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.

Cardiac Surgery in Low- and Middle-Income Countries: A State-of-the-Art Review.

BACKGROUND: Six billion people in low- and middle-income countries (LMICs) lack timely or ready access to safe and affordable cardiac surgical care when needed, which remains a low priority on the global public health and global surgery agenda. Here, we report the results of a state-of-the-art review of cardiac surgical care in LMICs to highlight the important milestones and current progress as well as the challenges associated with the expansion of sustainable global cardiac surgery for those in need. METHODS: A literature review was performed searching the PubMed/MEDLINE and Google Scholar databases using a combination of cardiac surgery, global health, and LMIC keywords. The Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool was used to assess the global burden of disease related to cardiovascular surgical diseases. RESULTS: High-income countries are estimated to have more than 100 times as many cardiac surgeons per million population compared with low-income countries. There are more than 4000 cardiac centers worldwide, but less than 1 center per 10 million population in LMICs. Approximately 1.5 million cardiac operations are performed globally, of which a disproportionally low number are in LMICs. Despite the high costs associated with cardiac operations, recent data suggest the favorable cost-effectiveness thereof in LMICs. Opportunities arise to sustainably integrate cardiac surgery in holistic health systems strengthening interventions. CONCLUSIONS: Skepticism underlying the need, feasibility, and cost-effectiveness of cardiac surgery in LMICs prevails, but recent advances, successful case studies, and existing data illustrate the potential of expanding cardiac care globally.

Pediatric Cardiac Surgery in Low-and Middle-Income Countries: Present Status and Need for a Paradigm Shift.

In low and mid-income countries, there has been a 50% global decrease in the incidence of preventable deaths of children since 1990. However, the mortality from non-communicable diseases (NCD) such as congenital heart disease (CHD) has not changed. Of the estimated 1.3 million children born with CHD annually, over 90% do not have access to cardiac care. With the increasing fertility rates in sub-Saharan Africa, the health burden of CHD will increase as well. Over the last 30 years much has been achieved with short term cardiac medical missions. However, much remains to be done to provide long term solutions needed to achieve the sustainable development goal of reducing deaths of children <5 years of age. This review discusses the present status and the need for a paradigm shift to achieve long term sustainability.

History of Pulmonary Tuberculosis.

Tuberculosis (TB) parallels the history of human development from the Stone Age to the present. TB continues to be in the top 10 causes of global human mortality over that period. This article highlights the history of pulmonary TB from the onset of human existence to the present. Despite its long history, TB was slowly identified as a major cause of disease, and defined causation and significant treatment strategies advances over the past 150 years. TB remains a major challenge for definitive global prevention and cure. This article gives a brief overview of the history of TB.

Surgical aspects of pulmonary tuberculosis: an update.

Tuberculosis remains a major global medical challenge and concern. In the world's population of over 7.4 billion people, 8.6 million are estimated to be infected with Mycobacterium tuberculosis; another 2.2 billion have latent tuberculosis. There is an annual incidence of 16,000 new cases in the USA and 7-8 million new cases worldwide, of which 440,000 are multidrug-resistant or extensively multidrug-resistant, mainly in developing countries or emerging economies. According to the World Health Organization, the incidence of tuberculosis is 133 cases per 100,000 of the population; 3.3% new cases are drug resistant and 20% are already treated cases. Of the drug-resistant cases, 9.7% are extensively drug-resistant. The annual global mortality attributable to tuberculosis is over 1.3 million people. The association with HIV/AIDS in 430,000 people has compounded the global concern and challenge. This review presents the historical indications for surgical treatment of tuberculosis, reviews the current literature and clinical experience, and collates this into increased awareness and contemporary understanding of the indications and need for surgery in primary active tuberculosis, adjuvant surgical therapy for multidrug-resistant tuberculosis, and the complications of chronic tuberculosis sequelae or previous tuberculosis surgery.

Paediatric cardiac surgery in low-income and middle-income countries: a continuing challenge.

Despite advances in surgical and catheter-based treatment for congenital heart disease (CHD), there remain wide disparities across the globe. Ongoing international humanitarian and in-country programmes are working to address these issues with the ultimate goal to increase the quality and quantity of paediatric cardiac care, particularly in under-served regions of the world. This review aims to illustrate the reasons for these inequalities and suggests novel ways of improving access and sustainability of CHD programmes in low-income and middle-income countries.

Pediatric cardiac surgery in low- and middle-income countries or emerging economies: a continuing challenge.

A number of recent publications, addresses, seminars, and conferences have addressed the global backlog and increasing incidence of both congenital and acquired cardiac diseases in children, with reference to early and delayed recognition, late referral, availability of and access to services, costs, risks, databases, and early and long-term results and follow-up. A variety of proposals, recommendations, and projects have been outlined and documented. The ultimate goal of these endeavors is to increase the quality and quantity of pediatric cardiac care and surgery worldwide and particularly in underserved areas. A contemporary review of past and present initiatives is presented with a subsequent focus on the more challenging areas.

Impact of perioperative glycemic control strategy on patient survival after coronary bypass surgery.

BACKGROUND: Glycemic control in the perioperative period decreases mortality and morbidity, but data are scarce with regard to the effects of glucose control approaches on survival. We assessed long-term survival in patients treated with 2 strategies of glucose control after first-time isolated coronary artery bypass graft. METHODS: In a previously published trial, patients were prospectively randomized to strict (90-120 mg/dL) or liberal (121-180 mg/dL) glucose control protocols. The aim of this study was to assess long-term data on survival and health-related quality of life based on the original prospective randomized study population. RESULTS: No differences were found in cumulative survival between the strict (95.5%) and liberal (93.5%) target range groups (log-rank = 0.32, p = 0.57) over a mean follow-up of 40.0 ± 4.4 months. Physical health-related quality of life significantly improved in all patients from baseline to 6 months after surgery (F = 17.73, p < 0.001), and there were no differences in improvement of health-related quality of life between the 2 target range groups (F = 0.15, p = 0.70). CONCLUSIONS: These results support our previous findings and indicate that a liberal glycemic control strategy after coronary artery bypass leads to survival rates and improvements in health-related quality of life that are similar to those achieved with a strict target range. In addition, the liberal strategy is superior in glucose control and target range management.

Cruciate Fenestration in Ventricular Septal Defect Patch for High-Risk Patients With High Pulmonary Vascular Resistance.

Late presentation of patients with large ventricular septal defect (VSD) and elevated pulmonary vascular resistance (PVR) is not uncommon in developing countries. Surgical VSD closure in these patients carries risks of persistent pulmonary hypertension, right ventricular failure, and mortality. Several techniques for creation of valved patches or fenestrated patches have been developed to address these issues. We have successfully used a simple and easily reproducible technique in which a cruciate fenestration is created in the patch used for VSD closure.

Blunt traumatic left atrial appendage rupture and cardiac herniation.

A 42-year-old man sustained blunt thoracic trauma after a motor vehicle accident. He underwent an urgent operation. Operative findings included a large hematoma, a 4-cm tear in the left atrial appendage, and a long pleuropericardial rupture along the right phrenic nerve. We repaired the left atrial appendage without cardiopulmonary bypass, and closed the pericardial defect primarily. The patient recovered fully and was discharged on the 6th postoperative day.

Hybrid stage I palliation for hypo-plastic left heart condition without a hybrid suite: suggestions for developing nations.

Cardiac hybrid procedures are performed in modern, spacious, and highly equipped hybrid suites in developed countries. Organizing such expensive suites in countries with an emerging economy is difficult from both a financial and logistics point of view. We share our experience of safely performing a Hybrid stage I palliation procedure for Aortic atresia with ventricular septal defect on a 2-month-old infant weighing 3.35 kg using minimal resources in a conventional catheterization laboratory.

Global aspects of cardiothoracic surgery with focus on developing countries.

The incidence and prevalence of cardiothoracic disease continue to increase globally, especially in emerging economies and developing countries. Cardiothoracic surgery is also growing despite limited access, availability of surgical centers, political and cost issues. The increase in atherosclerotic coronary artery disease, rheumatic heart disease, congenital heart disease, trauma, and thoracic malignancies is a more urgent problem than realized in these emerging economies and developing countries, or low- and middle-income countries. A determined focus and cooperation between the preventive and curative elements of care is warranted. This represents a paradigm shift to develop a consensus that fosters a multi-integrated disease-specific approach that includes prevention, promotion, diagnosis, treatment, and rehabilitation. In addition, the concept or acceptance of surgery as a necessary component of public health policy is critical to improving overall global healthcare.