Heart Surgery Practice in Sub Saharan Africa: Single Nigerian Institutional Midterm Results and Challenges
Affiliation(s)
Department of Surgery, Atlanta Medical Center, Atlanta, USA. Department of Surgery, Lagos State University Teaching Hospital, Lagos, Nigeria. Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria.
Department of Surgery, Atlanta Medical Center, Atlanta, USA. Department of Surgery, Lagos State University Teaching Hospital, Lagos, Nigeria. Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria.
ABSTRACT
Background: The majority of prospective cardiac surgical patients in sub Saharan Africa lack access to open heart surgery. We reviewed our midterm results to identify the obstacles to growth and challenges with sustainability. Methods: Records of patients undergoing heart surgery at LASUTH from December 2004 to March 2006 were retrospectively reviewed for clinical and outcome data. Results: Twenty four patients age 10-50, mean 28.0 +/? 10.49 years and 13 (54.2%) males underwent surgery. 12 (50.0%) patients had mechanical valve replacements, 11 (45.8%) closure of septal defects and 1 (4.2%) left atrial myxoma resection. Logistic euroscore for valve patients was 5.81 +/? 4.74 while observed mortality was 8.3% (1/12). Overall 30 days operative mortality was 8.3% (2/24) and major morbidity 4.2% (1/24). Patients with septal defects closure stopped clinic visits within a year. Valve patients follow up was complete in 90.1% with mean duration of 55.2 +/? 15.3 months. Late events occurred only in females with mitral valve replacements. The 5-year freedom from thromboembolism and bleeding was 74.0% and survival 82.0% in valve patients. Conclusion: Despite limited resources heart surgery can safely be performed with good outcomes by trained local personnel under supervision of visiting foreign teams until they are proficient to operate independently. Patients with less complex congenital defects have excellent postsurgical outcomes, while patients with rheumatic valve replacement are subject to ongoing valve related morbidity and mortality therefore require lifetime follow up. Choice of prosthetic valve for the mostly indigent and poorly educated population remains a challenge. We now prefer stented tissue valve despite its known limitations, in child bearing age females desirous of childbirth and others unlikely to comply with anticoagulation regimen. Barriers to sustainability include poor infrastructures, few skilled manpower, inadequate funding and restricted patient access due to inability to pay without third party insurance or government Medicaid.
Background: The majority of prospective cardiac surgical patients in sub Saharan Africa lack access to open heart surgery. We reviewed our midterm results to identify the obstacles to growth and challenges with sustainability. Methods: Records of patients undergoing heart surgery at LASUTH from December 2004 to March 2006 were retrospectively reviewed for clinical and outcome data. Results: Twenty four patients age 10-50, mean 28.0 +/? 10.49 years and 13 (54.2%) males underwent surgery. 12 (50.0%) patients had mechanical valve replacements, 11 (45.8%) closure of septal defects and 1 (4.2%) left atrial myxoma resection. Logistic euroscore for valve patients was 5.81 +/? 4.74 while observed mortality was 8.3% (1/12). Overall 30 days operative mortality was 8.3% (2/24) and major morbidity 4.2% (1/24). Patients with septal defects closure stopped clinic visits within a year. Valve patients follow up was complete in 90.1% with mean duration of 55.2 +/? 15.3 months. Late events occurred only in females with mitral valve replacements. The 5-year freedom from thromboembolism and bleeding was 74.0% and survival 82.0% in valve patients. Conclusion: Despite limited resources heart surgery can safely be performed with good outcomes by trained local personnel under supervision of visiting foreign teams until they are proficient to operate independently. Patients with less complex congenital defects have excellent postsurgical outcomes, while patients with rheumatic valve replacement are subject to ongoing valve related morbidity and mortality therefore require lifetime follow up. Choice of prosthetic valve for the mostly indigent and poorly educated population remains a challenge. We now prefer stented tissue valve despite its known limitations, in child bearing age females desirous of childbirth and others unlikely to comply with anticoagulation regimen. Barriers to sustainability include poor infrastructures, few skilled manpower, inadequate funding and restricted patient access due to inability to pay without third party insurance or government Medicaid.
Cite this paper
Nwiloh, J. , Oludara, M. and Adebola, P. (2014) Heart Surgery Practice in Sub Saharan Africa: Single Nigerian Institutional Midterm Results and Challenges. World Journal of Cardiovascular Surgery, 4, 35-41. doi: 10.4236/wjcs.2014.43006.
Nwiloh, J. , Oludara, M. and Adebola, P. (2014) Heart Surgery Practice in Sub Saharan Africa: Single Nigerian Institutional Midterm Results and Challenges. World Journal of Cardiovascular Surgery, 4, 35-41. doi: 10.4236/wjcs.2014.43006.
References
[1] Pezella, A. (2002) International Cardiac Surgery: A Global Perspective. Seminars in Thoracic and Cardiovascular Surgery, 14, 298-320. http://dx.doi.org/10.1053/stcs.2002.0140298 [2] Anyanwu, C., Ihenacho, H., Okoroma, E., et al. (1982) Initial Experience with Open Heart Surgery in Nigeria. Tropical Cardiology, 8, 123-127. [3] Eze, J. and Ezemba, N. (2007) Open Heart Surgery in Nigeria: Indication and Challenges. Texas Heart Institute Journal, 34, 8-10. [4] Metras, D., Ouezzin-Coulibaly, A., Ouattara, K., et al. (1983) Open Heart Surgery in Tropical Africa-Results and Peculiar Problems of the 1st 300 Cases of Extracorporeal Circulation Performed in Abidjan. La Presse Médicale, 12, 621-624. [5] Edwin, F., Sereboe, L., Tettey, M., et al. (2010) Experience from a Single Centre Concerning the Surgical Spectrum and Outcome of Adolescents and Adults with Congenitally Malformed Hearts in West Africa. Cardiology in the Young, 20, 159-164. http://dx.doi.org/10.1017/S1047951109990679 [6] WHO (2006) World Health Report: Working Together for Health.
http://www.who.int/whr/2006/whr06en.pdf [7] MacGowan, W. (1987) Surgical Manpower Worldwide. Bulletin of the American College of Surgeons, 72, 5-7, 9. [8] Turino, M. (2002) EACTS: Carrying the Torch. European Journal Cardio-Thoracic Surgery, 22, 857-869. [9] Edwin, F., Tettey, M., Aniteye, E., et al. (2011) The Development of Cardiac Surgery in West Africa—The Case of Ghana. The Pan African Medical Journal, 9, 15. [10] Williams, M.A. and Van Riet, S. (2006) The On-X Heart Valve: Mid-Term Results in a Poorly Anticoagulated Population. The Journal of Heart Valve Disease, 15, 80-86. [11] Ozgediz, D., Jamison, D., Cherian, M. and McQueen, K. (2008) The Burden of Surgical Conditions and Access to Surgical Care in Low and Middle Income Countries. Bulletin of World Health Organization, 86, 846-847.
[1] Pezella, A. (2002) International Cardiac Surgery: A Global Perspective. Seminars in Thoracic and Cardiovascular Surgery, 14, 298-320. http://dx.doi.org/10.1053/stcs.2002.0140298 [2] Anyanwu, C., Ihenacho, H., Okoroma, E., et al. (1982) Initial Experience with Open Heart Surgery in Nigeria. Tropical Cardiology, 8, 123-127. [3] Eze, J. and Ezemba, N. (2007) Open Heart Surgery in Nigeria: Indication and Challenges. Texas Heart Institute Journal, 34, 8-10. [4] Metras, D., Ouezzin-Coulibaly, A., Ouattara, K., et al. (1983) Open Heart Surgery in Tropical Africa-Results and Peculiar Problems of the 1st 300 Cases of Extracorporeal Circulation Performed in Abidjan. La Presse Médicale, 12, 621-624. [5] Edwin, F., Sereboe, L., Tettey, M., et al. (2010) Experience from a Single Centre Concerning the Surgical Spectrum and Outcome of Adolescents and Adults with Congenitally Malformed Hearts in West Africa. Cardiology in the Young, 20, 159-164. http://dx.doi.org/10.1017/S1047951109990679 [6] WHO (2006) World Health Report: Working Together for Health.
http://www.who.int/whr/2006/whr06en.pdf [7] MacGowan, W. (1987) Surgical Manpower Worldwide. Bulletin of the American College of Surgeons, 72, 5-7, 9. [8] Turino, M. (2002) EACTS: Carrying the Torch. European Journal Cardio-Thoracic Surgery, 22, 857-869. [9] Edwin, F., Tettey, M., Aniteye, E., et al. (2011) The Development of Cardiac Surgery in West Africa—The Case of Ghana. The Pan African Medical Journal, 9, 15. [10] Williams, M.A. and Van Riet, S. (2006) The On-X Heart Valve: Mid-Term Results in a Poorly Anticoagulated Population. The Journal of Heart Valve Disease, 15, 80-86. [11] Ozgediz, D., Jamison, D., Cherian, M. and McQueen, K. (2008) The Burden of Surgical Conditions and Access to Surgical Care in Low and Middle Income Countries. Bulletin of World Health Organization, 86, 846-847.