|Year : 2018 | Volume
| Issue : 1 | Page : 9-13
Pattern and outcome of pediatric patients referred abroad for cardiac surgery from a tertiary hospital in the Niger Delta region of Nigeria
Chika O Duru1, Njideka Mesiobi-Anene1, Susan Ujuanbi2, Emmanuel Akalonu2, Ibrahim Aliyu3, Felix Akinbami1
1 Department of Paediatrics and Child Health, Niger Delta University Teaching Hospital, Okolobiri, Yenagoa, Bayelsa State, Nigeria
2 Department of Paediatrics, Federal Medical Centre, Yenagoa, Bayelsa State, Nigeria
3 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria
|Date of Web Publication||7-May-2018|
Dr. Chika O Duru
Department of Paediatrics and Child Health, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State
Source of Support: None, Conflict of Interest: None
Background: The high cost of open-heart surgery, poor funding, and lack of adequate facilities and workforce are some of the challenges facing Nigerian children with structural heart diseases in need of cardiac surgery. This study was undertaken to highlight the pattern and outcome of those referred abroad for cardiac surgery from a tertiary institution in the Niger Delta region of Nigeria.
Materials and Methods: Thirty-five children attending the pediatric cardiology clinic of the Niger Delta University Teaching Hospital over a 5-year period (February 01, 2012 to January 31, 2017) were enrolled in the study. A cardiac register was opened at the onset of this program and those in need of cardiac surgery were recruited to a list. When space was available, they were sent to Italy for corrective surgery.
Results: Over the 5-year period, 13 (37.1%) of the 35 patients seen at the cardiology clinic had cardiac surgery abroad. Ventricular septal defects and tetralogy of Fallot were the most common structural heart diseases seen. The types of surgeries performed included patent ductus arteriosus ligation, Glenn shunt, embolization of aortopulmonary collaterals, closure of atrial and ventricular septal defects, pulmonary aortoplasty, mitral valve replacement, and total intracardiac repair of tetralogy of Fallot. There was an average duration of 6.77 ± 3.14 months between initial presentation and surgical intervention. There was no in-hospital mortality, but there was a case fatality of 15.4% after 30 days postsurgery. Causes of death were cardiac arrhythmias and infective endocarditis. Eight of the 35 children died giving a mortality rate of 22.9%. Six (75%) died awaiting surgery.
Conclusion: Financial aid from nongovernmental organizations is insufficient to meet the growing demand for surgical intervention of pediatric cardiology patients in Nigeria. Reduction in the cost of open-heart surgery, equipping surgical facilities, and training local medical personnel could help to increase access to pediatric cardiac surgical care in Nigeria.
Keywords: Cardiac surgery, foreign aid, pediatrics, referral, structural heart diseases
|How to cite this article:|
Duru CO, Mesiobi-Anene N, Ujuanbi S, Akalonu E, Aliyu I, Akinbami F. Pattern and outcome of pediatric patients referred abroad for cardiac surgery from a tertiary hospital in the Niger Delta region of Nigeria. Nig J Cardiol 2018;15:9-13
|How to cite this URL:|
Duru CO, Mesiobi-Anene N, Ujuanbi S, Akalonu E, Aliyu I, Akinbami F. Pattern and outcome of pediatric patients referred abroad for cardiac surgery from a tertiary hospital in the Niger Delta region of Nigeria. Nig J Cardiol [serial online] 2018 [cited 2019 Mar 20];15:9-13. Available from: http://www.nigjcardiol.org/text.asp?2018/15/1/9/231974
| Introduction|| |
Managing structural heart diseases in Nigerian children remains a major challenge due to the high cost of open-heart surgery, poor government funding, lack of health insurance, and inadequate skilled medical personnel and facilities.,,, Most of the affected children are either referred abroad for cardiac surgery or have their surgeries done in Nigeria during periodic visits from foreign cardiac teams to local hospitals in the country.,,,, Foreign aid is usually through the help of non governmental organizations (NGOs) who offer their services at no or greatly subsidized costs. Surgeries done by visiting surgeons during cardiac missions are often geared toward attending to those with simple lesions, minimal mortality, and good prognosis. As a result, even though there are a lot of children meeting the criteria for surgical intervention, only a few eventually benefit from such programs.,
This study was conducted to highlight the pattern and outcome of pediatric patients presenting to the cardiology unit of the Niger Delta University Teaching Hospital (NDUTH), Okolobiri, Bayelsa State, with structural heart diseases who were referred abroad for cardiac surgery through funding from an Italian-based NGO.
| Materials and Methods|| |
This was a retrospective descriptive study carried out at the NDUTH, Okolobiri, Bayelsa State, over a 5-year period (February 01, 2012 to January 31, 2017). Hospital records of children between the ages of 0 and 13 years presenting to the cardiology unit of the department were analyzed.
The NDUTH is a tertiary hospital in Okolobiri, a semi-urban community located about 20 km from Yenagoa, the Bayelsa State capital. Pediatric cases from the host community, other parts of Bayelsa State, or those referred from neighboring states are attended to. All cases with suspected cardiac pathologies presenting to the hospital were referred to the cardiology clinic. Following a detailed history and physical examination, routine tests such as chest radiograph, electrocardiogram, and echocardiography were ordered for. A cardiac register was opened for all the patients and data such as name, age, sex, presenting complaints, echo diagnosis, and indication for referral were documented. After the initial evaluation, medical reports of the patients were sent to the Italian NGO (Open Heart POBIC International) and those requiring surgery were recruited to a list. When space was available, the patients were sent to Italy for corrective surgery. Following surgery, the patients were followed up at the pediatric cardiology clinic of the NDUTH monthly and also seen by a visiting team of doctors from the Italian NGO twice a year in Nigeria. Medical care postsurgery consisted of antifailure medications and antihypertensives.
Ethical approval for the study was granted by the Ethics and Research Committee of the NDUTH.
The data were entered into an excel spreadsheet and analyzed by calculation of means, percentages, and ratios.
| Results|| |
Over the 5-year period, 35 pediatric patients were seen at the pediatric cardiology clinic of the NDUTH. They consisted of 26 males (74.3%) and 9 females (25.7%) with a male:female ratio of 3:1. The ages of the children ranged from 6 weeks to 156 months with a mean age of of 32.00±50.57 months. The majority (32) of the children presented with congenital heart defects (27 [84.4%] acyanotic and 5 [15.6%] cyanotic), while there were 3 cases of acquired heart defects (all were rheumatic heart disease with valvular affectation) [Table 1].
|Table 1: Pattern of pediatric structural heart diseases seen at the Niger Delta University Teaching Hospital (n=35)|
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Thirteen (37.1%) children with structural heart diseases had corrective cardiac surgical interventions abroad. The time interval between the first presentation at the clinic and surgery ranged from 3 to 12 months with a mean of 6.77 ± 3.14 months [Table 2]. Indication for referral for surgical intervention included congestive cardiac failure in 4, malnutrition in 2, recurrent respiratory infections in 2, effort intolerance in 1, and hypercyanotic spells in 4 children.
Of the 13 children who had cardiac surgery, there was no in-hospital mortality. However, 2 died (case fatality of 15.4%) within a year of return to Nigeria postsurgery from infective endocarditis and cardiac arrhythmias, respectively. Five children died in Nigeria before they could travel abroad for surgery (the common cause of death was congestive cardiac failure), while one died in Italy before the surgery. Overall, eight children died, giving an overall mortality rate of 22.9%.
The remaining eleven postsurgical patients who were contacted through telephone or seen on an outpatient basis at least 2 years after surgery are alive and well with no complications. Medical missions through the Italian NGO has been continuing from November 2016 till date with regular visits of the foreign cardiac team for 6 monthly follow-up of the postsurgical patients in Nigeria [Table 3].
| Discussion|| |
Managing structural heart diseases in Nigerian children remains a major health challenge due to the high cost of open-heart surgeries, poor government funding, lack of health insurance, and inadequate skilled personnel and facilities.,,, As a result, late presentation of cardiac diseases is common, leading to a high incidence of morbidity and mortality.,,
In our study, ventricular septal defects and tetralogy of Fallot were the most common structural heart diseases seen, which is similar to reports from other Nigerian authors.,,, Despite this, there was no disparity in the type of cases that were recruited for surgery because the patients were chosen consecutively according to their position on the list. This was unlike reports from other parts of Nigeria where particular lesions were chosen to be operated upon because the foreign teams had a limited time to perform surgeries on as many children as possible., Usually, those with simple lesions were selected because of the potential for the surgeries to be devoid of major postoperative complications and mortality.,
Over 30% of the children presenting to our cardiology clinic had successful surgical interventions. This is in contrast to reports from other centers in Nigeria and other parts of Africa where <10% of affected children were able to have surgical interventions, whether locally or abroad.,,,,,,,, This disparity may have been due to the fact that there were fewer children presenting to our clinic and there was no selective process in our recruitment of our patients for surgery. Furthermore, our patients benefitted from full funding through the NGO which was in contrast to reports from other centers in Nigeria, where only a few benefitted from funding by some NGOs or the government.,
Following surgery, there was a mortality rate of 14.5%; all the deaths occurred more than 30 days postsurgery. This is similar to mortality rates of 17.4% and 15.7% postcardiac surgery reported by Anyanwu et al. and Falase et al., respectively. The causes of mortality in our study were due to infective endocarditis and cardiac arrhythmias which are the common cause of mortality in children with congenital heart diseases. Studies have shown that with or without intervention, survival rates of children with structural heart diseases in developing countries are low with mortality rates ranging from 8% to 20%.,
The average age at presentation was 3 years with over half of the patients diagnosed in infancy, which agrees with reports by other Nigerian authors.,,, This is in contrast to reports from developed countries where early presentation is common due to routine neonatal screening. Reasons for late presentation of children with structural heart diseases in developing countries have been attributed to poverty, ignorance and misconceptions, lack of government funding of cardiac services, and noninclusion in the National Insurance Scheme.,, Thus, most Nigerians are unable to afford early correction or palliative surgery and so present late with complications which could lead to surgically inoperable lesion.,
Despite the foreign aid available to the patients in our center, there was an average waiting time of 6 months between diagnosis and access to surgery or intervention. This delay in access to treatment could have contributed to the overall mortality of 22.9%, majority of whom died while awaiting surgery. Delay from the time of diagnosis to intervention was noted as an important cause of mortality in pediatric cardiac patients in a study by Brousse et al. Few centers in Nigeria are now able to offer services such as interventional cardiac catheterization and open-heart surgeries, but the high cost of surgical materials and maintenance of equipment limit its use for the average Nigerian with no financial support.,, The inadequacy of cardiology services in Nigeria such as shortage of skilled medical personnel, ill-equipped facilities, and high cost of cardiac surgery are other factors contributing to delay in access to treatment.,,,,,
| Conclusion|| |
Despite an average waiting time of 6 months for financial aid, <40% of the patients attending this cardiology clinic had cardiac surgery. This postulates that the financial aids from NGOs are insufficient to meet the growing demand for surgical intervention of pediatric cardiac patients. Reduction in the high cost of open-heart surgery through government funding, equipping surgical facilities, and training and retraining medical personnel could further increase access to pediatric surgical care for Nigerian children with structural heart diseases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ekure EN, Sadoh WE, Bode-Thomas F, Orogade AA, Animasahun AB, Ogunkunle OO, et al.
Audit of availability and distribution of paediatric cardiology services and facilities in Nigeria. Cardiovasc J Afr 2017;28:54-9.
Falase B, Sanusi M, Majekodunmi A, Ajose I, Idowu A, Oke D, et al.
The cost of open heart surgery in Nigeria. Pan Afr Med J 2013;14:61.
Bode-Thomas F. Overcoming challenges in the management of structural heart diseases in children. J Med Trop 2011;13:3-10.
Eze JC, Ezemba N. Open-heart surgery in Nigeria: Indications and challenges. Tex Heart Inst J 2007;34:8-10.
Nwafor I, Onyekwulu F, Ezemba N, Eze JC, Chinawa J, Ngene CI. Open heart surgery in Nigeria: Experience with International Cardiac Surgery Missions. Ther Adv Cardiol 2017;1:19-27.
Stolf NA. Congenital heart surgery in a developing country: A few men for a great challenge. Circulation 2007;116:1874-5.
Aliku TO, Lubega S, Lwabi P, Oketcho M, Omagino JO, Mwambu T, et al.
Outcome of patients undergoing open heart surgery at the Uganda heart institute, Mulago hospital complex. Afr Health Sci 2014;14:946-52.
Omokhiodion SI, Adegboye VO, Ogunkunle OO. Treatment of structural heart disease through International collaboration: The Ibadan Experience. Niger J Cardiol 2005;1:39-46.
Ekure EN, Okoromah CN. In-hospital outcome of children referred for cardiac surgery abroad from a developing country. Niger J Paediatr 2009;36:80-6.
Nwafor IA, Eze JC, Anyanwu CH, Ezemba N, Onyia UO, Enwerem NU, et al
. The scope of cardiac surgery at a national cardiothoracic center of excellence (NCTCE) in Nigeria: A 3 year review. J Vasc Med Surg 2017;5:1-7.
Anyanwu CH, Okoromah EO, Ihenacho HN, Umeh BU. Experience with surgical management of cardiovascular diseases in children. Niger J Paediatr 1980;8:94.
Zilla P, Hewitson J. Congenital heart diseases in sub-Saharan Africa: Challenging the burden of disease. SA Heart 2010;7:18-29.
Zühlke L, Mirabel M, Marijon E. Congenital heart disease and rheumatic heart disease in Africa: Recent advances and current priorities. Heart 2013;99:1554-61.
Otaigbe BE, Tabansi PN. Congenital heart disease in the Niger delta region of Nigeria: A four-year prospective echocardiographic analysis. Cardiovasc J Afr 2014;25:265-8.
Adebayo BE, Ogunkunle OO, Omokhiodion SI, Luke RD. The spectrum of structural heart diseases seen in children at the University College Hospital, Ibadan. Niger J Cardiol 2016;13:130-5.
Asani M, Aliyu I, Kabir H. Profile of congenital heart defects among children at Aminu Kano Teaching Hospital, Kano, Nigeria. J Med Trop 2013;15:131-4. [Full text]
Ibadin MO, Sadoh WE, Osarogiagbon W. Congenital heart diseases at the University of Benin Teaching Hospital. Niger J Paediatr 2005;32:29-32.
Animashaun BA, John O, Ogunkule OO. The rejuvenation of cardiac catheterization for congenital heart disease in Nigeria: Profile, challenges and prospects. Afr J Int Med 2013;2:47-51.
Chelo D, Ngueback F, Ndombo PO, Kingua S. Challenges in surgical management of children with cardiac disease in sub-Saharan Africa- Experience of a Paediatric Cardiology Unit in Yaounde, Cameroun. Int Pediatr Res 2016;1:103.
Falase B, Sanusi M, Animasahun A, Mgbajah O, Majekodunmi A, Nzewi O, et al.
The challenges of cardiothoracic surgery practice in Nigeria: A 12 years institutional experience. Cardiovasc Diagn Ther 2016;6:S27-43.
Hoffman JI. The global burden of congenital heart disease. Cardiovasc J Afr 2013;24:141-5.
Farmer PE, Kim JY. Surgery and global health: A view from beyond the OR. World J Surg 2008;32:533-6.
Sulafa KM, Karani Z. Diagnosis, management and outcome of heart disease in Sudanese patients. East Afr Med J 2007;84:434-40.
Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002;39:1890-900.
Eboh A, Akpata GO, Akintoye AE. Health care financing in Nigeria: An assessment of the National Health Insurance Scheme (NHIS). Eur J Bus Manage 2016;8:24-34.
Brousse V, Imbert P, Mbaye P, Kieffer F, Thiam M, Ka AS, et al.
Evaluation of long-term outcome of senegalese children sent abroad for cardiac surgery. Med Trop (Mars) 2003;63:506-12.
[Table 1], [Table 2], [Table 3]