Echocardiographic screening is a powerful tool for early rheumatic heart disease (RHD) detection, so important considering the known impact of secondary prophylaxis on disease regression.1 Over the last decades, RHD has been a target for echocardiographic screening. In a landmark study, Marijon et al compared auscultatory to echocardiographic screening in over 5000 school-aged children and showed that RHD was 10 times more detected through echocardiography.2 Additional studies consistently highlighted the high sensibility of echocardiography for detecting RHD.

A number of criteria to assess left-heart valve morphology and function have been proposed for diagnosing RHD. In an attempt to standardise diagnostic criteria, the World Heart Federation (WHF) published an evidence-based guideline, which became the gold standard for the diagnosis of latent RHD.3 Based on the WHF approach, morphological and functional changes of the valves are assessed to classify patients into the categories of normal, borderline or definite RHD. However, with a growing experience using these criteria, concerns emerged regarding their specificity and complexity. Morphological rheumatic valvular abnormalities take time to develop and may not be present at early disease phase seen both in daily clinical practice and community-based screening. In addition, some parameters have low prevalence, and therefore less clinical significance in the context of screening, which may contribute to the complexity of the protocols and a larger burden of …