Inpatient costs of congenital heart surgery in China: Results from the National Centre for Cardiovascular Diseases

Economic data on congenital heart disease (CHD) in China are scarce. Therefore, this study aimed to explore the inpatient costs of congenital heart surgery and related healthcare policies from a hospital perspective.

We used data from the Chinese Database for Congenital Heart Surgery (CDCHS) to prospectively analyse the inpatient costs of congenital heart surgery from May 2018 to December 2020. The total expenditure was divided into 11 columns (medications, imaging, consumable items, surgery, medical cares, laboratory tests, therapy, examinations, medical services, accommodations, and others), and explored according to the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category, year, different age group, and CHD complexity. Authority economic data (index for gross domestic product [GDP], GDP per capita, per capita disposable income and average annual exchange rate of 2020 Chinese Yuan against US dollar) were accessed via the National Bureau of Statistics of China to better describe the burden. In addition, potential factors contributing to the costs were also investigated by using generalised linear model.

All values are presented in 2020 Chinese Yuan (¥). A total of 6568 hospitalisations were enrolled. The median of overall total expenditure was ¥64,900 (≈9409 US Dollar [USD], interquartile range [IQR]: ¥35,819), with the lowest in STAT 1 (¥57,014 ≈ 8266 USD, [IQR]: ¥16,774) and the highest in STAT 5 (¥194,862 ≈ 28,251 USD, [IQR]: ¥130,010). The median costs during the 2018 to 2020 period were ¥62,014 (≈8991 USD, [IQR]: ¥32,628), ¥64,846 (≈9401 USD, [IQR]: ¥34,469) and ¥67,867 (≈9839 USD, [IQR]: ¥41,496). Regarding to age, the median costs were highest in the ≤1 month group (¥144,380 ≈ 20,932 USD, [IQR]: ¥92,584). Age, STAT category, emergency, genetic syndrome, delay sternal closure, mechanical ventilation time, and complications were significantly contributed to the inpatient costs.

For the first time, the inpatient costs of congenital heart surgery in China are delineated in detail. According to the results, CHD treatment has achieved significant progress in China, but it still causes substantial economic burden to both families and society. In addition, ascending trend of the inpatient costs was observed during the period of 2018–2020, and the neonatal was revealed to be the most challenging group.

This study was supported by the CAMS Innovation Fund for Medical Sciences (CIFMS,2020-I2M-C&T-A-009), Capital Health Research and Development of Special Fund (2022-1-4032), and The City University of Hong Kong New Research Initiatives/Infrastructure Support from Central (APRC, 9610589).

Retrospective analysis: checkpoint inhibitor accessibility for thoracic and head and neck cancers and factors influencing it in a tertiary centre in India

Background: Access to cancer care is an issue in low and low middle-income countries. The problem is worse with respect to access to new therapies like checkpoint inhibitors. Hence, we decided to audit our practice in the head and neck and thoracic medical oncology unit from 2015 to 2019 to study the accessibility of checkpoint inhibitors and factors influencing it.

Methods: All patients who were registered in the head and neck and thoracic medical oncology unit between 2015 and 2019 were included in the study. Patients who received immunotherapy were identified from the prospective database of immunotherapy maintained by the department. We made a list of patients who were eligible for immunotherapy per year and identified how many of them received recommended immunotherapy. The indication for eligibility of immunotherapy was based on published pivotal data and it was applicable from the date of publication of the study online. Descriptive statistics were performed. For nominal and ordinal variable percentage with 95% confidence intervals (95% CI) was provided. Factors impacting the accessibility of immunotherapy were identified.

Findings: A total of 15,674 patients were identified who required immunotherapy; out of them only 444 (2.83%, 95% CI: 2.58–3.1) received it. Among head and neck cancer patients, 4.5% (156 out of 3,435) received immunotherapy versus 2.35% (288 out of 12,239) among thoracic cancer patients (p < 0.001). Among the general category (low socioeconomic), 0.29% (28 out of 9,405 ) versus 6.6% (416 out of 6,269) among the private category (high socioeconomic) received immunotherapy (p < 0.001). While 3.7% (361 out of 9,737) among males versus 1.39% (83 out of 5,937) females received immunotherapy (p < 0.001). There was also a temporal trend seen in the accessibility of immunotherapy (p < 0.001). Conclusion: The accessibility of immunotherapy is below 3% in India. Patients with head and neck cancers, those registered as private category and male patients had higher access to this therapy. There was also a temporal trend observed suggesting increased accessibility over the years.

Chest trauma epidemiology and emergency department management in a tertiary teaching hospital in Kigali, Rwanda

Chest trauma is a major contributor to injury morbidity and mortality, and understanding trends is a crucial part of addressing this burden in low- and middle-income countries. This study reports the characteristics and emergency department (ED) management of chest trauma patients presenting to Rwanda’s national teaching hospital in Kigali.

This descriptive analysis included a convenience sample of patients presenting to a single tertiary hospital ED with chest trauma from June to December 2017. Demographic data were collected as well as injury mechanism, thoracic and associated injuries, types of imaging obtained, and treatments performed. Chart review was conducted seven days post-admission to follow up on outcomes and additional diagnoses and interventions. Incidences were calculated with Microsoft Excel.

Among the 62 patients included in this study, 74% were male, and mean age was 35 years. Most patients were injured in road traffic crashes (RTCs) (68%). Common chest injuries included lung contusions (79% of cases), rib fractures (44%), and pneumothoraces (37%). Head trauma was a frequent concurrent extra-thoracic injury (61%). Diagnostic imaging primarily included E-FAST ultrasound (92%) and chest x-ray (98%). The most common therapies included painkillers (100%), intravenous fluids (89%), and non-invasive oxygen (63%), while 29% underwent invasive intervention in the form of thoracostomy. The majority of patients were admitted (81%). Pneumonia was the most common complication to occur in the first seven days (32% of admitted patients). Ultimately, 40% of patients were discharged home within seven days of presentation, 50% remained hospitalized, and 5% died.

This study on the epidemiology of chest trauma in Rwanda can guide injury prevention and medical training priorities. Efforts should target prevention in young males and those involved in RTCs. ED physicians in Rwanda need to be prepared to diagnose and treat a variety of chest injuries with invasive and noninvasive means.

Efficacy of extended focused assessment with sonography for trauma using a portable handheld device for detecting hemothorax in a low resource setting; a multicenter longitudinal study


Chest trauma is one of the most important and commonest injuries that require timely diagnosis, accounting for 25-50% of trauma related deaths globally. Although CT scan is the gold standard for detection of haemothorax, it is only useful in stable patients, and remains unavailable in most hospitals in low income countries. Where available, it is very expensive. Sonography has been reported to have high accuracy and sensitivity in trauma diagnosis but is rarely used in trauma patients in low income settings in part due to lack of the sonography machines and lack of expertise among trauma care providers. Chest X-ray is the most available investigation for chest injuries in low income countries. However it is not often safe to wheel seriously injured, unstable trauma patients to X-ray rooms. This study aimed at determining the efficacy of extended Focused Assessment with Sonography for Trauma (eFAST) in detection of haemothorax using thoracostomy findings as surrogate gold standard in a low resource setting.


This was an observational longitudinal study that enrolled 104 study participants with chest trauma. Informed consent was obtained from all participants. A questionnaire was administered and eFAST, chest X-ray and tube thoracotomy were done as indicated. Data were analysed using SPSS version 22. The sensitivity, specificity, predictive values, accuracy and area under the curve were determined using thoracostomy findings as the gold standard. Ethical approval for the study was obtained from the Research and Ethics Committee of Kampala International University Western Campus REC number KIU-2021-53.


eFAST was found to be superior to chest X-ray with sensitivity of 96.1% versus 45.1% respectively. The accuracy was also higher for eFAST (96.4% versus 49.1%) but the specificity was the same at 100.0%. The area under the curve was higher for eFAST (0.980,P=0.001 versus 0.725, p=0.136). Combining eFAST and X-ray increased both sensitivity and accuracy.


This study revealed that eFAST was more sensitive at detecting haemothorax among chest trauma patients compared to chest X-ray. All patients presenting with chest trauma should have bedside eFAST for diagnosis of haemothorax.

A New Dawn for Brazilian Pediatric Cardiac Surgery Is on the Way — Issues Around and Outside the Operating Room

In some developing countries, congenital heart disease still stands out among the leading causes of death in the first year of life. Therefore, there is a great need to develop programs designed to improve outcomes in the diagnosis and surgical treatment of congenital heart disease in these nations, where children have always been and still are severely underserved.
The Brazilian Public Health Care System demands universal access to treatment as a constitutional right. Therefore, an underfunded Pediatric Cardiac Surgery program is unacceptable since it will cost lives and increase the infant mortality rate. Additionally, poor funding decreases providers’ interest, impedes technological advances and multidisciplinary engagement, and reduces access to comprehensive care.
Unfortunately, in most developing countries, Pediatric Cardiac Surgery progress is still the result of isolated personal efforts, dedication, and individual resilience. This article aims to present the current state of Brazilian pediatric cardiac surgery and discuss the structural and human limitations in developing a quality care system for children with congenital heart disease. Considering such constraints, quality improvement programs via International collaboration with centers of excellence, based on proper data collection and outcomes analysis, have been introduced in the country. Such initiatives should bring a new dawn to Brazilian Pediatric Cardiac Surgery

Design and Rationale of the National Tunisian Registry of Percutaneous Coronary Intervention: Protocol for a Prospective Multicenter Observational Study

Coronary artery diseases remain the leading cause of death in the world. The management of this condition has improved remarkably in the recent years owing to the development of new technical tools and multicentric registries.

The aim of this study is to investigate the in-hospital and 1-year clinical outcomes of patients treated with percutaneous coronary intervention (PCI) in Tunisia.

We will conduct a prospective multicentric observational study with patients older than 18 years who underwent PCI between January 31, 2020 and June 30, 2020. The primary end point is the occurrence of a major adverse cardiovascular event, defined as cardiovascular death, myocardial infarction, cerebrovascular accident, or target vessel revascularization with either repeat PCI or coronary artery bypass grafting (CABG). The secondary end points are procedural success rate, stent thrombosis, and the rate of redo PCI/CABG for in-stent restenosis.

In this study, the demographic profile and the general risk profile of Tunisian patients who underwent PCI and their end points will be analyzed. The complexity level of the procedures and the left main occlusion, bifurcation occlusion, and chronic total occlusion PCI will be analyzed, and immediate as well as long-term results will be determined. The National Tunisian Registry of PCI (NATURE-PCI) will be the first national multicentric registry of angioplasty in Africa. For this study, the institutional ethical committee approval was obtained (0223/2020). This trial consists of 97 cardiologists and 2498 patients who have undergone PCI with a 1-year follow-up period. Twenty-eight catheterization laboratories from both public (15 laboratories) and private (13 laboratories) sectors will enroll patients after receiving informed consent. Of the 2498 patients, 1897 (75.9%) are managed in the public sector and 601 (24.1%) are managed in the private sector. The COVID-19 pandemic started in Tunisia in March 2020; 719 patients (31.9%) were included before the COVID-19 pandemic and 1779 (60.1%) during the pandemic. The inclusion of patients has been finished, and we expect to publish the results by the end of 2022.

This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of PCI in this limited-income region.

Trial Registration: NCT04219761;

International Registered Report Identifier (IRRID):

The microeconomic impact of out-of-pocket medical expenditure on the households of cardiovascular disease patients in general and specialized heart hospitals in Ibadan, Nigeria

Cardiovascular diseases (CVDs) present a huge threat to population health and in addition impose severe economic burden on individuals and their households. Despite this, there is no research evidence on the microeconomic impact of CVDs in Nigeria. Therefore, this study estimated the incidence and intensity of catastrophic health expenditures (CHE), poverty headcount due to out-of-pocket (OOP) medical spending and the associated factors among the households of a cohort of CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan, Nigeria.

This study adopts a descriptive cross-sectional study design. A standardized data collection questionnaire developed by the Initiative for Cardiovascular Health Research in Developing Countries was adapted to electronically collect data from all the 744 CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan between 4th November 2019 to the 31st January 2020. A sensitivity analysis, using rank-dependent thresholds of CHE which ranged from 5%-40% of household total expenditures was carried out. The international poverty line of $1.90/day recommended by the World Bank was utilized to ascertain poverty headcounts pre-and post OOP payments for healthcare services. Categorical variables like household socio-demographic and clinical characteristics, CHE and poverty headcounts, were presented using percentages and proportions. Unadjusted and adjusted logistic regression models were used to assess the factors associated with CHE and poverty. Data were analyzed using STATA version 15 and estimates were validated at 5% level of significance.

Catastrophic OOP payment ranged between 3.9%-54.6% and catastrophic overshoot ranged from 1.8% to 12.6%. Health expenditures doubled poverty headcount among households, from 8.13% to 16.4%. Having tertiary education (AOR: 0.49, CI: 0.26–0.93, p = 0.03) and household size (AOR: 0.40, CI: 0.24–0.67, p = 0.001) were significantly associated with CHE. Being female (AOR: 0.41, CI: 0.18–0.92, p = 0.03), household economic status (AOR: 0.003, CI: 0.0003–0.25, p = <0.001) and having 3–4 household members (AOR: 0.30, CI: 0.15–0.61, p = 0.001) were significantly associated with household poverty status post payment for medical services.

OOP medical spending due to CVDs imposed enormous strain on household resources and increased the poverty rates among households. Policies and interventions that supports universal health coverage are highly recommended.

Right-sided Weakness in a Rwandan Patient with Unrepaired Tetralogy of Fallot


Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease encountered in pediatrics. Long-term survival after surgical repair has improved; however, reported mortality rates in unrepaired TOF are significant. Associated complications include neurological sequelae, most frequently brain abscess and stroke. In countries without early intervention for congenital heart disease including TOF, delayed presentations and complications require recognition by healthcare workers.

Case presentation

A 22 year old male with a history of unrepaired TOF presented to Rwanda’s tertiary university hospital, University Teaching Hospital of Kigali (CHUK) with acute right-sided hemiparesis. Diagnostic imaging identified a left-sided brain lesion consistent with brain abscess and cardiac mass concerning for an endocardial vegetation. He was managed with intravenous antibiotics, but subsequently died due to complications of septicemia.


In countries where surgical repair of TOF is not available, early recognition and medical management are key in temporizing the development of devastating sequelae. Describing the prevalence of CHD in Rwanda is urgent, requiring further research by which effective prevention and treatment strategies can be developed.

Chronic rheumatic heart disease with recrudescence of acute rheumatic fever on histology: a case report

Rheumatic heart disease (RHD) is endemic in sub-Saharan Africa where it is the leading cause of cardiovascular mortality in the young. Rheumatic heart disease results from recurrent episodes of acute rheumatic fever (ARF), which are often difficult to diagnose clinically. Acute rheumatic fever may be diagnosed based on the revised Jones Criteria 2015 for the diagnosis of ARF. Histologically, acute rheumatic valvulitis manifests with active inflammation characterized by lymphocytic infiltration, Aschoff bodies, and Anitschkow cells. Chronic rheumatic valvulitis is associated with neovascularization, and/or dystrophic calcification. The combination of histological features of both ARF and chronic RHD is a rare finding.

Case summary
Here we report on a case of a 59-year-old woman with mixed aortic and mitral valve disease of probable rheumatic aetiology (elevated C-reactive protein and prolonged PR interval) and with histological evidence of lymphocytic infiltration, Aschoff bodies, and fibrinoid necrosis admixed with features of chronic RHD.

Cases of chronic RHD admixed with ARF are very rare; however, they should be considered in regions with a high prevalence of RHDs.

Rheumatic heart disease prevalence in Namibia: a retrospective review of surveillance registers

Rheumatic heart disease (RHD) is the most commonly acquired heart disease in children and young people in low and middle-income settings. Fragile health systems and scarcity of data persist to limit the understanding of the relative burden of this disease. The aims of this study were to estimate the prevalence of RHD and to assess the RHD-related health care systems in Namibia.

Data was retrieved from outpatient and inpatient registers for all patients diagnosed and treated for RHD between January 2010 to December 2020. We used descriptive statistics to estimate the prevalence of RHD. Key observations and engagement with local cardiac clinicians and patients helped to identify key areas of improvement in the systems.

The outpatient register covered 0.032% of the adult Namibian population and combined with the cumulative incidence from the inpatient register we predict the prevalence of clinically diagnosed RHD to be between 0.05% and 0.10% in Namibia. Young people (< 18 years old) are most affected (72%), and most cases are from the north-eastern regions. Mitral heart valve impairment (58%) was the most common among patients. We identified weaknesses in care systems i.e., lack of patient unique identifiers, missing data, and clinic-based prevention activities.

The prevalence of RHD is expected to be lower than previously reported. It will be valuable to investigate latent RHD and patient follow-ups for better estimates of the true burden of disease. Surveillance systems needs improvements to enhance data quality. Plans for expansions of the clinic-based interventions must adopt the “Awareness Surveillance Advocacy Prevention” framework supported by relevant resolutions by the WHO.