related child deaths. In the absence of a clear profile of injury deaths from official cause-of-death...The President of South Africa addressed the nation on 15 November 2024 regarding the rise in food-borne illnesses and related child deaths. In the absence of a clear profile of injury deaths from official cause-of-death data, we used empirical, nationally representative surveys from 2017 and 2020/21 to analyse poisoning deaths. For children (aged 0 - 17 years), deaths from poison ingestion increased in 2020/21 for Gauteng Province, and became more prominent in KwaZulu-Natal, Eastern Cape and Mpumalanga provinces. Adults (≥18 years) showed similar developments, but on a larger scale. Among children in 2020/21, poison ingestion deaths were mostly unintentional (274 cases). Adults had higher proportions for suicide-related poisoning, but unintentional poisoning deaths (791 cases) accounted for 43.8% in males and 32.5% in females. Overall, pesticides were the most common cause of poisoning deaths in children (42%) and adults (29%). A promising intervention is that suspected agricultural or stock remedy poisoning, as a notifiable medical condition (NMC), should now be reported to the NMC Surveillance System within 24 hours. For a rapid public health response to the country's burden of disease, we call on the government for a collaborative approach, to improve the quality and timeliness of death notification data, and to implement electronic capturing of deaths nationally.
Hendricks C, Viljoen I, Botes M
… +12 more, Brittain D, Mahlangu J, Verburgh E, Gerdener T, Herd C, Logan M, Marais AL, Glatt TN, Cockeran R, Poole C, Du Toit J, Pepper MS
S Afr Med J
· 2025 Jun · PMID 41378607
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The fields of molecular and cellular medicine have, in recent years, witnessed a great deal of progress globally, particularly in understanding disease pathogenesis and through the development of advanced cellular therap...The fields of molecular and cellular medicine have, in recent years, witnessed a great deal of progress globally, particularly in understanding disease pathogenesis and through the development of advanced cellular therapy products and gene therapies. Despite the transformative potential of these new therapies, low- and middle-income countries face significant barriers to their access. Advanced cellular therapy legislation in South Africa (SA) has not kept up with this fast-advancing field, and requires a fast-tracked renewal. Furthermore, the prohibitive cost of commercial therapies, including chimeric antigen receptor (CAR) T-cell products, and the lack of infrastructure, manufacturing and research capacity, must be addressed to make equitable patient access an achievable goal in our setting. To this end, a national cell and gene therapy consortium, comprising clinicians, clinician-scientists, scientists, legal experts, postgraduate students and representatives from industry, the national blood service and the pharmaceutical industry, was initiated. The mandate of this group is to aid the progression of advanced cellular therapies in SA, and the purpose of this article is to outline the progress that has been made. We will highlight the gaps in each core field of practice within this space, and provide a proposal for making these therapies more accessible in SA.
Solanki G, Brijlal V, Morar R
… +3 more, Cornell J, Myburgh N, Cleary S
S Afr Med J
· 2025 Jun · PMID 41378606
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The passing of the National Health Insurance (NHI) Act was an important milestone in the reform of the South African healthcare system and will have a profound impact on the funding and provision of healthcare in the cou...The passing of the National Health Insurance (NHI) Act was an important milestone in the reform of the South African healthcare system and will have a profound impact on the funding and provision of healthcare in the country. While the impacts will be felt across the entire system, the focus of this article is on the potential impact on the private health funding sector, which currently enables financial risk protection for those with private health insurance. This article highlights some key trends and challenges in this sector from 2007 to 2022 and then examines two possible extreme scenarios for the sector during the NHI transition phases. In the first scenario, a passive' process is assumed. This is characterised as a continuation of the current policy environment, where the sector is allowed to continue a downward trajectory without any specific actions to maintain its viability during the transition. A key risk in this scenario is that the sector becomes unsustainable before the NHI can provide an alternative financial risk protection mechanism to those currently protected through private health insurance. In the second scenario, an active' process is followed, where steps are taken to keep the sector sustainable during the NHI transition. While part of this would include the purposive shifting of government-related funding from the private funding sector to the NHI, other actions would include regulatory and other reforms necessary to keep the private funding sector viable, which would also provide a stronger foundation for the NHI.
Van As AB, Sidler D, Allema JH
… +16 more, Leva E, Marincowitz GJO, Tonkin S, Rose PC, Govender S, London L, de Agustin JC, Schimanek C, De Bruin G, Khamag O, Peck C, Almaliki MS, Jaffer MN, Hamunyela KS, Arnold M, Elhosny A
S Afr Med J
· 2025 Jun · PMID 41378605
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Wearne N, Chothia Y, Bisiwe F
… +13 more, Cullis B, Freercks R, Rekhviashvili V, Wadee S, Davies M, Diana N, McCulloch M, Paget G, Van Hougenhouck-Tulleken W, Barday Z, Jacobs L, Thomson D, Muranda A
S Afr Med J
· 2025 Oct · PMID 41378600
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Chronic kidney disease (CKD) in South Africa (SA) is a growing public health crisis, driven by the intersecting burdens of HIV, tuberculosis, hypertension, diabetes and obesity. In Black African populations, high-risk ap...Chronic kidney disease (CKD) in South Africa (SA) is a growing public health crisis, driven by the intersecting burdens of HIV, tuberculosis, hypertension, diabetes and obesity. In Black African populations, high-risk apolipoprotein L1 (APOL1) variants add a genetic predisposition to non-diabetic kidney diseases, compounding risk. Global recognition of CKD has recently advanced, marked by the 2025 World Health Organization (WHO) non-communicable disease resolution, which urges the integration of kidney care into national health strategies. This resolution emphasises prevention, early detection and treatment, while strengthening primary healthcare and addressing social determinants of health, particularly in low-income countries. However, in SA, domestic capacity has not kept pace. Public-sector dialysis slots have remained static since 1994, while the private sector has expanded rapidly, deepening inequities by province and income. In the public sector, dialysis is rationed to patients eligible for transplantation, yet transplant access is limited by organ shortages, logistical barriers and variable provincial resources. Expanding deceased donation and implementing kidney paired donation (KPD) programmes are essential to increase transplant opportunities, particularly for incompatible donor- recipient pairs, and to improve equity in access. Children and adolescents face additional barriers, including limited age-specific pathways and the absence of structured transition to adult care. Workforce shortages, inadequate regulatory oversight, inconsistent procurement processes and incomplete registry reporting undermine service quality, limit expansion and perpetuate inequities in access. Without urgent reform, CKD will continue to drive preventable morbidity, premature mortality and escalating costs. Scaling equitable dialysis and transplantation services, integrating KPD and investing in prevention, workforce and infrastructure are critical to reversing current trends and fulfilling the WHO's call for action.
Kinandu K, Bobat B, Crawford R
… +16 more, Eagar M, Gaylard P, Khan Z, Kuka W, Lala V, Mahomed A, Mokgoko D, Parbhoo D, Rambarran S, Van der Schyff F, Seabi M, Sobnach S, Ströbele B, Wing J, Loveland J, Fabian J
S Afr Med J
· 2025 Oct · PMID 41378599
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BACKGROUND: Wits Donald Gordon Medical Centre (WDGMC) in Johannesburg, South Africa, established a liver transplant programme in 2004. Acute cellular rejection (ACR) of the transplanted liver is a serious complication be...BACKGROUND: Wits Donald Gordon Medical Centre (WDGMC) in Johannesburg, South Africa, established a liver transplant programme in 2004. Acute cellular rejection (ACR) of the transplanted liver is a serious complication because of the potential for graft loss. ACR is defined as allograft dysfunction secondary to predominantly T-cell-mediated injury to the graft, and has been reported in up to 50% of liver transplants worldwide. While the advent of tacrolimus-based immunosuppression reduces the incidence of ACR in liver transplant recipients, it remains a concern. OBJECTIVES: To review the incidence and risk factors for ACR, as well as the impact of ACR on graft survival in adult liver transplant recipients at WDGMC. METHODS: This was a retrospective review of first-time adult liver transplants performed from 1 January 2014 to 31 December 2022. Data collected included donor and recipient sociodemographic and clinical characteristics; transplant surgical procedure details; postoperative surgical complications; overall post-transplant ACR incidence rates in the first 365 days; ACR incidence stratified as early (≤90 days) and late (>91 days - <365 days); diagnosis and treatment details of biopsy-proven ACR episodes, including steroid resistance; and graft survival. RESULTS: Of 326 first-time adult liver transplants performed during the review period, 295 were eligible for inclusion. The post-transplant ACR incidence rates were 10.7% (early), 8.8% (late) and 20.3% overall (first 365 days). Corticosteroid resistance occurred in 19% of adult liver transplant recipients with biopsy-proven ACR. Risk factors for early ACR were younger recipient age, black ethnicity and male-donor- to-female-recipient sex discordance. A higher pre-transplant model for end-stage liver disease (MELD) score was a risk factor in late ACR. Younger recipient age, black ethnicity, female sex, acute liver failure, lower donor risk index scores and postoperative biliary complications were associated with increased risk for ACR in the first 365 days. ACR was not significantly associated with increased graft loss in this cohort. CONCLUSION: While the incidence of ACR was low in this cohort, identification of ACR risk factors and presence of steroid-resistant ACR indicate the need for personalised and context-specific immunosuppression.
Wang CY, Schapkaitz E, Louw S
… +1 more, Jacobson B
S Afr Med J
· 2025 Oct · PMID 41378598
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BACKGROUND: In 2020, during the coronavirus disease 2019 (COVID-19) outbreak, eligible patients were converted from warfarin to rivaroxaban therapy to limit the transmission of COVID-19 infection. OBJECTIVE: To assess th...BACKGROUND: In 2020, during the coronavirus disease 2019 (COVID-19) outbreak, eligible patients were converted from warfarin to rivaroxaban therapy to limit the transmission of COVID-19 infection. OBJECTIVE: To assess the thrombosis and bleeding outcomes associated with converting patients on warfarin therapy to rivaroxaban during the COVID-19 pandemic. METHODS: A retrospective audit was performed that identified 190 participants with venous thromboembolism (VTE) and 112 participants with non-valvular atrial fibrillation at the anticoagulation clinic service at Charlotte Maxeke Johannesburg Academic Hospital, South Africa. Participants were converted to rivaroxaban 20 mg for a median (interquartile range) period of 4 (2) months between April and October 2020. Follow-ups were conducted telephonically and face-to-face on conversion back to warfarin. Rates of COVID-19 infections, bleeding and thrombosis were objectively confirmed. RESULTS: The COVID-19 infection rate among participants was 3.3% (95% confidence interval (CI) 1.6 - 6.0), with five (1.7%) hospital admissions and two (0.7%) COVID-19-related deaths. The deaths occurred in one participant on rivaroxaban, and in another after switching back to warfarin. One week after switching to rivaroxaban, the rate of clinically relevant non-major bleeding was 0.7% (95% CI 0.02 - 2.54), while minor bleeding occurred at a rate of 9.2% (95% CI 6.16 - 13.40). No major bleeding events were reported, and bleeding rates on rivaroxaban were not significantly higher compared with warfarin. Additionally, two (0.7%) myocardial infarctions were recorded. One occurred on rivaroxaban and the other after switching back to warfarin. A single (0.3%) VTE presenting as a newly diagnosed pulmonary embolism was reported in a participant on rivaroxaban. CONCLUSION: This study provides practical insights regarding the conversion of eligible participants from warfarin to rivaroxaban during the first wave of COVID-19, with the aim of informing future public health interventions in similar crisis settings.
Conradie W, Lübbe J, Martin L
… +7 more, Luvhengo T, Razack R, Afrogheh A, Crabbia F, Nayler S, Davies J, Baatjes K
S Afr Med J
· 2025 Oct · PMID 41378597
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BACKGROUND: The South African (SA) health sector and laboratories comprise a dual system that includes public and private providers. SA studies illustrate diverse thyroid cancer incidence across provinces, with papillary...BACKGROUND: The South African (SA) health sector and laboratories comprise a dual system that includes public and private providers. SA studies illustrate diverse thyroid cancer incidence across provinces, with papillary thyroid cancer (PTC) more prevalent in urban provinces than follicular thyroid cancer (FTC) and anaplastic thyroid carcinoma. OBJECTIVES: To provide a deeper insight into the geographic intricacies of thyroid cancer types from public and private provider perspectives. METHODS: This study investigated thyroid cancer pathology in SA between 2015 and 2019, overall and by province and facility type (private, public). Laboratories provided data in different formats, requiring manual processing. The data extracted included date of birth, sex, province, specimen type and final histology results. RESULTS: A total of 14 157 reports were included, of which 3 235 were thyroid cancers. Multiple challenges were experienced in terms of data processing. The public sector contributed 53.6% of thyroid cancer cases. Preoperative cytology was performed in 19.8% of thyroid cancers, and was diagnostic in 23.6%. There was significantly more FTC in the public sector (20.8% v. 5.6%), and more PTC in the private sector (87.1% v. 55.2%). T3 tumours were most prevalent in the public sector (52.3%), and T1 tumours in the private (38.8%). CONCLUSION: The dual SA health system and the geographical distribution of the population appear to influence the pathological landscape of thyroid cancer. Standardised thyroid cancer reporting across all public and private laboratories in the form of a prospective national thyroid registry would allow for a more accurate evaluation of thyroid disease, ultimately improving thyroid cancer care in SA.
S Afr Med J
· 2025 Oct · PMID 41378596
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BACKGROUND: Fragility hip fracture is a rising pandemic, with the burden currently shifting to developing countries. A fracture liaison service (FLS) was implemented in September 2021 in a regional South African (SA) hos...BACKGROUND: Fragility hip fracture is a rising pandemic, with the burden currently shifting to developing countries. A fracture liaison service (FLS) was implemented in September 2021 in a regional South African (SA) hospital. OBJECTIVE: To describe two groups of patients with surgically treated fragility hip fractures - those before and after implementation of the FLS - in terms of early mortality, refracture and readmission rates. METHODS: Patients aged >50 years who sustained hip fractures between January 2020 and June 2022 were considered; those with high-energy injuries, pathological and periprosthetic fractures were excluded. Associations between treatment group and mortality, readmission and refracture rates within the first year after surgery were investigated. Subgroup analyses were also conducted for specific risk factors. RESULTS: A total of 299 patients (mean (standard deviation) age of 74.5 (11.0) years, 68.2% female) were included, of whom 32.8% (n=98) received bisphosphonates. The overall 30-day, 90-day and 1-year mortality rates were 9.4% (n=28), 17.4% (n=52) and 29.8% (n=89), respectively, while 24.1% (n=72) of patients had unplanned readmissions to hospital, and 2.7% (n=8) refractured within the first year after surgery. No statistical difference in 30-day, 90-day or 1-year mortality rate, refracture incidence or readmission incidence was observed between patient groups. Time to surgery was shorter after the implementation of the FLS (median (interquartile range (IQR)) 30.8 (22.3 - 48.9) hours v. before (median (IQR) 42.5 (23.1 - 70.8) hours, p=0.039). CONCLUSION: An FLS was successfully implemented in a regional SA hospital. Early mortality, refractures and readmission rates were low or comparable with the existing literature, and not affected by treatment within the FLS nor by bisphosphonate initiation. Treatment within the FLS, however, resulted in a decrease in time to surgery.
S Afr Med J
· 2025 Oct · PMID 41378595
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BACKGROUND: Medical doctors manage trauma cases daily, most needing medicolegal documentation. Wound documentation is a vital skill required by doctors. OBJECTIVES: To describe and compare the knowledge and practices of...BACKGROUND: Medical doctors manage trauma cases daily, most needing medicolegal documentation. Wound documentation is a vital skill required by doctors. OBJECTIVES: To describe and compare the knowledge and practices of documentation of clinical findings on the J88 form, looking at the accuracy of wound features and wound size estimation, focusing on participant gender, medical level of experience and type of injury simulated. METHODS: This was a multi-centre, prospective, observational, cross-sectional study of three academic emergency departments in the University of the Witwatersrand academic circuit using questionnaires, moulage and wound characteristic rubrics. RESULTS: Eighty-three doctors participated in the study. This was equally spread between sexes. According to wound rubrics, participants scored an average of 48% for accuracy of J88 form completion. The most precise wound description was abrasion (62.5%). The least precise wound description was stab wound (33.3%). Most participants (63.8%) noted on the questionnaire that they always indicate bruises; however, 25.3% missed the simulated bruise. The most frequently documented wound features were location and size estimation (98.8%). The least documented wound feature was the age and mechanism of the injury (<6%). Large wounds (>5 cm length) were underestimated (p<0.001), with accurate size estimations of smaller wounds (<5 cm). Perceptions of undergraduate training in wound documentation were evenly divided between acceptable and poor, while postgraduate training was generally regarded as poor. CONCLUSION: This study found that wound documentation among emergency department doctors was poor, with participants scoring an average of 48% across the marking rubric. More training at both undergraduate and postgraduate levels is recommended.
BACKGROUND: There is a high incidence of rheumatic valvular heart disease involving the mitral valve in Soweto, Johannesburg. Many of these patients go on to have mitral valve replacement (MVR). Data regarding clinical a...BACKGROUND: There is a high incidence of rheumatic valvular heart disease involving the mitral valve in Soweto, Johannesburg. Many of these patients go on to have mitral valve replacement (MVR). Data regarding clinical and echocardiographic characteristics of patients with prosthetic mitral valves are scarce in South Africa. OBJECTIVE: To document the clinical and echocardiographic profiles of contemporary patients with MVR. METHODS: Clinical, electrocardiographic and echocardiographic data in these patients were collected prospectively from March 2020 to August 2021 at Chris Hani Baragwanath Academic Hospital prosthetic valve clinic. RESULTS: The study included 186 participants with a median (interquartile range (IQR)) age of 52 (41 - 60) years. Of these, 96% were of black African ethnicity (79% female). The median (IQR) body mass index (BMI) among participants was 27 (23.5 - 30.4) kg/m2, with 29% of participants classified as obese (BMI >30 kg/m2). Eighty-two percent of patients had New York Heart Association class 1 dyspnoea. The most common complications were atrial fibrillation (AF, 39%), heart failure (HF, 25%) and stroke (13%). There were two cases of previously documented prosthetic valve thrombosis, two cases of prosthetic valve endocarditis, two of paravalvular regurgitation and one with structural valve deterioration. Seventy percent of patients had subtherapeutic international normalised ratios (INRs), with a median (IQR) INR of 2.55 (2.03 - 2.92). Forty-seven percent of patients had a left ventricular ejection fraction (EF) of <40%. Seventy-four percent of participants were on some combination of guideline-directed medical therapy for HF with reduced EF, although only 12% were on at least three medications. Pulmonary hypertension was present in 37% of patients, with a median (IQR) pulmonary artery systolic pressure of 28.5 (17 - 41) mmHg. Tricuspid annuloplasty ring was noted in a minority (12 patients). CONCLUSION: The contemporary patients with MVR were middle-aged obese females with significant AF burden, residual left ventricular dysfunction that was suboptimally managed, and subtherapeutic INR.