Rheumatic heart disease: The role of global cardiac surgery.

Rheumatic heart disease (RHD) remains a neglected disease of poverty. While nearly eradicated in high-income countries due to timely detection and treatment of acute rheumatic fever, RHD remains highly prevalent in low- and middle-income countries (LMICs) and among indigenous and disenfranchised populations in high-income countries. As a result, over 30 million people in the world have RHD, of which approximately 300,000 die each year despite this being a preventable and treatable disease. In LMICs, such as in Latin America, sub-Saharan Africa, and Southeast Asia, access to cardiac surgical care for RHD remains limited, impacting countries’ population health and resulting economic growth. Humanitarian missions play a role in this context but can only make a difference in the long term if they succeed in training and establishing autonomous local surgical teams. This is particularly difficult because these populations are typically young and largely noncompliant to therapy, especially anticoagulation required by mechanical valve prostheses, while bioprostheses have unacceptably high degeneration rates, and valve repair requires considerable experience. Devoted and sustained leadership and local government and public health cooperation and support with the clinical medical and surgical sectors are absolutely essential. In this review, we describe historical developments in the global response to RHD with a focus on regional, international, and political commitments to address the global burden of RHD. We discuss the surgical and clinical considerations to properly manage surgical RHD patients and describe the logistical needs to strengthen cardiac centers caring for RHD patients worldwide.

Survival of Left-to-Right Shunt Repair in Children with Pulmonary Arterial Hypertension at a Tertiary Hospital in a Low-to-Middle-Income Country

Background: In low-to-middle-income countries, repair of the left-to-right shunts congenital heart disease (CHD) are often done with existing pulmonary arterial hypertension (PAH). Long-term outcomes data of this condition in either low-to-middle or high-income countries are limited. We conducted a study to evaluate the outcomes of children with PAH related to left-to-right shunt CHD who underwent surgical or transcatheter repair.

Methods: All cases of PAH related to left-to-right shunt CHD repairs from 2015–2018 were retrospectively reviewed with additional new patients who underwent repair within our study period (2019–2020). Cases with complex congenital heart disease and incomplete hemodynamic echocardiography or catheterization measurements were excluded. Kaplan-Meier curves, log-rank test, Cox regression with Firth’s correction and restricted mean survival time were used for survival analysis.

Results: Of the 118 patients, 103 patients were enrolled and 15 patients were excluded due to complex congenital heart disease and missing hemodynamic measurements prior to repair. Overall, median age at intervention was 44 months, mPAP mean was 43.17 ± 16.05 mmHg and Pulmonary Vascular Resistance index (PVRi) mean was 2.84 ± 2.09 (WU.m2). Nine patients died after repair. The survival rate for patients with PAH-CHD at 1 day, 30 days and 1400 days (4 years) was 96.1%, 92.1%, and 91.0% respectively. Patients with persisting PAH after correction had –476.1 days (95% confidence interval [CI]: –714.4, –237,8) shorter survival over 4 years of follow up compared to patients with reversed PAH. PVRi was found to be the influencing covariate of the difference of restricted mean survival time between these groups.

Conclusion: In low-to-middle income settings, with accurate PAH reversibility assessment prior to intervention, repair of left-to-right shunt CHD with existing PAH in children has a favourable outcome. Inferior survival is found in patients with persistence of PAH. PVRi at baseline predicts between-group survival difference.

Primary care and pulmonary physicians’ knowledge and practice concerning screening for lung cancer in Lebanon, a middle‐income country

Background
Screening for lung cancer with low‐dose computed tomography (LDCT) was shown to reduce lung cancer incidence and overall mortality, and it has been recently included in international guidelines. Despite the rising burden of lung cancer in low and middle‐income countries (LMICs) such as Lebanon, little is known about what primary care physicians or pulmonologists know and think about LDCT as a screening procedure for lung cancer, and if they recommend it.

Objectives
Evaluate the knowledge about LDCT and implementation of international guidelines for lung cancer screening among Lebanese primary care physicians (PCPs) and pulmonary specialists.

Methodology
PCPs and PUs based in Lebanon were surveyed concerning knowledge and practices related to lung cancer screening by self‐administered paper questionnaires.

Results
73.8% of PCPs and 60.7% of pulmonary specialists recognized LDCT as an effective tool for lung cancer screening, with 63.6% of PCPs and 71% of pulmonary specialists having used it for screening. However, only 23.4% of PCPs and 14.5% of pulmonary specialists recognized the eligibility criteria for screening. Chest X‐ray was recognized as ineffective by only 55.8% of PCPs and 40.7% of pulmonary specialists; indeed, 30.2% of PCPs and 46% of pulmonary specialists continue using it for screening. The majority have initiated a discussion about the risks and benefits of lung cancer screening.

Conclusion
PCPs and pulmonary specialists are initiating discussions and ordering LDCT for lung cancer screening. However, a significant proportion of both specialties are still using a non‐recommended screening tool (chest x‐ray); only few PCPs and pulmonary specialists recognized the population at risk for which screening is recommended. Targeted provider education is needed to close the knowledge gap and promote proper implementation of guidelines for lung cancer screening.

Ultrasound-Guided Transthoracic Mediastinal Biopsy: A Safe Technique for Tissue Diagnosis in Middle- and Low-Income Countries

Background and objectives
The high cost of video-assisted transthoracic procedures precludes their use in the diagnostics of mediastinal masses in low- and middle-income countries (LMICs). This study aims to assess the technical success rate and diagnostic yield of ultrasound-guided transthoracic mediastinal biopsies at a tertiary care hospital.

Methods
This descriptive cross-sectional study was conducted in patients presenting with mediastinal masses referred to radiology services at Dr. Ziauddin University Hospital. Karachi, Pakistan. Ultrasonography was performed using Toshiba Xario 200 & Aplio 500 using convex and linear probes accordingly. Biopsy was performed using a combination of 18G semiautomatic trucut and 17G co-axial needles. Complications and overall diagnostic yields were determined.

Results
In all 70 patients referred, the procedure was completed successfully with an overall procedural yield of 95.7%. Inconclusive biopsies due to inadequate specimen were seen in two (4.2%) patients. No post-procedure major complication or mortality was observed. Minor complications were seen in three (4.2%) out of 70, including hematoma (<3 cm) in one patient and small pneumomediastinum in two patients.

Conclusion
Ultrasound-guided transthoracic mediastinal biopsy may be the pragmatic technique of choice in LMICs for the diagnosis of mediastinal masses as they provide real-time visualization and is cost-effective and saf

Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study

Peri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS‐CoV‐2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9–2.1)). After a ≥ 7 week delay in undertaking surgery following SARS‐CoV‐2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS‐CoV‐2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay

Cardiovascular disease risk profile and management practices in 45 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level survey data

Background
Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population’s median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines.

Methods and findings
We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%–4.2%) and 1.6% (1.3%–2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%–37.2%) for males and 41.6% (23.9%–53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%–58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis.

Conclusions
This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.

Cardiac anesthesiologist and the global capacity building to tackle rheumatic valvular heart disease

Rheumatic heart disease (RHD) is considered the neglected disease of the tropics and is endemic in several low- and middle-income countries (LMIC). 1 It still is an important cause of preventable morbidity and mortality associated with cardiovascular disease among children and young adults. The disease has seen a sharp decrease in most high-income countries (HIC) and primarily, the LMICs of Asia and Africa face the brunt of RHD, which also imposes huge economic burden. 2 In addition, RHD is also a significant cause of maternal mortality. 3 For precise understanding of the burden of RHD, it needs to be appreciated that LMICs are more populous (more than 5 times that of HICs) and that RHD remains the single most common cardiovascular disease in young adult and adolescent patients in need of heart surgery. 4 Furthermore, LMICs provide very different levels of cardiac surgical services for their population. There has been an impressive significant growth in the cardiac surgical capacity in middle-income countries, even so, there is a wide gap between patients in need of intervention / surgery and those who actually receive it. In addition, the diversity of health care facilities in these countries has led to availability of state-of-the art facilities to a select few (affluent) with majority (poor and under-privileged) having to rely on the overwhelmed public hospitals. The situation in the low-income countries is even worse.

Starting and Operating a Public Cardiac Catheterization Laboratory in a Low Resource Setting: The Eight-Year Story of the Uganda Heart Institute Catheter Laboratory

Abstract
Background: Low- and-middle-income-countries (LMICs) currently bear 80% of the world’s cardiovascular disease (CVD) mortality burden. The same countries are underequipped to handle the disease burden due to critical shortage of resources. Functional cardiac catheterization laboratories (cath labs) are central in the diagnosis and management of CVDs. Yet, most LMICs, including Uganda, fall remarkably below the minimum recommended standards of cath lab:population ratio due to a host of factors including the start-up and recurring costs.

Objectives: To review the performance, challenges and solutions employed, lessons learned, and projections for the future for a single cath lab that has been serving the Ugandan population of 40 million people in the past eight years.

Methods: A retrospective review of the Uganda Heart Institute cath lab clinical database from 15 February 2012 to 31 December 2019 was performed.

Results: In the initial two years, this cath lab was dependent on skills transfer camps by visiting expert teams, but currently, Ugandan resident specialists independently operate this lab. 3,542 adult and pediatric procedures were conducted in 8 years, including coronary angiograms and percutaneous coronary interventions, device implantations, valvuloplasties, and cardiac defect closures, among others. There was a consistent expansion of the spectrum of procedures conducted in this cath lab each year. The initial lack of technical expertise and sourcing for equipment, as well as the continual need for sundries present(ed) major roadblocks. Government support and leveraging existing multi-level collaborations has provided a platform for several solutions. Sustainability of cath lab services remains a significant challenge especially in relation to the high cost of sundries and other consumables amidst a limited budget.

Conclusion: A practical example of how centers in LMIC can set up and sustain a public cardiac catheterization laboratory is presented. Government support, research, and training collaborations, if present, become invaluable leverage opportunities.

How do caregivers of children with congenital heart diseases access and navigate the healthcare system in Ethiopia?

Background
Surgery can correct congenital heart defects, but disease management in low- and middle-income countries can be challenging and complex due to a lack of referral system, financial resources, human resources, and infrastructure for surgical and post-operative care. This study investigates the experiences of caregivers of children with CHD accessing the health care system and pediatric cardiac surgery.

Methods
A qualitative study was conducted at a teaching hospital in Ethiopia. We conducted semi-structured interviews with 13 caregivers of 10 patients with CHD who underwent cardiac surgery. We additionally conducted chart reviews for triangulation and verification. Interviews were conducted in Amharic and then translated into English. Data were analyzed according to the principles of interpretive thematic analysis, informed by the candidacy framework.

Results
The following four observations emerged from the interviews: (a) most patients were diagnosed with CHD at birth if they were born at a health care facility, but for those born at home, CHD was discovered much later (b) many patients experienced misdiagnoses before seeking care at a large hospital, (c) after diagnosis, patients were waiting for the surgery for more than a year, (d) caregivers felt anxious and optimistic once they were able to schedule the surgical date. During the care-seeking journey, caregivers encountered financial constraints, struggled in a fragmented delivery system, and experienced poor service quality.

Conclusions
Delayed access to care was largely due to the lack of early CHD recognition and financial hardships, related to the inefficient and disorganized health care system. Fee waivers were available to assist low-income children in gaining access to health services or medications, but application information was not readily available. Indirect costs like long-distance travel contributed to this challenge. Overall, improvements must be made for district-level screening and the health care workforce.

Shared learning in and beyond the COVID-19 pandemic

The COVID-19 pandemic has cost the lives of over 1.5 million people to date and resulted in severe surgical backlogs up to tens of millions of surgeries worldwide [1]. Steinmaurer and Bley [2] appropriately question whether the transformability of cardiac surgery in high-income country epicentres of the COVID-19 pandemic can lead to changes elsewhere in the world. Six billion people lack access to safe, timely and affordable cardiac surgical care when needed, and this pandemic has only aggravated disparities in access to care [3, 4]. As countries have adapted and vaccines are on the horizon, it is paramount to think above and beyond what we have learned in our specialty during these challenging times and recognize the sustained disparities across the globe.

These disparities can be further explored by assessing service provision and workforce capacity in low- and middle-income countries (LMICs). This is especially prominent in low-income countries, where 0.04 cardiac surgeons are available per million population compared to 7.15 in high-income countries [4]. The loss of even 1 surgeon can lead to disastrous consequences in service provision. Now, travel restrictions imposed due to the pandemic have substantially increased these discrepancies. LMIC centres acting as regional hubs, often offering free or subsidized surgery, have experienced significant volume reductions while adapting to COVID-19 responses [4]. The pandemic also affected visiting teams, who have been unable to reach regions where local capacity is scant. These issues signpost the need for urgent solutions.

The pandemic has emphasized the importance of a global health view for cardiac surgery. Mutual learning can act as a vector for exponential change and improvement in meeting these disparities. George et al. [5] have described multiple strategies used in the New-York Presbyterian Hospital within their cardiac surgical service such as split ventilation and using additional operating room space for intensive care beds. Such innovations may be utilized to increase the long-term cardiac surgical capacity in LMICs in intensive care units, which can be rate-limiting factors when deciding to take on new patients. In addition, personal protective equipment may be preserved by reducing the number of personnel scrubbed in and switching between operations [5]. This was mirrored in Boston Children’s Hospital, where do-it-yourself elastomeric respirators were developed as a result of N95 shortages [6]. With such low-cost options being successfully incorporated into high-performance units, these examples highlight the importance of shared learning and its symbiotic relationship.

The COVID-19 era has facilitated change in clinical practice to reach a new normal, but with recent developments of imminent vaccine rollout, there is hope for resolving the challenges presented to us both in the short and long terms. With high-income countries dictating and dominating vaccine distribution, we can expect a significant hiatus before adequate herd immunity can be established in LMICs. As a result of these economic imbalances, cardiovascular care disparities will continue to pose a substantial burden. It is our moral responsibility to recognize the privileged position we inhabit and use the experiences from this pandemic to fuel shared learning and bilateral partnerships.