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BACKGROUND: Current data on cardiac surgery capacity on which to base effective concepts for developing sustainable cardiac surgical programs in Africa are lacking or of low quality. METHODS: A questionnaire concerning cardiac surgery in Africa was sent to 29 colleagues-26 cardiac surgeons and 3 cardiologists in 16 countries. Further, data on numbers of surgeons practicing in Africa were retrieved from the Cardiothoracic Surgery Network (CTSNet). RESULTS: There were 25 respondents, yielding a response rate of 86.2%. Three models emerged: the Ghanaian/German model with a senior local consultant surgeon (Model 1); surgeons visiting for a short period to perform humanitarian surgery (Model 2); and expatriate surgeons on contract to develop cardiac programs (Model 3). The 933 cardiothoracic surgeons listed by CTSNet translated into one surgeon per 1.3 million people. In North Africa, the figure was three surgeons per 1 million and in sub-Saharan Africa (SSA), one surgeon per 3.3 million people. The identified 156 cardiac surgeons represented a surgeon to population ratio of 1:5.9 million people. In SSA, the ratio was one surgeon per 14.3 million. In North Africa, it was one surgeon per 1.1 million people. Open heart operations were approximately 12 per million in Africa, 2 per million in SSA, and 92 per million people in North Africa. CONCLUSION: Cardiothoracic health care delivery would worsen in SSA without the support of humanitarian surgery. Although all three models have potential for success, the Ghanaian/German model has proved to be successful in the long term and could inspire health care policy makers and senior colleagues planning to establish cardiac programs in Africa.
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Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , África del Sur del Sahara/epidemiología , África del Norte/epidemiología , Procedimientos Quirúrgicos Cardíacos/normas , Encuestas de Atención de la Salud , Política de Salud , Humanos , Desarrollo de Programa , Estudios RetrospectivosRESUMEN
OBJECTIVE: To determine maternal and fetal outcomes in postoperative women with rheumatic heart disease who become pregnant after valve surgery and evaluate current anticoagulation management during pregnancy. METHODS: Data from the Rwandan rheumatic heart disease cardiac surgical registry identified all female patients who underwent valve surgery before or during childbearing age since 2006. In total, 136 participants completed a mixed-methods questionnaire detailing each pregnancy after surgery, including anticoagulation regimen and outcomes. RESULTS: We found that 38.2% (n = 136) of patients reported at least 1 pregnancy after surgery, of which more than one half were unintentional (53.9%, n = 52). Among those patients with mechanical valves, most remained on warfarin alone during pregnancy (58.5%, n = 53) whereas one third were switched to low molecular weight heparin during the first, second, or third trimesters (5 vs 4 vs 7, n = 18). Women with bioprosthetic valve replacement or valve repair were more likely to experience live term births (84.6% vs 45.3%, P < .01) and less likely to report spontaneous abortion (3.9% vs 30.2%, P < .01) compared with women with mechanical valve replacement. Excessive bleeding was the most common complication during pregnancy (9.1%, n = 79), and 2 infants were diagnosed with congenital defects associated with warfarin embryopathy (4.8%, n = 42). CONCLUSIONS: Despite preoperative counseling discouraging conception, many women with prosthetic valves still become pregnant after surgery. The results of this study will inform evidence-based and context-specific practices for anticoagulation during pregnancy in Rwanda and the region.
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Background: More than 5 billion people lack access to surgical care, disproportionately in low- and middle-income countries. The emerging literature demonstrates high interest in global surgery across specialties; however, participation in global cardiothoracic surgical care remains low. To date, there has been no research quantifying the attitudes of cardiothoracic surgeons about global surgery. Our study aimed to acquire a broader understanding of cardiothoracic surgical trainees' interest in global surgery to address barriers and promote cardiac healthcare worldwide. Methods: An online survey was sent to all North American cardiothoracic surgical residents via the Thoracic Surgery Residents Association email listserv. The survey was designed in the REDCap database and administered twice, in 2021 and 2022. Data were analyzed by descriptive and chi-square analysis using Stata. Results: Seventy-three cardiothoracic surgical trainees responded to our survey, of whom 95.3% considered increasing cardiothoracic surgical access to be important, and 67.2% identified this as a future career priority. Most respondents (82.8%) would participate in global surgery if opportunities were available through their home institution. Lack of opportunities (70.0%) and finances (66.7%) were the primary barriers to participation. Respondents identified funding (85%) and institutional support (83.3%) as the most significant incentives to increase involvement. Conclusions: There is strong interest in global surgery among cardiothoracic trainees; however, involvement remains low. A consensus among the North American cardiothoracic surgical community is needed to address barriers to global volunteerism within surgical residency and improve access to cardiac surgery worldwide.
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The global burden of paediatric and congenital heart disease (PCHD) is substantial. We propose a novel public health framework with recommendations for developing effective and safe PCHD services in low-income and middle-income countries (LMICs). This framework was created by the Global Initiative for Children's Surgery Cardiac Surgery working group in collaboration with a group of international rexperts in providing paediatric and congenital cardiac care to patients with CHD and rheumatic heart disease (RHD) in LMICs. Effective and safe PCHD care is inaccessible to many, and there is no consensus on the best approaches to provide meaningful access in resource-limited settings, where it is often needed the most. Considering the high inequity in access to care for CHD and RHD, we aimed to create an actionable framework for health practitioners, policy makers and patients that supports treatment and prevention. It was formulated based on rigorous evaluation of available guidelines and standards of care and builds on a consensus process about the competencies needed at each step of the care continuum. We recommend a tier-based framework for PCHD care integrated within existing health systems. Each level of care is expected to meet minimum benchmarks and ensure high-quality and family centred care. We propose that cardiac surgery capabilities should only be developed at the more advanced levels on hospitals that have an established foundation of cardiology and cardiac surgery services, including screening, diagnostics, inpatient and outpatient care, postoperative care and cardiac catheterisation. This approach requires a quality control system and close collaboration between the different levels of care to facilitate the journey and care of every child with heart disease. This effort was designed to guide readers and leaders in taking action, strengthening capacity, evaluating impact, advancing policy and engaging in partnerships to guide facilities providing PCHD care in LMICs.
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Países en Desarrollo , Cardiopatías Congénitas , Humanos , Niño , Salud Pública , Cardiopatías Congénitas/cirugía , Sistema de Registros , Continuidad de la Atención al PacienteRESUMEN
This paper explores the role and place of national, regional, and international society collaborations in addressing the major global burden of rheumatic heart disease (RHD). On the same order of HIV, RHD affects over 40 million people worldwide. In this article, we will outline the background and current therapeutic landscape for cardiac surgery in low- and middle-income countries (LMICs) including the resource-constrained settings within which RHD surgery often occurs. This creates numerous challenges to delivering adequate surgical care and post-operative management for RHD patients, and thus provides some context for a growing movement for and applicability of structural heart approaches, innovative valve replacement technologies, and minimally invasive techniques in this setting. Intertwined and building from this context will be the remainder of the paper which elaborates how national, regional, and international societies have collaborated to address rheumatic heart disease in the past (e.g., Drakensberg Declaration, World Heart Federation Working Group on RHD) with a focus on primary and secondary prevention. We then provide the recent history and context of the growing movement for how surgery has become front and center in the discussion of addressing RHD through the passing of the Cape Town Declaration.
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BACKGROUND: Rheumatic heart disease (RHD) affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration On Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for RHD patients. METHODS: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites. RESULTS: The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care, and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda). CONCLUSIONS: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for RHD patients.
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Cardiología , Países en Desarrollo , Accesibilidad a los Servicios de Salud , Cooperación Internacional , Cardiopatía Reumática/cirugía , Sociedades Médicas/organización & administración , Procedimientos Quirúrgicos Cardíacos , Humanos , Cardiopatía Reumática/epidemiología , SudáfricaRESUMEN
BACKGROUND: Rheumatic heart disease (RHD) affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration On Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for RHD patients. METHODS: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites. RESULTS: The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care, and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda). CONCLUSIONS: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for RHD patients.
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Creación de Capacidad/organización & administración , Cardiopatía Reumática/cirugía , Cirugía Torácica/organización & administración , Humanos , Mozambique , RwandaRESUMEN
BACKGROUND: Rheumatic heart disease affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for rheumatic heart disease patients. METHODS: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance was formed, the purpose of this article is to describe the history of the Cardiac Surgery Intersociety Alliance, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites. RESULTS: The Cardiac Surgery Intersociety Alliance is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for Cardiac Surgery Intersociety Alliance support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda). CONCLUSIONS: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the Cardiac Surgery Intersociety Alliance, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for rheumatic heart disease patients.
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Procedimientos Quirúrgicos Cardíacos , Cardiopatía Reumática , Cirugía Torácica , Humanos , Cardiopatía Reumática/diagnóstico , Cardiopatía Reumática/cirugía , Rwanda , SudáfricaRESUMEN
OBJECTIVES: Rheumatic heart disease (RHD) affects >33 000 000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World was published in August 2018, signalling the commitment of the global cardiac surgery and cardiology communities to improving care for patients with RHD. METHODS: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities and future directions, including the announcement of selected pilot sites. RESULTS: The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment and publication of selection criteria for cardiac surgery centres to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care and desire to engage in future research. Eleven applications were received for which 3 finalist sites were selected and site visits conducted. The 2 selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda). CONCLUSIONS: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry and government-will be necessary to improve access to life-saving cardiac surgery for patients with RHD.
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Procedimientos Quirúrgicos Cardíacos , Cardiopatía Reumática , Accesibilidad a los Servicios de Salud , Humanos , Rwanda , SudáfricaRESUMEN
BACKGROUND: Open heart surgery is commonly associated with cardiopulmonary bypass and cardioplegic arrest. The attendant risks of cardiopulmonary bypass may be prohibitive in high-risk patients. We present a novel endoscopic technique of performing tricuspid valve repair without cardiopulmonary bypass in a beating ovine heart. METHODS: Six sheep underwent sternotomy and creation of a right heart shunt to eliminate right atrial and right ventricular blood for clear visualization. The superior vena cava, inferior vena cava, pulmonary artery, and coronary sinus were cannulated, and the blood flow from these vessels was shunted into the pulmonary artery via a roller pump. The posterior leaflet of the tricuspid valve was partially excised to create tricuspid regurgitation, which was confirmed by Doppler echocardiography. A 7.0-mm fiberoptic videoscope was inserted into the right atrium to visualize the tricuspid valve. Under cardioscopic vision, an endoscopic needle driver was inserted into the right atrium, and a concentric stitch was placed along the posterior annulus to bicuspidize the tricuspid valve. Doppler echocardiography confirmed reduction of tricuspid regurgitation. RESULTS: All animals successfully underwent and tolerated the surgical procedure. The right heart shunt generated a bloodless field, facilitating cardioscopic tricuspid valve visualization. The endoscopic stitch resulted in annular plication and functional tricuspid valve bicuspidization, significantly reducing the degree of tricuspid regurgitation. CONCLUSION: Cardioscopy enables less invasive, beating-heart tricuspid valve surgery in an ovine model. This technique may be useful in performing right heart surgery without cardiopulmonary bypass in high-risk patients.
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Endoscopía Capsular/métodos , Procedimientos Quirúrgicos Cardiovasculares/métodos , Procedimientos de Cirugía Plástica/métodos , Válvula Tricúspide/cirugía , Animales , OvinosRESUMEN
OBJECTIVE: Minimal access cardiac valve surgery is increasingly utilized. We report our 11-year experience with minimally invasive aortic valve surgery. METHODS: From 07/96 to 12/06, 1005 patients underwent minimally invasive aortic valve surgery. Early and late outcomes were analyzed. RESULTS: Median patient age was 68 years (range: 24-95), 179 patients (18%) were 80 years or older, 130 patients (13%) had reoperative aortic valve surgery, 86 (8.4%) had aortic root replacement, 62 (6.1%) had concomitant ascending aortic replacement, and 26 (2.6%) had percutaneous coronary intervention on the day of surgery (hybrid procedure). Operative mortality was 1.9% (19/1005). The incidences of deep sternal wound infection, pneumonia and reoperation for bleeding were 0.5% (5/1005), 1.3% (13/1005) and 2.4% (25/1005), respectively. Median length of stay was 6 days and 733 patients (72%) were discharged home. Actuarial survival was 91% at 5 years and 88% at 10 years. In the subgroup of the elderly (> or =80 years), operative mortality was 1.7% (3/179), median length of stay was 8 days and 66 patients (37%) were discharged home. Actuarial survival at 5 years was 84%. There was a significant decreasing trend in cardiopulmonary bypass time, the incidence of bleeding, and operative mortality over time. CONCLUSIONS: Minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement, and reoperative surgery can be performed with these approaches. These procedures are particularly well-tolerated in the elderly.
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Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/normas , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Factibilidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas/rehabilitación , Implantación de Prótesis de Válvulas Cardíacas/tendencias , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/rehabilitación , Procedimientos Quirúrgicos Mínimamente Invasivos/normas , Procedimientos Quirúrgicos Mínimamente Invasivos/tendencias , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Academic global surgery is a nascent field focused on improving surgical care in resource-poor settings through a broad-based scholarship agenda. Although there is increasing momentum to expand training opportunities in low-resource settings among academic surgical programs, most focus solely on establishing short-term elective rotations rather than fostering research or career development. Given the complex nature of surgical care delivery and programmatic capacity building in the resource-poor settings, many challenges remain before global surgery is accepted as an academic discipline and an established career path. Brigham and Women's Hospital has established a specialized global surgery track within the general surgery residency program to develop academic leaders in this growing area of need and opportunity. Here we describe our experience with the design and development of the program followed by practical applications and lessons learned from our early experiences.
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Cirugía General/educación , Salud Global/educación , Internado y Residencia , Modelos Educacionales , Haití , Cooperación Internacional , Massachusetts , RwandaRESUMEN
We report a case of a 71-year-old man with a mycotic aneurysm of the aortic arch who presented with progressive hoarseness. Three weeks prior to this event the patient was admitted to an outside hospital in septic condition and was diagnosed with a mycotic abdominal aortic aneurysm. Resection of the infected abdominal aortic aneurysm with right axillofemoral and femoral-femoral bypass grafts was performed and the patient was discharged home on intravenous antibiotics. At our institution, the aortic arch aneurysm was treated with extensive debridement and replaced with a Dacron prosthesis under circulatory arrest with antegrade cerebral perfusion through the axillofemoral bypass.
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Aneurisma Infectado/complicaciones , Aneurisma de la Aorta Torácica/complicaciones , Parálisis de los Pliegues Vocales/etiología , Anciano , Aneurisma Infectado/diagnóstico , Aneurisma de la Aorta Torácica/diagnóstico , Aortografía , Diagnóstico Diferencial , Humanos , Masculino , Tomografía Computarizada por Rayos X , Parálisis de los Pliegues Vocales/diagnósticoRESUMEN
Left atrial-esophageal fistula (LAEF) is a rare complication of radiofrequency ablation (RFA) procedures undertaken for atrial fibrillation (AF). This complication is associated with significant morbidity and mortality. Currently, there is no clear consensus on the appropriate management strategy. We report a case of a LAEF that developed in a patient 2 weeks after RFA for medication refractory AF. The patient underwent successful repair of the fistula through a left posterolateral thoracotomy, wherein the esophageal and atrial lesions were repaired primarily with an intercostal muscle flap and bovine pericardial patch to reinforce and prevent recurrence.
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Functional mitral regurgitation (MR) is a common clinical entity which will likely increase in the future due to predicted demographic changes. It is also associated with poor long-term survival. The anatomic structure of the mitral valve apparatus is complex and consists of several components, each of which can be affected by a variety of diseases resulting in MR. In primary MR, the valvular incompetence is caused by compromised or structurally disrupted components of the valve apparatus; the valve in functional MR is structurally normal, with the regurgitation resulting from failure of coaptation of the mitral valve leaflets without coexisting structural changes of the valve itself. Therefore, we defined functional MR as a systolic retrograde flow from the left ventricle into the left atrium due to reduction and/or elimination of the normal systolic coaptation of the mitral valve leaflets. A slow progression of the symptoms is typical for this valve disease and often ends in irreversible left ventricular dysfunction. The pathophysiology and treatment of functional MR are quite complex. This article reviews and summarizes the existing literature, with a focus on the pathophysiology and current treatment of functional MR.
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Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral/patología , Válvula Mitral/patología , Cateterismo Cardíaco , Progresión de la Enfermedad , Humanos , Anuloplastia de la Válvula Mitral , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/epidemiología , Pronóstico , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: Current ventricular restraint devices do not allow for either the measurement or adjustment of ventricular restraint level. Periodic adjustment of restraint level post-device implantation may improve therapeutic efficacy. We evaluated the feasibility of an adjustable quantitative ventricular restraint (QVR) technique utilizing a fluid-filled polyurethane epicardial balloon to measure and adjust restraint level post-implantation guided by physiologic parameters. METHODS: QVR balloons were implanted in nine ovine with post-infarction dilated heart failure. Restraint level was defined by the maximum restraint pressure applied by the balloon to the epicardium at end-diastole. An access line connected the balloon lumen to a subcutaneous portacath to allow percutaneous access. Restraint level was adjusted while left ventricular (LV) end-diastolic volume (EDV) and cardiac output was assessed with simultaneous transthoracic echocardiography. RESULTS: All nine ovine successfully underwent QVR balloon implantation. Post-implantation, restraint level could be measured percutaneously in real-time and dynamically adjusted by instillation and withdrawal of fluid from the balloon lumen. Using simultaneous echocardiography, restraint level could be adjusted based on LV EDV and cardiac output. After QVR therapy for 21 days, LV EDV decreased from 133+/-15 ml to 113+/-17 ml (p<0.05). CONCLUSION: QVR permits real-time measurement and physiologic adjustment of ventricular restraint therapy after device implantation.