United in Earnest: First Pilot Sites for Increased Surgical Capacity for Rheumatic Heart Disease Announced by Cardiac Surgery Intersociety Alliance.

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.

United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance.

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.

United in earnest: first pilot sites for increased surgical capacity for rheumatic heart disease announced by cardiac surgery intersociety alliance.

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.

Screening for basal metabolic rate and visceral fat among postmenopausal osteoporosis with type 2 diabetes mellitus.

BACKGROUND: In people with type 2 diabetes mellitus, there is an increase in basal metabolic rate (BMR) which is associated with level of glycaemic control. Women with postmenopausal osteoporosis have decreased BMR. The aim of the present study is to find the BMR using Meffin-St Jeor predictive equation in women with type 2 diabetes mellitus (T2DM) who have attained menopause with osteoporosis. MATERIALS & METHODS: 100 women who have attained menopause, who were diagnosed to have osteoporosis with type 2 diabetes mellitus were assessed for BMR using Meffin-St Jeor predictive equation. Detailed history of diabetes and menopause were obtained. Blood glucose value was measured using standard glucometers. Body composition for visceral fat (VF) was measured using bioelectrical impedance analysis. Level of physical activity of the participants was measured using global physical activity questionnaire (GPAQ). RESULTS: The median BMR of the participants was 1.075 (714, 1483.25). Statistically significant correlation was found between BMR and GPAQ (rs = 0.731), BMR and VF (rs = 0.678). However BMR was not correlated with FBS (rs = 0.083) duration of diabetes (rs = -0.046). CONCLUSION: There is a decrease in BMR in women with T2DM with postmenopausal osteoporosis. BMR was significantly correlated with level of physical activity and visceral fat.

Photobiomodulation therapy in neuroischaemic diabetic foot ulcers: a novel method of limb salvage.

OBJECTIVE: Low-level laser therapy (also known as photobiomodulation therapy, PBMT) promotes accelerated healing of diabetic foot ulcers (DFUs), thereby preventing the risk of future complications and amputation. The aim of this study was to determine the effect of PBMT, with structured, graded mobilisation and foot care, on DFU healing dynamics. METHOD: Patients diagnosed with type 2 diabetes, diabetic peripheral neuropathy and presenting with a chronic neuroischaemic DFU, were treated with PBMT using scanning and non-contact probe methods. The DFU was clinically observed and the area measured every seven days until complete healing. Neuropathic parameters were also measured. The PBMT was administered until complete closure of the DFU and patients also undertook a programme of graded mobilisation. RESULTS: A total of 17 participants were recruited, with a mean age of 69±8 years, and a mean duration of diabetes of 13±5 years. Mean complete closure time was 26±11days. In addition, a mean reduction of the semi-quantitative vibration pressure threshold from 49±2 volts to 20±4 volts was observed in all participants. CONCLUSION: PBMT can be effectively used as a treatment mode for neuroischaemic DFUs in patients with type 2 diabetes. Graded mobilisation with focused foot care could improve the function of people living with type 2 diabetes with a chronic DFU.

Documentation of virulence and races of Xanthomonas citri pv. malvacearum in India and its correlation with genetic diversity revealed by repetitive elements (REP, ERIC, and BOX) and ISSR markers.

Thirty-four Xanthomonas citri pv. malvacearum (Xcm) isolates collected from three cotton-growing zones of India were subjected for virulence and race documentation and further correlated with genetic diversity as revealed by repetitive elements [repetitive extragenic palindromic (REP), enterobacterial repetitive intergenic consensus (ERIC) and BOX elements] and intersimple sequence repeat (ISSR)-PCR analyses. Among the 34 isolates tested for virulence on susceptible cultivar LRA 5166, 7 were recorded as highly virulent (HV), 16 were moderately virulent (MV) and 11 were less virulent (LV). Eight different races were recorded by using ten cotton host differentials. Twenty-two isolates (65%) belonged to race 18. Twelve isolates (35%) pertained to races 3, 5, 6, 7, 8, 11 and 13. REP, ERIC, BOX, combined repetitive elements, and ISSR analyses revealed the presence of 7, 10, 9, 11, and 8 clusters, respectively, at similarity coefficient of 0.70 in dendrograms. Principal coordinate analysis (PCoA) exhibited 76.4% and 77.5% cumulative variability for combined repetitive elements and ISSR analyses. ERIC produced the highest polymorphic information content (PIC) value (0.928). A lot of intra-pathovar variability was observed in virulence and genomic fingerprinting among Xcm isolates. Many of the isolates grouped based on geographical origin irrespective of virulence or race. The spread of the pathogen races in India might be due to the transport of germplasm lines and seed materials from one place to others.

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.

Large Eustachian valve: an incidental finding yet perplexing.

Eustachian valve (EV), a remnant of the right valve of sinus venosus in the right atrium can be puzzling. Often it is confused with Chiari network or atrial adhesions and is reported with unusual complications. We report a case of large EV impeding cannulation of inferior vena cava (IVC) during aortic valve replacement. Transesophageal echocardiography diagnosed the presence of large EV and warned of the difficulty with IVC cannulation and helped preparedness for an alternative plan during surgery.

Health care-associated native valve endocarditis: importance of non-nosocomial acquisition.

BACKGROUND: The clinical profile and outcome of nosocomial and non-nosocomial health care-associated native valve endocarditis are not well defined. OBJECTIVE: To compare the characteristics and outcomes of community-associated and nosocomial and non-nosocomial health care-associated native valve endocarditis. DESIGN: Prospective cohort study. SETTING: 61 hospitals in 28 countries. PATIENTS: Patients with definite native valve endocarditis and no history of injection drug use who were enrolled in the ICE-PCS (International Collaboration on Endocarditis Prospective Cohort Study) from June 2000 to August 2005. MEASUREMENTS: Clinical and echocardiographic findings, microbiology, complications, and mortality. RESULTS: Health care-associated native valve endocarditis was present in 557 (34%) of 1622 patients (303 with nosocomial infection [54%] and 254 with non-nosocomial infection [46%]). Staphylococcus aureus was the most common cause of health care-associated infection (nosocomial, 47%; non-nosocomial, 42%; P = 0.30); a high proportion of patients had methicillin-resistant S. aureus (nosocomial, 57%; non-nosocomial, 41%; P = 0.014). Fewer patients with health care-associated native valve endocarditis had cardiac surgery (41% vs. 51% of community-associated cases; P < 0.001), but more of the former patients died (25% vs. 13%; P < 0.001). Multivariable analysis confirmed greater mortality associated with health care-associated native valve endocarditis (incidence risk ratio, 1.28 [95% CI, 1.02 to 1.59]). LIMITATIONS: Patients were treated at hospitals with cardiac surgery programs. The results may not be generalizable to patients receiving care in other types of facilities or to those with prosthetic valves or past injection drug use. CONCLUSION: More than one third of cases of native valve endocarditis in non-injection drug users involve contact with health care, and non-nosocomial infection is common, especially in the United States. Clinicians should recognize that outpatients with extensive out-of-hospital health care contacts who develop endocarditis have clinical characteristics and outcomes similar to those of patients with nosocomial infection. PRIMARY FUNDING SOURCE: None.

Criterions for selection of patients for, and results of, a new technique for construction of the modified Blalock-Taussig shunt.

BACKGROUND: We describe alternative surgical techniques for construction of systemic-to-pulmonary arterial shunts, and propose criterions for their application in selected patients. PATIENTS AND METHODS: We constructed a variety of modified systemic-to-pulmonary arterial shunts, using polytetrafluoroethylene grafts, in 92 selected patients with cyanotic congenital heart disease and anomalies of the aortic arch and systemic veins. Their age ranged from 7 days to 3.6 years, with a mean of 7.08 months. We performed 88 operations through a thoracotomy. Of this cohort, 60 patients underwent a second-stage operation, with 15 receiving a superior cavopulmonary connection, 16 a total cavopulmonary connection, and 29 proceeding to biventricular repair after a mean interval of 15.6 months. We have 21 patients awaiting their second or final stage of palliation. RESULTS: There were five early (5.4%) and six late deaths (6.8%), two of which were related to construction of the shunts. At a mean follow-up of 45.29 months, the increase in diameter of pulmonary trunk and its right and left branches was uniform and significant (p value less than 0.001). Pulmonary arterial distortion requiring correction at the time of second-stage operation was observed in 5 patients (6.1%). Adequate overall palliation was achieved in 98% of the cohort at 8 months, 91% at 12 months, and 58% at 18 months. CONCLUSIONS: Patients with a right- or left-sided aortic arch and right-sided descending thoracic aorta, those with anomalies of systemic venous drainage masking the origin of great arterial branches, and those with disproportionately small subclavian arteries, constitute the ideal candidates for our suggested modification of the construction of a modified Blalock-Taussig shunt. The palliation provided by these shunts was satisfactory, with predictable growth of pulmonary arteries, insignificant distortion in the great majority, and easy take-down.

Noninvasive assessment of repaired tetralogy of Fallot by magnetic resonance imaging and dynamic radionuclide studies.

BACKGROUND: This study was designed to validate the diagnostic accuracy of magnetic resonance imaging (MRI) in evaluating biventricular ejection fraction and to quantify pulmonary regurgitant fraction (PRF) in patients after repair of tetralogy of Fallot. METHODS: Two hundred and eighty survivors of repaired tetralogy of Fallot aged 42 months to 40 years (mean, 142.2 +/- 85.3 months) underwent cardiac MRI, first-pass and gated radionuclide ventriculography (RNV) for the assessment of biventricular function, and PRF after 89.26 +/- 42.40 months. The receiver operating characteristic curve analysis was done to quantify the diagnostic accuracy of MRI. RESULTS: There was statistically significant agreement between MRI and RNV in evaluating right and left ventricular function. An MRI-derived right ventricular ejection fraction 47.2% or greater than normal was associated with a sensitivity of 92.3% and a specificity of 92.3%. An MRI-derived left ventricular ejection fraction 53.9% or greater than normal was associated with a sensitivity of 93.2% and a specificity of 93.3%. Area analysis indicated that 97.34% (standard error [SE] = 0.0118) and 98.56% (SE = 0.0052) of the time values of right and left ventricular ejection fraction were higher for patients with normal right and left ventricular functions, respectively, compared with abnormal. There was a strong agreement between velocity-encoded and stroke volume-derived PRF [(r = 0.886, p < 0.001; d = 2.62 +/- 1.12, p < 0.0001; r' = 0.121, p = 0.051; b = 0.96 (SE = 0.012); p < 0.0001; ICC = 0.98, p < 0.0001). Higher PRF was associated with increased indexed right ventricular dimensions and inversely correlated with biventricular ejection fractions. CONCLUSIONS: The MRI-derived ejection fraction values predictably separate patients with normal ventricular function from abnormal. Velocity-encoded MRI can accurately quantitate PRF in tetralogy of Fallot.