Treating Children With Advanced Rheumatic Heart Disease in Sub-Saharan Africa: The NGO EMERGENCY’s Project at the Salam Centre for Cardiac Surgery in Sudan

Rheumatic heart disease is endemic in Sub-Saharan Africa and while efforts are under way to boost prophylaxis and early diagnosis, access to cardiac surgery is rarely affordable. In this article, we report on a humanitarian project by the NGO EMERGENCY, to build and run the Salam Centre for Cardiac Surgery in Sudan. This hospital is a center of excellence offering free-of-charge, high-quality treatment to patients needing open-heart surgery for advanced rheumatic and congenital heart disease. Since it opened in 2007, more than 8,000 patients have undergone surgery there; most of them Sudanese, but ~20% were admitted from other countries, an example of inter-African cooperation. The program is not limited to surgical procedures. It guarantees long-term follow-up and anticoagulant treatment, where necessary. By way of example, we report clinical features and outcome data for the pediatric cohort: 1,318 children under the age of 15, operated on for advanced rheumatic heart disease between 2007 and 2019. The overall 5-year survival rate was 85.0% (95% CI 82.7–87.3). The outcomes for patients with mitral valves repaired and with mitral valves replaced are not statistically different. Nevertheless, observing the trend of patients undergoing valve repair, a better outcome for this category might be assumed. RHD in children is an indicator of poor socio-economic conditions and an inadequate health system, which clearly will not be cured by cardiac surgery alone. Nevertheless, the results achieved by EMERGENCY, with the crucial involvement and participation of the Sudanese government over the years, show that building a hospital, introducing free cardiac surgery, and offering long-term post-operative care may help spread belief in positive change in the future.

Quality of Life in Patients Undergoing Cardiac Surgery: Role of Coping Strategies

Adaptive coping strategies are used to reduce stress in patients undergoing cardiac surgery. These strategies have a major role in physical health, psychological health, quality of life and also affect an individual’s response to the disease. The current study was conducted to comprehend the impact of coping strategies on the quality of life of patients suffering from cardiac disease. A purposive convenient sampling method was used to collect data from different hospitals in South Punjab. We applied Carver’s Brief Coping Orientation to Problem Experienced (Brief COPE) inventory and the WHO quality of life scale. A cross-sectional research design was proposed for the study. The findings of the study showed that coping strategies and quality of life are associated with each other, and the use of emotion-focused and problem-focused coping strategies have a significant impact on patients experiencing cardiac surgery. Demographic details of patients also revealed the differences in both variables. Implications and future recommendations have also been discussed.

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.

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.

Treating Pediatric and Congenital Heart Disease Abroad? Imperatives for Local Health System Development

Over one million children are born with congenital heart defects each year, whereas four million children live with with rheumatic heart disease. Although a majority of these patients will eventually require surgical or interventional care, most live in areas without access to safe, timely, and affordable cardiac surgical care. Countries with limited or no local cardiac surgical care spend up to over 10% of their health budgets on sending patients abroad to receive cardiac care. Similarly, billions of dollars are spent each year on international medical tourism, notably including seeking cardiac surgical care abroad. Some low- and middle-income countries have successfully invested in domestic cardiac surgical services, saving tens of millions of dollars over time whilst strengthening local health systems. In this article, we describe international medical tourism for pediatric and congenital heart disease, and present an analysis on whether expenditure in seeking foreign care for cardiovascular patients is worth the cost in light of a neglect of investments in local cardiac services in countries with growing health systems.

Global Unmet Needs in Cardiac Surgery.

More than 6 billion people live outside industrialized countries and have insufficient access to cardiac surgery. Given the recently confirmed high prevailing mortality for rheumatic heart disease in many of these countries together with increasing numbers of patients needing interventions for lifestyle diseases due to an accelerating epidemiological transition, a significant need for cardiac surgery could be assumed. Yet, need estimates were largely based on extrapolated screening studies while true service levels remained unknown. A multi-author effort representing 16 high-, middle-, and low-income countries was undertaken to narrow the need assessment for cardiac surgery including rheumatic and lifestyle cardiac diseases as well as congenital heart disease on the basis of existing data deduction. Actual levels of cardiac surgery were determined in each of these countries on the basis of questionnaires, national databases, or annual reports of national societies. Need estimates range from 200 operations per million in low-income countries that are nonendemic for rheumatic heart disease to >1,000 operations per million in high-income countries representing the end of the epidemiological transition. Actually provided levels of cardiac surgery range from 0.5 per million in the assessed low- and lower-middle income countries (average 107 ± 113 per million; representing a population of 1.6 billion) to 500 in the upper-middle-income countries (average 270 ± 163 per million representing a population of 1.9 billion). By combining need estimates with the assessment of de facto provided levels of cardiac surgery, it emerged that a significant degree of underdelivery of often lifesaving open heart surgery does not only prevail in low-income countries but is also disturbingly high in middle-income countries.

Global Incidence and Outcomes of Adult Patients With Acute Kidney Injury After Cardiac Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVES:
To estimate the global incidence and outcomes of acute kidney injury (AKI) after cardiac surgery in adult patients.

DESIGN:
A systematic review and meta-analysis.

SETTING:
Cardiac surgery wards.

PARTICIPANTS:
Adult patients after cardiac surgery

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
The authors searched PubMed, Web of Science, Cochrane Library, OVID, and EMBASE databases for all articles on cardiac surgery patients published during 2004 to 2014. Meta-analyses were conducted to generate pooled incidence, mortality, ICU length of stay, and length of hospital stay. The authors also described the variations according to study design, criteria of AKI, surgical methods, countries, continents, and their economies. After a primary and secondary screen, 91 observational studies with 320,086 patients were identified. The pooled incidence rates of AKI were 22.3% (95% confidence interval [CI], 19.8 to 25.1) in total and 13.6%, 3.8%, and 2.7% at stages 1, 2, and 3, respectively, whereas 2.3% of patients received renal replacement therapy. The pooled short-term and long-term mortality were 10.7% and 30%, respectively, and increased along with the severity of stages. The pooled unadjusted odds ratio for short-term and long-term mortality in patients with AKI relative to patients without AKI was 0.144 (95% CI, 0.108 to 0.192, p<0.001) and 0.342 (95% CI 0.287-0.407, p<0.001), respectively. The pooled average ICU length of stay and length of hospital stay in the AKI group were 5.4 and 15 days, respectively, while they were 2.2 and 10.5 days in the no-AKI group.

CONCLUSIONS:
AKI is a great burden for patients undergoing cardiac surgery and can affect short-term and long-term prognoses of these patients.