Rheumatic heart disease (RHD) is a long-term consequence of acute rheumatic fever, an immune-mediated, multisystem inflammatory disease that develops following a group A streptococcal infection. RHD is characterised by leaflet thickening, commissural fusion, calcification and restricted leaflet motion in the heart valves.1 The burden of RHD and, by extension, the prevalence of rheumatic aortic valve disease and the potential need for nonsurgical treatment solutions remains significant.2 It is estimated that RHD affects 33 million patients worldwide and accounts for up to 1.4 million deaths per year in low-income to middle-income countries. The level of cardiac surgery provided ranges from 0.5 per million in the assessed low-income and lower-middle-income countries to 500 per million in the upper-middle-income countries, indicating that a significant degree of disparity in open heart surgery exists, particularly in low-income countries.3 The Global Rheumatic Heart Disease Registry reported that oral anticoagulants were prescribed to 69.5% of patients with mechanical valves, atrial fibrillation and high-risk mitral stenosis in sinus rhythm in low-income countries. Only 28.3% of patients had a therapeutic international normalised ratio. There is a serious concern in patients …