Anticoagulation control among patients on vitamin K antagonists in nine countries in Sub-Saharan Africa.

Vitamin K antagonists (VKA) is the primary anticoagulant in most settings of Sub-Saharan Africa. Understanding the quality of anticoagulation services in the continent is vital in optimising the intended benefits. This study assessed the quality of anticoagulation and associated factors among VKA-treated patients in nine SSA countries. We conducted a retrospective cohort study of randomly selected patients on anticoagulation from 20 clinics in Botswana, the Democratic Republic of Congo, Ethiopia, Gambia, Ghana, Mozambique, Nigeria, Tanzania, and South Africa. Eligible participants were those on VKAs for at least three months and with at least four international normalised ratios (INR) results in 2019-2021. We report the proportion of INR values in the therapeutic range, time-in-therapeutic range (TTR) using the Rosendaal method, and the proportion of patients with TTR ≥ 65% (optimal anticoagulation). The mean age was 51.1(16.1) years, and 64.2% were women. The most common indications for VKA included venous thromboembolism (29.6%), prosthetic valves (26.7%) and atrial fibrillation/flutter (30.1%). We analysed 6743 INR tests from 1011 participants, and of these, 48.5% were sub-therapeutic, 34.1% therapeutic, and 17.4% were supratherapeutic relative to disease-specific reference ranges. TTR was calculated for 660 patients using 4927 INR measurements. The median (interquartile range [IQR]) TTR was 35.8(15.9,57.2) %. Optimal anticoagulation control was evident in 19.2% of participants, varying from 2.7% in Tanzania to 23.1% in Ethiopia. The proportion of patients with TTR ≥ 65% was 15,4% for prosthetic heart valves, 21.1% for venous thromboembolism and 23.7% for atrial fibrillation or flutter. Countries with universal health coverage had higher odds of optimal anticoagulation control (adjusted odds ratio (aOR) 1.79, 95% confidence interval [CI], 1.15- 2.81, p = 0.01). Patients on VKAs for different therapeutic indications in SSA had suboptimal TTR. Universal health coverage increased the odds of achieving TTR by 79%. The evidence calls for more intensive warfarin management strategies in SSA, including providing VKA services without out-of-pocket payments.

Pulmonary hemorrhage and associated risk factors among newborns admitted to a tertiary level neonatal unit in Botswana.

Introduction: Pulmonary hemorrhage (PH) is a life-threatening complication seen in very sick newborns with high morbidity and mortality. There is little data on the incidence, risk factors, and ultimate survival of newborns with pulmonary hemorrhage in sub-Saharan countries, where the healthcare provision and facility differ in many ways compared to high-income countries. Hence, this study aimed to determine the incidence, identify the risk factors, and describe the outcome of pulmonary hemorrhage in newborns in a low middle income country setting. Methods and materials: A cohort study with prospective data collection was conducted in a public, tertiary-level hospital in Botswana, the Princess Marina Hospital (PMH). All newborns admitted to the neonatal unit from 1 January 2020 to 31 December 2021 were included in the study. Data were collected using a checklist developed on the RedCap database (https//:ehealth.ub.ac.bw/redcap). The incidence rate of pulmonary hemorrhage was calculated as the number of newborns who had pulmonary hemorrhage per 1,000 newborns in the 2-year period. Group comparisons were made using X2 and Student's t-tests. Multivariate logistic regression was used to identify risk factors independently associated with pulmonary hemorrhage. Result: There were 1,350 newborns enrolled during the study period, of which 729 were male newborns (54%). The mean (SD) birth weight was 2,154(±997.5) g, and the gestational age was 34.3 (±4.7) weeks. In addition, 80% of the newborns were delivered in the same facility. The incidence of pulmonary hemorrhage was 54/1,350 {4% [95% CI (3%-5.2%)]} among the newborns admitted to the unit. The mortality rate in those diagnosed with pulmonary hemorrhage was 29/54 (53.7%). Multivariate logistic regression identified birth weight, anemia, sepsis, shock, disseminated intravascular coagulopathy (DIC), apnea of prematurity, neonatal encephalopathy, intraventricular hemorrhage, mechanical ventilation, and blood transfusion as risk factors independently associated with pulmonary hemorrhage. Conclusion: This cohort study identified a high incidence and mortality rate of pulmonary hemorrhage in newborns in PMH. Multiple risk factors, such as low birth weight, anemia, blood transfusion, apnea of prematurity, neonatal encephalopathy, intraventricular hemorrhage, sepsis, shock, DIC, and mechanical ventilation, were identified as independently associated risk factors for PH.

Vitamin K-dependent anticoagulant use and level of anticoagulation control in sub-Saharan Africa: protocol for a retrospective cohort study.

BACKGROUND: Given that vitamin K-dependent anticoagulants (VKAs) will continue to be the primary anticoagulant in Africa for a long time, understanding the quality of anticoagulation services in the continent is vital for optimising the intended benefits. Notably, a few small studies have assessed the quality of anticoagulation in sub-Saharan Africa (SSA) countries. This study will describe the current VKA use and anticoagulation control among patients in selected SSA countries. METHODS AND ANALYSIS: We plan to review the 2019 anticoagulation data of a cohort of 800 random patients from 19 selected clinics in Botswana, the Democratic Republic of Congo, Ethiopia, Gambia, Ghana, Mozambique, Nigeria, Tanzania and South Africa. We expect at least one participating site to enrol 100 participants in each country. Eligible participants will be those on VKAs for at least 3 months and with at least four international normalised ratio (INR) results. We will document the indications, type and duration of VKA use, sociodemographic factors, coexisting medical conditions, concurrent use of drugs that interact with warfarin and alcohol and tobacco products. The level of anticoagulation control will be determined by calculating the time-in-therapeutic range (TTR) using the Rosendaal and the Percent of INR in TTR methods. A TTR of less than 65% will define a suboptimal anticoagulation control. ETHICS AND DISSEMINATION: This study was approved by the Ministry of Health and Wellness Ethics Committee (HPDME13/8/1) in Botswana and local research ethics committees or institutional review boards of all participating sites. As the study collects data from existing records, sites applied for waivers of consent. We will disseminate research findings through peer-reviewed scientific publications.

Prevalence and Factors Associated with Microalbuminuria in Pediatric Patients with Type 1 Diabetes Mellitus at a Large Tertiary-Level Hospital in Botswana.

INTRODUCTION: Microalbuminuria is considered the earliest sign of diabetic nephropathy among patients with type 1 diabetes mellitus (T1DM). The prevalence of microalbuminuria among African children with T1DM is reported to be high, yet its prevalence and population-specific risk factors in Botswana are not known. AIM: This study aimed to determine the prevalence of microalbuminuria among children and young adults with T1DM in Botswana and identify factors associated with microalbuminuria in this population. METHODS: A retrospective cross-sectional study was conducted on 127 T1DM patients aged <24 years followed at a pediatric endocrinology clinic in Botswana from 2010 to 2017. Clinical, laboratory, and demographic data were collected using chart review and patient surveys. Descriptive statistics were reported as mean and standard deviation for continuous variables, and frequency and percentage for categorical variables. Prevalence of microalbuminuria was calculated as a simple proportion. Group comparison was done using two-sample independent t-test, X 2-test, or Fisher's exact test and logistic regression to assess for associations. Level of significance was set at p<0.05. RESULTS: There were a total of 71 (55.9%) females. The mean age was 18.7 (±5) years and mean duration of T1DM was 6.6 (±4.6) years. Most study participants were of African descent. The prevalence of microalbuminuria was 28.3%. Group comparison revealed gender (p= 0.040), duration of diabetes (p= 0.002), systolic blood pressure (p=0.003), baseline glycated hemoglobin (HbA1c) (p=0.009) and Tanner's stage (p=008) to be significantly associated with microalbuminuria. On binary logistic regression, only gender (p=0.039) and baseline HbA1c (p=0.039) were independently associated with the presences of microalbuminuria. CONCLUSION: This study identified a high prevalence of microalbuminuria among children and young adults with T1DM in Botswana and reaffirms the importance of early detection, glycemic control, and regular screening to prevent diabetic nephropathy.

Pediatric Spectrum of Allergic Diseases and Asthma in a Tertiary Level Hospital in Botswana: an Exploratory Retrospective Cross-Sectional Study.

PURPOSE: This study aims to describe the spectrum of allergic diseases of children and adolescents in a single allergy treatment centre in Botswana, over a period of 8 years. PATIENTS AND METHODS: A retrospective cross-sectional study was conducted using medical records of all patients aged 18 years or younger, seen at an allergy treatment centre in Botswana. Data were presented descriptively. Association between variables was explored by χ 2-test. RESULTS: Four hundred and seven patients with a mean age of 5.8 years (SD 4.4) at the time of presentation included 239 (58.7%) females and 365 (87.5%) black Africans. The most common diseases were asthma (n=249, 61.2%) followed by allergic rhinitis (AR) (n=232, 57.0%) and atopic dermatitis (AD) (n=165, 40.5%). One hundred and fifteen cases (46.2%) of asthmatic patients were skin prick test positive; sensitized to grass, moulds, dust mites and animal dander, in decreasing frequency, whereas those with allergic rhinitis (AR) and allergic conjunctivitis (AC) were sensitized to trees and all allergens identified in asthmatics. Concomitant asthma was diagnosed in 171 (73.7%) with AR, 71 (68.3%) with AC, 75 (45.5%) with AD and 42 (47.7%) with food allergy. The most common triggers for asthma exacerbations include upper respiratory tract infections, weather changes, and exposure to passive cigarette smoke. Paternal allergy and allergic disease in grandparents are predisposing factors for asthma (p=0.016 and p=0.001, respectively). Paternal allergy is also predisposed to AR (p=0.007), while maternal history of allergic disease was associated with AD (p=0.019). CONCLUSION: The most common chronic pediatric conditions seen in our allergic disease study were asthma, allergic rhinitis and atopic dermatitis with the most common triggers being viral upper respiratory tract infections, weather changes and exposure to cigarette smoke, all of which are modifiable risk factors. This exploratory study lays the foundation for future interventional studies that may be directed towards the spectrum of allergic diseases.

Clinical spectrum and prevalence of congenital heart disease in children in Botswana.

BACKGROUND: Reliable data on congenital heart disease (CHD) from diverse settings is important both for planning health systems in each country and to elucidate possible aetiologies of CHD in different settings. There is a lack of data on the clinical spectrum and prevalence of CHD in Botswana. The aim of this study was to describe the clinical spectrum and prevalence of CHD in Botswana. METHODS: This was a retrospective, descriptive, cross-sectional study of all children from birth to 15 years who had had an echocardiogram performed as an in- or out-patient at Princess Marina Hospital (PMH) between 1 January 2010 and 31 December 2012. RESULTS: Of 377 enrollees, 140 (40%) had normal echocardiographs, 170 (45%) had CHD, and 57 (15%) had an acquired lesion. In the CHD patients, median age was 0.9 years (Q1: 0.2, Q3: 4.1) and 85 (50%) were male. Ventricular septal defect (VSD) (29%), patent ductus arteriosus (18%), atrio-ventricular septal defect (AVSD) (10%) and tetralogy of Fallot (TOF) (6%) were the predominant pathologies. VSD was the most common acyanotic lesion and TOF the most common cyanotic lesion. The estimated prevalence of CHD was between 2.8 and 4.95 per 1 000 live births. CONCLUSIONS: The clinical spectrum of CHD in Botswana is similar to that observed in other African countries and in the Western world, with VSD the most common acyanotic lesion and TOF the most common cyanotic lesion. The prevalence of CHD was 2.8-4.95 per 1 000 live births, in keeping with other settings. This is the first study to describe CHD in Botswana, and it aimed to stimulate subsequent studies in this field.

Echocardiographic abnormalities in children and adolescents living with human immunodeficiency virus on highly active antiretroviral treatment.

BACKGROUND: The availability and use of highly active antiretroviral treatment (HAART) has turned human immunodeficiency virus (HIV) into a chronic disease, allowing patients to live much longer. OBJECTIVES: To report asymptomatic cardiac abnormalities in children and adolescents based on both conventional and tissue Doppler imaging (TDI) echocardiography. METHODS: One hundred and fifty-one patients on HAART were recruited. Demographic and clinical variables were collected through patient interviews and medical record reviews. Conventional echocardiography and TDI were performed on each patient. RESULTS: Mean age was 13.0 ± 3.2 (4.0-19.0) years. Eightythree patients (55%) were female. Age at diagnosis of HIV infection was 5.7 ± 3.3 years. Age at initiation of HAART was 7.34 ± 3.54 years, while duration of HAART was 59 ± 39.1 months. On conventional echocardiography, three cases of left ventricular (LV) systolic dysfunction, two of pulmonary hypertension and one of minimal pericardial effusion were identified. Calculation of myocardial mass index (MMI) revealed that 16 patients had abnormal values. Twenty-seven (17.9%) patients had evidence of LV diastolic dysfunction and 18 (11.9%) had right ventricular (RV) diastolic dysfunction. Nineteen (12.6%) patients had tricuspid annular systolic velocity of < 9.5 cm/s, indicating asymptomatic RV systolic dysfunction. CONCLUSIONS: While few patients had abnormalities such as reduced LV ejection fraction, pulmonary hypertension and minimal pericardial effusion detectable on conventional echocardiography, a larger proportion of patients had subtle abnormalities such as increased MMI, LV diastolic dysfunction on TDI, RV dysfunction and abnormal myocardial performance index. Such patients may need routine screening and cardiac follow up.

Radiation protection knowledge and practices in interventional cardiologists practicing in Africa: a cross sectional survey.

We conducted a survey of doctors working in the cardiac catheterisation laboratories in Africa on their knowledge, attitude and practice with respect to radiation protection. Of seventy-two respondents contacted, 61 (84.7%) completed the questionnaire. Twenty-eight, (45.9%) were younger than 45 years. Thirty-seven, (60.6%) had less than 10 years of experience in the laboratory. Only 28 (45.9%) had undertaken radiation protection training. Fifty-eight, (95.1%) consistently used lead aprons. Forty-seven, (77%) reported consistently using thyroid shields. Ten (16.4%) consistently used radiation protection eyeglasses, whilst 36 (59%) never used them. Thermoluminescent Dosimeter badges were consistently used in 23 (37.7%). Forty-two, (68.9%) reported having ceiling mounted lead/acrylic shields. Level of radiation exposure in the most recent one year was ≤2 mSv in 14, between 2 and 20 mSv in 8 and between 20 and 30 mSv in 2, whilst 33 did not know their dose readings. The use of basic radiation protection tools as well as the knowledge and measurement of radiation exposure among interventional cardiologists working in Africa is low. The unavailability of some of the protective tools and a knowledge gap in terms of radiation protection and monitoring of self-exposure were some of the reasons for suboptimal self-protection against ionising radiation among our respondents. We suggest that initiatives be taken by all stakeholders to train this group of medical professionals in basic radiation protection to avoid unnecessary exposure to themselves, co-workers and patients.

Factors associated with perioperative mortality in children and adolescents operated for tetralogy of Fallot: A sub-Saharan experience.

BACKGROUND: Patients with tetralogy of Fallot are now surviving to adulthood with timely surgical intervention. However, many patients in low-income countries have no access to surgical intervention. This paper reports the surgical access and perioperative mortality in a sub-Saharan center that was mainly dependent on visiting teams. METHODS: We reviewed records of patients operated from January 2009 to December 2014. We examined perioperative outcomes, primarily focusing on factors associated with perioperative mortality. RESULTS: During this period, 62 patients underwent surgery. Fifty-seven (91.9%) underwent primary repair, while 5 (6.5%) underwent palliative shunt surgery. Of the five patients with shunt surgery, four ultimately underwent total repair. Eight (12.9%) patients died during the perioperative period. Factors associated with perioperative mortality include repeated preoperative phlebotomy procedures (P < .001), repeated runs and long cardiopulmonary bypass time (P < .001), and aortic cross-clamp time (P < .001), narrow pulmonary artery (PA) valve annulus diameter (P = .022), narrow distal main PA diameter (P = .039), narrow left branch PA diameter (P = .049), and narrow right PA diameter (P = .039). Of these factors, cardiopulmonary bypass time/aortic cross-clamp time and pulmonary valve annulus diameter less than three SD were independently associated with perioperative mortality. CONCLUSION: In this series of consecutive patients operated by a variety of humanitarian surgical teams, cardiopulmonary bypass time/aortic cross-clamp time, and pulmonary valve annulus diameter less than three SD were independently associated with perioperative mortality risk. As some of these factors are modifiable, we suggest that they should be considered during patient selection and at the time of surgical intervention.

Diagnosis and Management of Acute Heart Failure in Sub-Saharan Africa.

PURPOSE OF REVIEW: Acute heart failure (AHF) is a common emergency presentation in Sub-Saharan Africa (SSA). In the current review, we present the most recent data on the epidemiology of AHF in SSA and discuss recommended approaches to management in resource-limited settings, with a particular focus on primary and secondary facilities (e.g., health centers and district hospitals), where these patients often present. RECENT FINDINGS: AHF in SSA is most often due to hypertension, cardiomyopathies, and rheumatic heart disease. The etiology of AHF may be different in rural as compared with urban settings. Diagnostic tools for AHF are often lacking in SSA, especially at the first-level facilities. Point-of-care ultrasound (POCUS) and biomarker tests, such as brain natriuretic peptide (BNP), offer promise in helping to mitigate diagnostic challenges. POCUS can also help distinguish among types of heart failure and prompt the correct treatment strategy. Many of the drugs and equipment commonly used to treat AHF in resource-rich settings are lacking in SSA. However, some adaptations of commonly available materials may provide temporary alternatives. The epidemiology of AHF in SSA differs from that of high-income settings. Management of AHF at the first-level facility in SSA is an important and understudied problem. Simplified diagnostic and treatment algorithms rooted in knowledge of the local epidemiology should be developed and tested as part of broader efforts to combat cardiovascular disease in SSA.

Factors associated with sub-optimal control of anticoagulation in patients with prosthetic heart valves taking oral anticoagulants in a sub-Saharan African setting.

BACKGROUND: Replacement of diseased valves reduces the morbidity and mortality rate associated with native valvular disease but comes at the expense of risking complications related to the implanted prosthetic device. Establishing the desired anticoagulation level in a sub-Saharan African setting may be a challenge. OBJECTIVES: This study was conducted to determine the challenges of maintaining a desired level of anticoagulation and factors associated with sub-optimal anticoagulation in patients with prosthetic heart valves on chronic anticoagulation. METHODS: We reviewed 73 patients who had undergone prosthetic valve replacement for chronic rheumatic valvular heart disease and were taking warfarin. The follow up ranged from one to 13 years. We studied international normalised ratio (INR) profiles of the patients for the six months preceding the study and defined optimal control as an INR of 2.5-3.5. We aimed to determine if there were factors associated with sub-optimal control of INR. RESULTS: Forty-two patients (57.5%) were female. Mean age of the participants was 21.5 ± 3.1 years (range 14-25 years). Warfarin was the anticoagulant in 55 (75.3%) of the patients and 18 (24.7%) were on combined warfarin and aspirin anticoagulation. Thirty-five (47.9%) patients had optimal control of their INR. Educational level of primary school or less, distance from follow-up medical facility of more than 300 km, quarterly or less-frequent check-up visit, and public health institution as a source of free warfarin supply were found to be significantly associated with sub-optimal control of INR. CONCLUSIONS: Educational level, distance from follow-up facility, number of follow-up visits and source of warfarin supply were found to be significantly associated with sub-optimal control of INR.

Percutaneous transmitral balloon commissurotomy using a single balloon with arteriovenous loop stabilisation: an alternative when there is no Inoue balloon.

BACKGROUND: The Inoue balloon technique is the standard technique for mitral valve balloon commissurotomy at this stage. However, the hardware for this technique is expensive and may not always be available in resource-limited settings. OBJECTIVE: This article reports our experience with percutaneous transmitral balloon commissurotomy using a single balloon (Nucleus) with arteriovenous loop stabilisation. METHOD: Eleven young patients, aged 12-26 years and weighing 23-48 kg, underwent transmitral balloon commissurotomy using the described technique at our centre from April to May 2014. RESULTS: Mean fluoroscopy time was 22.6 ± 6.4 min (18.5- 30.0). Mean transmitral gradient decreased from 24.1 ± 5.9 (16-35) to 6.6 ± 3.8 (3-14) mmHg, as measured on transoesophageal echocardiography. Mean mitral valve area increased from 0.69 ± 0.13 cm2 (range 0.5-0.9) before dilation to 1.44 ± 0.25 cm2 (1.1-1.9) after dilation (p < 0.001). Mean estimated pulmonary artery systolic pressure decreased from 110.0 ± 35 mmHg (75-170) before dilation to 28.0 ± 14.4 mmHg (range 10-60) after dilation. CONCLUSION: Our modified Nucleus balloon technique for mitral valve dilation in young patients with mitral stenosis is effective and safe. The technique differs from other over-the-wire techniques in that it avoids placing stiff wire in the left ventricle. It also offers better balloon stability and control owing to the arteriovenous loop. This technique may be easier for use by paediatric interventionists who might not be familiar with the Inoue balloon technique.

Hydatid cyst of the interventricular septum.

While cardiac involvement is not a common presentation in human echinococcosis, it may lead to life-threatening complications including cyst rupture; anaphylactic shock; tamponade; pulmonary, cerebral or peripheral arterial embolism; acute coronary syndrome; dysrhythmias; infection; ventricular or valvular dysfunction, as well as sudden death. Here we report a 9-year old girl who was diagnosed to have hydatid cyst of the interventricular septum four years after diagnosis and medical treatment of pulmonary hydatidosis. Presentation, management and follow-up of the patient is discussed.

Health-related quality of life of mothers of children with congenital heart disease in a sub-Saharan setting: cross-sectional comparative study.

BACKGROUND: While the Health Related Quality of Life of the children with congenital heart defects is primarily affected, caring for a child with birth defect has an impact on the family's quality of life as well. Understanding the level of quality of life of the parents, which is likely to vary in different cultural settings, beliefs and parental educational status may help to implement educational programs and other interventional measures that may improve the HRQOL of parents of such children. This cross-sectional comparative study reports the health-related quality of life of mothers of children with congenital heart diseases in a sub-Saharan setting. RESULTS: Mean age of the mothers in the study group was 32.2 ± 7.1 years where as that of the control group was 30.5 ± 6.5 years (p = .054). One hundred-four children had congenital cardiac lesions classified as mild to moderate while 31 patients had severe lesions. On average, mothers in the study group showed poor performance on the Short Form-36 (SF-36) with statistically significant differences on all sub-scales including general health perception, physical functioning, role physical, role emotional, social functioning, bodily pain, vitality and mental health. Severity of the congenital heart defect was not associated with statistically significant difference in the health-related quality of life of the mothers. CONCLUSIONS: Mothers of children with congenital heart disease in our study have significantly lower quality of life in all domains of SF-36 compared to the control group. Planning and devising a strategy to support these mothers may need to be part of management and clinical care of children with congenital heart diseases.

Spectrum of cardiovascular diseases in six main referral hospitals of Ethiopia.

BACKGROUND: The spectrum of cardiovascular diseases varies between and within countries, depending on the stage of epidemiological transition and risk factor profiles. Understanding this spectrum requires regional and national data for each region or country. This study was designed to determine the spectrum of cardiovascular diseases in six university hospitals in Ethiopia. METHODS: This is a cross-sectional study of the spectrum of cardiovascular diseases in six main referral/teaching hospitals located in different parts of the country. Consecutive patients visiting the follow-up cardiac clinics of these hospitals from 1 January to 30 June 2015 were included in the study. Data were collected on a pretested questionnaire. RESULTS: A total of 6275 patients (58.5% females) were included in the study. Nearly 61% of the patients were from urban areas. The median age was 33 years (IQR 14-55 years). Valvular heart disease was the most common diagnosis, accounting for 40.5% of the cases. Of 2541 patents with valvular heart disease, 2184 (86%) were cases of chronic rheumatic heart disease. CONCLUSION: Our study shows that chronic rheumatic valvular heart disease is the most common cardiovascular diagnosis among patients seen at cardiology clinics of six referral/teaching hospitals in the country, followed by congenital heart diseases. Hypertensive and ischaemic heart diseases also accounted for a significant proportion of the cases. Therefore, strategies directed towards primary and secondary prevention of acute rheumatic fever as well as prevention of risk factors for hypertension and ischaemic heart disease may need to be strengthened.

Humanitarian Cardiology and Cardiac Surgery in Sub-Saharan Africa: Can We Reshape the Model?

BACKGROUND: In recent decades, humanitarian cardiology and cardiac surgery have shifted toward sending short-term surgical and catheter missions to treat patients. Although this model has been shown to be effective in bringing cardiovascular care to the patients' environment, its effectiveness in creating sustainable service is questioned. This study reports the barriers to contribution of missions to effective skill transfer and possible improvements needed in the future, from the perspective of both the local and overseas teams. METHODS: We reviewed the mission-based activities in the Children's Heart Fund Cardiac Center in the past six years. We distributed questionnaires to the local surgeons and the lead surgeons of the overseas teams. RESULTS: Twenty-six missions visited the center 57 times. There were 371 operating days and 605 surgical procedures. Of the procedures performed, 498 were open-heart surgeries. Of the operations, 360 were congenital cases and 204 were rheumatic. Six local surgeons and 18 overseas surgeons responded. Both groups agree the current model of collaboration is not optimal for effective skill transfer. The local surgeons suggested deeper involvement of the universities, governmental institutions, defined training goals and time frame, and communication among the overseas teams themselves as remedies in the future. Majority of the overseas surgeons agree that networking and regular communication among the missions themselves are needed. Some reflected that it would be convenient if the local surgeons are trained by one or two frequently visiting surgeons in their early years and later exposed to multiple teams if needed. CONCLUSION: The current model of collaboration has brought cardiac care to patients having cardiac diseases. However, the model appears to be suboptimal for skill transfer. The model needs to be reshaped to achieve this complex goal.

Prevalence of rheumatic heart disease among school children in Ethiopia: A multisite echocardiography-based screening.

BACKGROUND: Auscultation-based surveys in Ethiopia conducted in the late 1990's reported a rural prevalence of 4.6/1000 and an urban prevalence of 6.4/1000 of rheumatic heart disease (RHD). With echo-based screening, we aimed to estimate the national prevalence of RHD in school children by taking school-based samples from six regions across the country using the 2012 World Heart Federation echocardiographic criteria. PATIENTS AND METHODS: We conducted a cross-sectional echocardiographic screening of RHD in school children aged 6-18years from 28 randomly selected primary and secondary schools found in six different geographic regions of Ethiopia. We used the standardized WHF echocardiographic criteria. RESULTS: A total of 3238 children (48.5% females) were screened. The mean age was 13.2±3.2years. Of these, 44 patients (1.4%) met the WHF criteria for definite RHD, while 15 (0.5%) met the criteria for borderline disease, yielding a prevalence of 19 [13.9-23.4, 95% CI] cases per 1000 school children between the ages of 6-18years. The majority of those who tested positive were girls (26/44). The prevalence was lowest in children aged 6-9years and otherwise uniformly distributed across ages 10-18years. Definite RHD involved the mitral valve in 42 subjects, 39 of whom had mitral regurgitation and 3 with mitral stenosis. The aortic valve was affected in 6 children. The ratio of definite to borderline cases was 2.9. CONCLUSION: This study demonstrated a consistent pattern of high prevalence of asymptomatic RHD with definite disease predominating over borderline involvement across six regions of Ethiopia.

Percutaneous recanalization of totally occluded coarctation of the aorta in children using Brockenbrough needle and covered stents.

Percutaneous treatment of totally occluded coarctation of the aorta has been reported predominantly in adults. The success and challenges of this procedure in children is reported in few patients. We report an outcome of percutaneous treatment of three children with completely occluded coarctation of the aorta. The age range was 9-14 years. All the patients had upper limb hypertension. One case had severe left ventricular dysfunction. In all cases, a pediatric Brockenbrough needle and a covered stent were implanted. Recanalization and implantation of a covered stent was successful in all patients. One of these patients developed transient postcoarctectomy syndrome. Percutaneous recanalization of totally occluded coarctation of the aorta using Brockenbrough needle and a covered stent in children is feasible and effective.

Percutaneous closure of patent arterial ducts in patients from high altitude: a sub-Saharan experience.

BACKGROUND: At high altitude, patent arterial ducts tend to be larger and associated with pulmonary hypertension. Patent ductus arteriosus device closure in this background could be challenging. OBJECTIVES: We report our experience with percutaneous closure of patent arterial ducts using a variety of devices in patients residing in a high altitude. PATIENTS AND METHODS: This is a retrospective review of the case records of 145 patients (age 9 months-20 years, mean 5.6 ± 3.9 years, and weight 7-54 kg, mean 17.7 ± 9.4) with duct sizes ranging between 2 and 21 mm, (mean, 5.8 ± 2.7) who underwent percutaneous closure of patent arterial ducts. One hundred thirty-six (93.8%) of the patients were from a geographic area of 2100-2800 m above sea level. RESULTS: Successful device closure was achieved in 143 cases. It was difficult to achieve device stability in two patients with expansile ducts. Therefore, they were treated surgically. The devices used were various types of duct occluder devices in 131 patients, while atrial and ventricular septal occluders were used in eight patients. For the group, mean systolic pulmonary artery (PA) pressure decreased from 47.0 ± 16.7 mmHg before occlusion to 29.0 ± 7.4 mmHg after occlusion (P ≤ 0.001)., mean diastolic PA pressure from 25.0 ± 10.9 mmHg to 14.8 ± 6.0 mmHg and the average mean PA pressure decreased from 35.9 ± 13.5 mmHg to 21.1 ± 6.5 mmHg. Complications (4.8%) included device and coil embolization, bleeding, and pulse loss. On follow-up (mean duration of 36.1 ± 12.1 months, range 12-62 months), 137 patients were in functional class 1, 3 had residual shunt, 2 had device migration and one patient had persisting pulse loss. CONCLUSIONS: Successful duct closure was achieved in the vast majority of patients, even though the ducts were larger and significant number of them had pulmonary hypertension in this high altitude group. There was a relatively higher incidence of residual shunts and device migration in this series, generally due to the nonavailability of optimal device and surgical support. Long-term follow-up is required before we can draw conclusions with regard to the sustainability of drop in PA pressures. Septal Occluder devices may be a possible alternative for large tubular or window-type ducts with severe pulmonary hypertension, where there may be concerns about the size and stability of duct occluder devices.