Evaluation of a Ten-Year Team-Based Collaborative Capacity-Building Program for Pediatric Cardiac Surgery in Uzbekistan: Lessons and Implications

Background:
Most children who have congenital heart disease in low- and middle-income countries (LMICs), including Uzbekistan, do not receive adequate and timely pediatric cardiac surgical care. To strengthen the surgical capacity of a local pediatric cardiac surgery team in Tashkent, Uzbekistan, the JW LEE Center for Global Medicine at Seoul National University College of Medicine has developed a team-based training program and has been collaboratively conducting surgeries and care in order to transfer on-site knowledge and skills from 2009 to 2019.

Objectives:
To evaluate the long-term effects of the collaborative program on the cardiac surgical capacity of medical staff (teamwork, surgical complexity, and patients’ pre-surgical weights) as well as changes in the lives of the patients and their families. To derive lessons and challenges for other pediatric cardiac surgical programs in LMICs.

Methods:
To assess the effects of this ten-year long program, a mixed-methods design was developed to examine the trend of surgical complexity measured by Risk Adjustment for Congenital Heart Surgery 1 score (RACHS-1) and patients’ pre-surgical weights via medical record review (surgical cases: n = 107) during the decade. Qualitative data was analyzed from in-depth interviews (n = 31) with Uzbek and Korean medical staff (n = 10; n = 4) and caregivers (n = 17).

Findings:
During the decade, the average RACHS-1 of the cases increased from 1.9 in 2010 to 2.78 in 2019. The average weight of patients decreased by 2.8 kg from 13 kg to 10.2 kg during the decade. Qualitative findings show that the surgical capacity, as well as attitudes toward patients and colleagues of the Uzbek medical staff, improved through the effective collaboration between the Uzbek and Korean teams. Changes in the lives of patients and their families were also found following successful surgery.

Conclusions:
Team-based training of the workforce in Uzbekistan was effective in improving the surgical skills, teamwork, and attitudes of medical staff, in addition, a positive impact on the life of patients and their families was demonstrated. It can be an effective solution to facilitate improvements in pediatric cardiovascular disease in LMICs if training is sustained over a long period.

Adult cardiac surgical cost variation around the world: Protocol for a systematic review

Introduction: Globally, over one million cardiac operations occur each year, whereas cardiac surgery is expensive and largely inaccessible without insurance or philanthropic support. Substantial cost variation has been reported within cardiac surgery in the United States and among non-cardiac surgical procedures globally, but little is known on the global procedural cost variation for common adult cardiac surgical procedures.

Objectives and significance: This review seeks to assess variation in procedural costs of coronary artery bypass grafting (CABG), mitral valve repair, mitral valve replacement, aortic valve repair, aortic valve replacement, and combined CABG-mitral or CABG-aortic valve procedures between and within countries. Results may give insights in the scope and drivers of cost variation around the world, posing cost reduction lessons. Results may further inform the potential of economies of scale in reducing procedural costs, benefiting patients, hospitals, governments, and insurers.

Methods and analysis: A systematic review will be performed using the EconLit, Embase, PubMed/MEDLINE, Web of Science, and WHO Global Index Medicus databases to identify articles published between January 1, 2000 and June 1, 2020. Studies describing procedural costs for CABG, mitral valve repair, mitral valve replacement, aortic valve repair, aortic valve replacement, and combined CABG-mitral or CABG-aortic valve procedures will be identified. Articles describing other types of cardiac surgery, concomitant aortic surgery, only describing costs related to non-surgical care, or with incomplete cost data will be excluded from the analysis. No exclusion will be based solely on article type or language. Identified costs will be converted to 2019 USD to account for local currency unit inflation and exchange fluctuations.

Ethics and dissemination: This study protocol has been prospectively registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols. This review requires no institutional review board approval. Results of this study will be summarized and disseminated in a peer-review journal.

Negative Pressure Wound Therapy in the Treatment of Surgical Site Infection in Cardiac Surgery

Objectives
To describe the relationship between epidemiological and clinical characteristics of postoperative cardiac surgery patients undergoing negative pressure wound therapy for the treatment of surgical site infection.
Methods
An observational, cross-sectional analytical study including a convenience sample consisting of medical records of patients undergoing sternal cardiac surgery with surgical site infection diagnosed in medical records treated by negative pressure wound therapy.
Results
Medical records of 117 patients, mainly submitted to myocardial revascularization surgery and with deep incisional surgical site infection (88; 75.2%). Negative pressure wound therapy was used on mean for 16 (±9.5) days/patient; 1.7% had complications associated with therapy and 53.8% had discomfort, especially pain (93.6%). The duration of therapy was related to the severity of SSI (p=0.010) and the number of exchanges performed (p=0.045).
Conclusions
Negative pressure wound therapy has few complications, but with discomfort to patients.

Considerations for Newborn Screening for Critical Congenital Heart Disease in Low- and Middle-Income Countries

We propose several considerations for implementation of critical congenital heart disease (CCHD) screening for low- and middle-income countries to assess health system readiness for countries that may not have all the downstream capacity needed for treatment of CCHD. The recommendations include: (1) assessment of secondary and tertiary level CHD health services, (2) assessment of birth delivery center processes and staff training needs, (3) data collection on implementation and quality surgical outcomes, (4) budgetary consideration, and (5) consideration of the CCHD screening service as part of the overall patient care continuum.

General Thoracic Surgery Services Across Asia During the 2020 COVID-19 Pandemic

The COVID-19 pandemic of 2020 posed an historic challenge to healthcare systems around the world. Besides mounting a massive response to the viral outbreak, healthcare systems needed to consider provision of clinical services to other patients in need. Surgical services for patients with thoracic disease were maintained to different degrees across various regions of Asia, ranging from significant reductions to near-normal service. Key determinants of robust thoracic surgery service provision included: preexisting plans for an epidemic response, aggressive early action to “flatten the curve”, ability to dedicate resources separately to COVID-19 and routine clinical services, prioritization of thoracic surgery, and the volume of COVID-19 cases in that region. The lessons learned can apply to other regions during this pandemic, and to the world, in preparation for the next one.

Incidence and Mortality Trend of Congenital Heart Disease at the Global, Regional, and National Level, 1990-2017

Congenital heart disease (CHD) is the most commonly diagnosed congenital disorder in newborns. The incidence and mortality of CHD vary worldwide. A detailed understanding of the global, regional, and national distribution of CHD is critical for CHD prevention.We collected the incidence and mortality data of CHD from the Global Burden of Disease study 2017 database. Average annual percentage change was applied to quantify the temporal trends of CHD incidence and mortality at the global, regional, and national level, 1990-2017. A sociodemographic index (SDI) was created for each location based on income per capita, educational attainment, and fertility.The incidence of CHD was relatively high in developing countries located in Africa and Asia, while low in most developed countries. Between 1990 and 2017, the CHD incidence rate remained stable at the global level, whereas increased in certain developed countries, such as Germany and France. The age-standardized mortality rate of CHD declined substantially over the last 3 decades, regardless of sex, age, and SDI region. The decline was more prominent in developed countries. We also detected a significant positive correlation between CHD incidence and CHD mortality in both 1990 and 2017, by SDI.The incidence of CHD remained stable over the last 3 decades, suggesting little improvement in CHD prevention strategies and highlighting the importance of etiological studies. The mortality of CHD decreased worldwide, albeit the greatly geographical heterogeneity. Developing countries located in Africa and Asia deserve more attention and priority in the global CHD prevention program.

Tuberculous Aortitis as a Rare Cause of Aortobronchial Fistula With Massive Haemoptysis: A Case Report

Background: Aortobronchial fistula is a rare condition, which is difficult to diagnose. It is fatal if misdiagnosed or not well treated. Massive haemoptysis is usually the first common symptom. Computed tomography angiogram (CTA) is the best non-invasive diagnostic modality. Treatment options include open repair procedure or Transthoracic Endovascular Aortic Repair (TEVAR) and resection of the destroyed lung tissue. The recurrent rate is high.

Case presentation: This report is a case of a 26-year-old African female patient who presented with massive haemoptysis. She had been treated for pulmonary tuberculosis two years before. The patient was diagnosed with retroviral disease and had been on treatment for two years. She underwent a 2-stage repair procedure. The initial treatment was TEVAR, which was followed by lung resection after two weeks. Both operations were uneventful. Histopathology analysis confirmed tuberculous aortitis as aetiology. The patient had been followed up for a year, with no recurrence.

Discussion: Aortobronchial is divided into primary and secondary subtypes. Primary aortobronchial fistula is commonly caused by inflammatory disease and atherosclerosis. Secondary aortobronchial fistula is a complication of surgery for thoracic aorta and congenital cardiac disease. Tuberculous fistula is an uncommon cause of aortobronchial fistula. Surgery for aortobronchial fistula should include controlling both aortic and pulmonary fistula sites. A healthy tissue or muscle flap should be used between the repaired sites to prevent refistulisation. Recurrence is common; hence, long-term follow up is important.

Conclusion: Early diagnosis and adequate treatment are important. A high index of suspicion is important for diagnosis, because the diagnosis is difficult.

Giant Mesenteric Cyst: Successful Management in Low-Resource Setting

Introduction: Mesenteric cysts are rare, generally benign intra-abdominal lesions with a wide range of presentation in terms of size, clinical presentation, etiology, radiological features, and pathological characteristics.

Presentation of case: We reported a case of giant mesenteric cyst in a 16-month-old girl successfully managed in a low-resource setting.

Discussion: This case is particularly important not only due to the rarity of the presented case, but also for the highlighted aspects from a public health point of view. We faced of the problem of a late stage disease and the lack of preoperative diagnosis due to cultural and economic reasons and the weaknesses of healthcare systems, as in the majority of low- and middle-income countries.

Conclusion: Despite all these limitation, this case illustrates that complex, rare diseases can also be managed successfully in a low-resource setting. It is mandatory to strengthen and improve the health system both in terms of equipment both in terms of public health policies in order to offer a better and more effective quality of care to patients also in low-income countries.

Epidemiology of surgical valvular heart diseases in a north african tertiary referral hospital

Introduction
The etiology of valvular heart disease (VHD) has changed dramatically in the last five decades. In the western world, the significant reduction of acute rheumatic fever and its sequelae, and the recognition of non-rheumatic causes of VHD induced the metamorphosis in the etiology of valvular disorders. The aim of this study was to assess the epidemiological profile of the patients undergoing valvular surgery in a north African center of cardiology.

Methods
A retrospective study involving the 246 last patients hospitalized in our department and proposed for valvular surgery from January 2012 to December 2017.

Results
The mean age was 57 years. One hundred twenty-one patients were male (49%). Before surgery mean LVEF is 60% ± 13. Ten percent of the patients were operated with (left ventricular dysfunction LVEF ≤ 40%). Arterial hypertension, diabetes mellitus and smoking are respectively present in 29, 7%, 21, 8% and 27, 7% of the patients. A history of rheumatic fever was present in 60, 8% of rheumatic valvular disease. The rheumatic etiology was the most important (50,5%). A preoperative coronary angiography was performed in 63,4% of the patients and coronary artery disease was associated to the valvular heart disease in 14,9%. Mitral valve replacement, aortic-valve replacement and double valve replacement were respectively performed in 38,7%, 35,4% and 18,7% of the cases. Bioprothesis were implanted in 5,29% of the cases. One eighth of the patients underwent coronary artery bypass graft in addition to the valvular surgery. In 16,8% of the cases it was a redo surgery.

Conclusion
Contemporary epidemiological data show a rise of the degenerative etiology and associated coronary artery disease. Surgery offers good results for patients with significant valvular heart disease. Valve replacement and repair are the main surgical options. Older patients and redo procedures are increasingly frequent.

Venoarterial extracorporeal membrane oxygenation in heart surgery post-operative pediatric patients: A retrospective study at Christus Muguerza Hospital, Monterrey, Mexico

Objectives:
Extracorporeal membrane oxygenation is a life support procedure developed to offer cardiorespiratory support when conventional therapies have failed. The purpose of this study is to describe the findings during the first years using venoarterial extracorporeal membrane oxygenation in pediatric patients after cardiovascular surgery at Christus Muguerza High Specialty Hospital in Monterrey, Mexico.

Methods:
This is a retrospective, observational, and descriptive study. The files of congenital heart surgery post-operative pediatric patients, who were treated with venoarterial extracorporeal membrane oxygenation from January 2013 to December 2015, were reviewed.

Results:
A total of 11 patients were reviewed, of which 7 (63.8%) were neonates and 4 (36.7%) were in pediatric age. The most common diagnoses were transposition of great vessels, pulmonary stenosis, and tetralogy of Fallot. Survival rate was 54.5% and average life span was 6.3 days; the main complications were sepsis (36.3%), acute renal failure (36.3%), and severe cerebral hemorrhage (9.1%). The main causes of death were multi-organ dysfunction syndrome (27.3%) and cerebral hemorrhage (18.2%).

Conclusion:
The mortality rates found are very similar to those found in a meta-analysis report published in 2013 and the main complication and causes of death are also very similar to the majority of extracorporeal membrane oxygenation reports for these kinds of patients. Although the results are encouraging, early sepsis detection, prevention of cerebral hemorrhage, and renal function monitoring must be improved.