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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 14-19

Early results of open-heart surgery for acquired heart diseases in Ibadan, Nigeria


1 Department of Surgery, Division of Cardiothoracic and Vascular Surgery, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
2 Department of Anaesthesia, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria

Date of Web Publication7-May-2018

Correspondence Address:
Dr. Mudasiru Abedayo Salami
Department of Surgery, College of Medicine, University College Hospital, University of Ibadan, P. O. Box 29225, Secretariat Post Office, Ibadan 200212
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njc.njc_25_17

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  Abstract 


Background: Cardiovascular disease burden is disproportionately high in Sub-Saharan Africa (SSA) where resources to provide optimum care for cardiothoracic patients are still very limited. Previous reports of open-heart surgery from new centers in SSA have shown a preponderance of valvular heart disease in published series, with wide variations in reported morbidity and mortality.
Objectives: We report on a series of patients who underwent open-heart surgery for acquired heart diseases to demonstrate pattern of disease, type of cardiac surgery done, and our results.
Methods: We conducted a retrospective review of patients who had open-heart surgery for acquired heart diseases between October 2013 and November 2016. Data collected included demographics, presenting symptoms, indication for surgery, preoperative evaluation and preparation, operative procedure, postoperative complications, and follow-up. Statistical analysis was carried out descriptively using frequencies and percentages.
Results: A total of 35 patients have undergone open-heart surgery between October 2013 and November 2016. The patients who had surgery for acquired heart disease were 17 (48.6%). These included valvular heart disease in 13 patients while the remaining patients had coronary artery bypass grafting (CABG) for ischemic heart disease. The mean age of patients who had valve replacement and CABG were 39 and 60 years, respectively. Parsonnet risk scoring was used with an average score of 8.5. Three (17.6%) patients were in good risk category while 7 (41.2%) patients each were in fair and poor risk categories. Postoperative complications included paravalvular leaks in two patients. There was no hospital mortality.
Conclusion: Early results of valvular and coronary artery bypass surgeries from our center show good outcome comparable to global standards with zero hospital mortality and low morbidity. The result is aided by good case selection, adequate preparation, and teamwork.

Keywords: Coronary bypass surgery, early results, hospital, Ibadan, open-heart surgery, South West Nigeria or University College, valvular heart disease


How to cite this article:
Salami MA, Akinyemi OA, Adegboye VO. Early results of open-heart surgery for acquired heart diseases in Ibadan, Nigeria. Nig J Cardiol 2018;15:14-9

How to cite this URL:
Salami MA, Akinyemi OA, Adegboye VO. Early results of open-heart surgery for acquired heart diseases in Ibadan, Nigeria. Nig J Cardiol [serial online] 2018 [cited 2018 Jul 19];15:14-9. Available from: http://www.nigjcardiol.org/text.asp?2018/15/1/14/231969




  Introduction Top


Cardiovascular disease remains a leading cause of death worldwide with the burden of disease disproportionately affecting Sub-Saharan Africa [SSA].[1] Resources to provide optimum cardiac care for cardiothoracic patients are still very limited in West African countries.[2] Besides the need for relatively sophisticated diagnostic and surgical techniques and high level infrastructure, highly skilled workforce are required.[3] Cardiothoracic surgery is also growing in Nigeria despite limitations posed by infrastructure, political, and cost issues.[4] The first open-heart surgery in the country took place in 1974, an effort later joined by University College Hospital Cardiothoracic team in December 1978.[5] Funding and infrastructure constraints which have remained persistent burdens led to stunting of growth of various centers all over Nigeria interested in sustainable open-heart surgeries in the country. Since October 2013, a number of open-heart surgeries have been performed at the University College Hospital, Ibadan after a lacuna of almost three decades. Previous reports of open-heart surgery from other centers in SSA have shown a preponderance of valvular heart disease with wide variations in reported morbidity and mortality.[2],[4] We hereby report a series of patients who underwent open-heart surgery for acquired heart diseases to demonstrate pattern of disease profile, type of procedure, outcomes, challenges, and lessons learnt. We also intend to make recommendations for other nascent cardiac programs based on our experience in a low-resource setting.


  Methods Top


The University of Ibadan/University College Hospital Ethics Committee approval was obtained for this study (UI/EC/17/0311). We conducted a retrospective review of a prospectively collected data of consecutive series of patients who had open-heart surgery for acquired heart diseases in the cardiothoracic surgery unit of University College Hospital, Ibadan, in the last 3 years. Using specifically designed pro forma, data were obtained from the medical records of the patients; operation summaries were used to maintain a continuously updated database. Demographic and clinical information of each patient including the age at surgery, sex, presenting symptoms, indication for surgery, preoperative workup imaging, intraoperative events, postoperative complications, recovery, and follow-up were evaluated. Statistical analysis was carried out descriptively using frequencies and percentages.

Institutional setting

The study was carried out in the cardiothoracic unit of the Department of Surgery, University College Hospital, Ibadan, located in South West Nigeria. The cardiothoracic surgeons in the unit are part of the cardiac team constituted to resuscitate the conduct of open-heart surgeries in the hospital. Other members of the team include cardiac anesthetists, cardiac operating room nurses, cardiac intensive care nurses, and cardiopulmonary physiotherapists. The operative procedures, cardiac catheterizations, and intensive unit care took place in the new cardiac unit equipped with a three-bedded cardiac Intensive Care Unit, a cardiac catheterization laboratory, and cardiothoracic theater. Surgeries were recommenced in October 2013 under initially two different arrangements. The first operation was conducted as a public-private partnership arrangement with a team from the United States (Tristate Cardiovascular team) and the other was a single mission visit from India. The Tristate Cardiovascular team included two interventional cardiologists, two cardiac surgeons, one perfusionist, and one cardiac operating room nurse. The Indian team included a pediatric cardiac surgeon, an interventional cardiologist, and a perfusionist. Recently, another team from Italy under Bambini initiative is also collaborating with the University College Hospital to further develop the infrastructure and personnel for sustainable open-heart surgeries. Skill transfer and improvement of local infrastructure (fully equipped cardiac theaters and cardiac catheterization laboratory) were core components of the process. The center has now commenced independent open-heart surgeries following skills transfer from several teams we have worked with.


  Results Top


A total of 35 patients had open-heart surgery between October 2013 and November 2016 [Table 1]. Indications for surgeries included acquired heart diseases in 17 (48.6%) patients. The spectrum of acquired heart diseases seen included valvular heart disease in 13 (76.5%) patients and coronary artery disease in 4 (23.5%) patients [Figure 1]. The mean age of patients who had valve replacement and coronary artery bypass grafting (CABG) were 39 and 60 years, respectively. The average preoperative Parsonnet risk score [6] was 8.5; 3 (17.6%) patients were in good risk category while 7 (41.2%) patients each were in fair and poor risk categories [Table 2]. Overall, there was hospital mortality. The demographic and clinical characteristics of the 13 patients who had valvular heart surgery are shown in [Table 3]. The age of the patients ranged from 19 to 78 years. Six of the patients had isolated mitral valve disease while four patients had combined valvular heart disease (mitral and aortic (3), mitral and tricuspid (1)). Three patients had aortic valve replacement for aortic valve disease. Mechanical valve was utilized for valve replacements in eight patients while the other five patients had implantation of perimount bioprosthesis. Seven (53.8%) of the patients who had mechanical valves had ATS valves (ATS Medical) while one had On-X bileaflet mechanical valve (On-X Life Technologies, Austin, Texas, USA). The patients who had mechanical valve prosthesis were placed on postoperative anticoagulation with monitoring done in concert with referring physicians. There was a prolonged hospital stay among patients on warfarin to achieve target International Normalized Ratio (INR) and stabilization. The postoperative complications included paravalvular leak in two patients who had valvular replacement and one incidence of sternal wound infection.
Table 1: Patient characteristics

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Figure 1: Spectrum of acquired heart diseases

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Table 2: Parsonnet score table

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Table 3: Details of patients who had valvular surgery

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Four patients (23.5%) had CABG for coronary artery disease. Indications for bypass grafting were three-vessel coronary artery disease in all the four patients who were symptomatic – one with unstable angina and another with a past history of myocardial infarction. They all had 3 grafts each, utilizing left internal mammary artery to left anterior descending artery and venous grafts to obtuse marginal or posterior descending artery. There was one incident of perioperative myocardial infarction in the patient who had preoperative unstable angina. He subsequently had a cardiac event with neurological deficit and was later transferred out to another hospital for rehabilitation.

There were challenges with funding of patient's care with several patients partially or wholly sponsored through philanthropy.


  Discussion Top


The successful performance of valvular heart and coronary bypass surgeries under cardiopulmonary bypass with zero 30-day mortality in this UCH, Ibadan cardiac programme suggests that with adequate preparation and teamwork, quality cardiac surgeries can be safely conducted with good outcome in low-resource settings. This apparent good outcome may be due to strict case selection procedure put in place to screen out high-risk patients based on Parsonnet risk scoring system. Only 7 of our patients were in poor risk category with great care taken by the visiting teams who were at great expertise level. Although the hospital mortality is lower than the expected for each category, we must remember that the risk scoring system was based on a model derived from figures that were achieved a decade ago.[7] The spread of indications for surgery reflects the general pattern of presentation of adult cardiac patients in developing countries.[1],[2],[4] The only exception is the increased proportion (22%) of coronary artery bypass surgeries in the acquired cardiac disease group. This may be due to a facility selection bias as our center now has a new cardiac catheterization laboratory or a true rise in incidence of ischemic heart disease in the population.[8] The pattern of disease in all the operated patients appeared to be quite severe with three-vessel disease clearly indicating a need for surgical intervention. This may be due to lack of routine medical checkups and resultant late presentations by patients in Nigeria.

Valvular heart disease remains common in the Nigerian population mainly as a complication of rheumatic valvular heart disease.[9] Mitral valve disease is the most common either occurring as isolated mitral stenosis, mitral regurgitation, or mixed lesions. The high proportion of mitral valve disease is probably related to the persistent high prevalence of sequelae of rheumatic heart disease (RHD) in Nigeria and SSA.[10],[11],[12],[13] The preponderance of young patients in the cohort of patients explains the more common use of mechanical valves. However, some patients opted not to accept mechanical valves on account of need for lifetime warfarin use and monitoring. The other reason is cost issues in poor patients which necessitated use of bioprosthesis in four young patients. Lifelong anticoagulation remains a challenge in patients who have had mechanical valve implanted and was associated with prolonged postoperative stay in the majority of those patients who had mechanical valve implanted. The challenge remains achieving early time to target INR and time to stabilization while on warfarin. The target INR for patients who had implantations of mechanical valves was 2.5–3.0 for aortic and 2.5–3.5 for mitral positions. The challenge to achieving stable INR may be due to varying dietary contents of Vitamin K or genetic variations which affect warfarin metabolism as observed in the literature.[14],[15] This is an area worth further studying in African patients. In view of the changes in diet causing fluctuating warfarin requirements and dosing, we currently form a partnership with the primary referring physicians to ensure regular monitoring of INR. Two of our patients had paravalvular leak with one scheduled for redo surgery. We hope intraoperative use of transesophageal echocardiography (TEE) will be helpful to prevent the occurrence in subsequent cases. Intraoperative TEE has been shown to influence cardiac surgical decisions in more than 9% of patients undergoing valve procedures.[16]

Funding for cardiac surgeries especially for valvular diseases which are mainly rheumatic has remained a challenge as observed in this series. The persistent high prevalence and mortality rates of RHD in many parts of Africa has led to arguments for comparative cost-effectiveness of different RHD interventions in limited-resource settings. Watkins et al. using a newly developed economic evaluation tool to assist ministries of health in allocating resources and planning RHD control found that primary prevention would be cost saving and secondary prevention would be very cost-effective. They therefore suggested that international referral for VS (e.g., to a country like India that has existing surgical capacity) would be cost-effective, but building in-country VS services would not be cost-effective at typical low-income country thresholds.[17] This argument while specific for rheumatic valve disease control missed the point concerning other benefits of full-fledged cardiac surgical services in the developing world. The authors in fact accepted that cost-effectiveness analysis might not adequately address the issue of whether to build local surgical capacity. Surgical centers have important implications outside the narrow field of RHD.[18] A cardiac surgical facility would be treating congenital heart disease, coronary artery disease, and vascular diseases which are all in need of better-organized care in SSA. And like Watkins et al. submitted, such a center could also be an important hub for clinical training and scientific research, which have important nonhealth benefits to society, and cost-benefit analysis may be a better approach to account for these broader economic considerations.[19]

In the light of challenges faced by patients in paying for cardiac surgery, we will suggest implementation of cost-saving measures which can be learnt from India which has a similar profile of patients. More than two-thirds of the population in India live on <$2 a day and 86% of health care is paid out of pocket by individuals which is similar to Nigeria.[20] Surgeons were recently reported to have succeeded in bringing down the cost of surgeries to 95,000 rupees ($1,583) for coronary bypass surgery, compared to a cost of $106,385 at Ohio's Cleveland Clinic, according to data from the U. S. Centers for Medicare and Medicaid Services.[20] This path will be important for us to consider locally toward evolving sustainable cardiac programs. Part-financing as done by the NHIS for some of our pediatric patients in another series needs to be further developed and sustained. It is a beneficial support – new centers are kept busy and sustainable while many indigent patients can be helped.

The current experience with open-heart surgery for acquired heart diseases has taught us some lessons including need for meticulous case selection, preoperative multiprofessional cardiac team meetings, need for cooperative follow-up from primary physicians, and the veritable role of international colleagues in a cardiac center at a developing stage. The overall goal of the recommencement of open-heart surgeries in Ibadan remains development of a complete local team that can sustain the cardiac program which is now yielding fruits with independent operation by the local team now commenced in 2017. We share the belief that a coordinated approach to training is key to program sustainability as these ensure there are no gaps to prevent the service being initiated and sustained.[21] Regionalizing care which may help increase case volume and improve expertise should bring down costs as better cooperation is achieved between cardiac surgeons and cardiologists.[22] We will also suggest more active involvement of our public health colleagues to improve advocacy for care at all levels. Improved coordination from the developed world in partnership with Africans [21] currently being championed by Pan African Society of Cardiology [23] will prove vital as partnerships toward creation of regional cardiac surgery training centers becomes a reality. One of such is set to be sited in our institution.

Limitations

This study being a product of work with three different teams from USA, India, and Italy who operated the patients with the local team at different point in time between 2013 and 2016 to date, limits the extent of outcome analysis and generalization that could be done considering that the visiting surgeons were from different backgrounds, training, and competencies. These might have introduced a great deal of selection bias therefore indicating we can only do simple analysis of outcome based on mortality which informed the use of Parsonnet risk scoring system. Again, the small sample size of 17 patients may limit the generalizability of the study findings.


  Conclusion Top


Early results of valvular and coronary artery bypass surgeries from the University College Hospital, Ibadan, show good outcome comparable to global standards with zero hospital mortality and low morbidity. The result was aided by good case selection, adequate preparation, and international collaboration. We recommend learning and instituting cost-saving measures from high-volume centers in India to develop sustainable cardiac surgery programs in Nigeria. Financing can also be improved in the form of special takeoff grants and performance-based subventions to new centers from the federal government. This will help develop local surgical capacity and improve access to advanced cardiac care in Nigeria.

Acknowledgment

We would like to thank Members of Ibadan Cardiac Team for their outstanding work, The Tristate, and Bambini Cardiovascular team for their strong partnership.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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