|Year : 2020 | Volume
| Issue : 1 | Page : 67-70
Initial experience with interventional and definitive solutions for structural heart diseases in a resource-challenged setting
Oluwatoyin O Ogunkunle, Bosede E Adebayo, A Famosaya, Samuel Ilenre Omokhodion
Department of Paediatrics, Cardiology Unit, College of Medicine, University of Ibadan, Ibadan, Nigeria
|Date of Submission||13-Dec-2019|
|Date of Acceptance||14-Dec-2019|
|Date of Web Publication||30-Jun-2020|
Prof. Samuel Ilenre Omokhodion
Department of Paediatrics, Cardiology Unit, College of Medicine, University of Ibadan, Ibadan
Source of Support: None, Conflict of Interest: None
Background: The first case of open-heart surgery (OHS) in the University College Hospital, Ibadan, took place on December 19, 1978. Since then, various attempts have been made to provide definitive solutions for patients with structural cardiac diseases, but till now, no permanent regular service exists. We present our initial experience with interventional cardiology (IC) and OHS in a resource-challenged setting. The challenges encountered are discussed, and the solutions we have proffered with each situation are presented as we forge ahead toward achieving a more regular service for IC and OHS in our center.
Results: In January 2016, eight children underwent diagnostic cardiac catheterization with a view to performing a possible corrective intervention. Two subsequently had device closure of patent ductus arteriosus – the first in the history of the hospital. Four patients (one with a large atrial septal defect (ASD), one severe pulmonary stenosis, one with a large ventricular septal defect (VSD), and one with Fallot's tetralogy) were deemed to be more suitable for OHS and were, therefore, deferred. The muscular VSD in another patient was thought to be too small to need intervention. The last patient, initially thought to have a coarctation of the aorta, was found to have normal cardiac anatomy. The patient with large ASD and VSD subsequently underwent successful total repair of his lesions in our facility.
Conclusion: The successful outcome in the three patients has encouraged us to be optimistic that despite various resource challenges, it will soon be possible to establish a regular service for both IC and OHS in our center.
Keywords: Interventional cardiology, open heart surgery, structural heart defects
|How to cite this article:|
Ogunkunle OO, Adebayo BE, Famosaya A, Omokhodion SI. Initial experience with interventional and definitive solutions for structural heart diseases in a resource-challenged setting. Nig J Cardiol 2020;17:67-70
|How to cite this URL:|
Ogunkunle OO, Adebayo BE, Famosaya A, Omokhodion SI. Initial experience with interventional and definitive solutions for structural heart diseases in a resource-challenged setting. Nig J Cardiol [serial online] 2020 [cited 2020 Aug 12];17:67-70. Available from: http://www.nigjcardiol.org/text.asp?2020/17/1/67/288652
| Introduction|| |
The first successful case of open-heart surgery (OHS) in the University College Hospital (UCH), Ibadan, took place on September 18, 1979., This was a case of open pulmonary valvotomy and followed years of preparation in terms of workforce, materials and method, as well as a previous mortality following the first attempt at OHS on December 19, 1978., Since then, several unsuccessful attempts were made to establish a regular service of definitive solutions (OHS and more recently, interventional cardiology [IC]) for patients with cardiac lesions at the premier teaching hospital in Nigeria, but till date, this has not materialized.
A collaboration with the Save a Child's Heart, Israel, which started in 1998 and led to the inception of Save a Child's Heart, Nigeria, and missions from the United States, India, and Italy, have occurred over the years. OHS in Nigeria remains a very costly service, occurring in only six centers at the present time, the main obstacles being shortage of requisite workforce, inadequate infrastructure, inadequate laboratory support, inadequate supply lines for the necessary consumables, high cost of surgery, poor funding mechanisms for surgery, multiple models for the development of cardiac surgery, institutional blunting of initiatives and centralization of efforts, and lack of outcome data.,
Similarly, IC as a service for patients with cardiac lesions is not readily available in Nigeria. In October 2009, a private cardiac catheterization laboratory was opened in Lagos, majorly catering for adults,, but in October 2010, in collaboration with the Lagos State University College of Medicine/Lagos State University Teaching Hospital, a successful patent ductus arteriosus (PDA) device closure was performed on a 3-year-old girl, the first of its kind in Nigeria. Since then, the same hospital has reported a few further device closures, both in adults and children.
Following a few OHSs in the UCH between July 2006 and December 2013, in January 2016, during a medical mission from Prime Hospitals, Hyderabad, India, eight children underwent diagnostic cardiac catheterization, with a view to performing possible corrective intervention for those found suitable. The profiles, presumptive diagnoses, definitive diagnoses, and outcomes of the patients are as shown in [Table 1].
|Table 1: Profile and outcome of patients who underwent cardiac catheterization|
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Two patients went on to have device closure of PDA at the same sitting – the first in the history of the hospital. The planned pulmonary valvotomy in the patient with pulmonary stenosis failed, due to the severity of the stenosis. She, along with three others (one with a large atrial septal defect (ASD), one with a large ventricular septal defect (VSD) and one whose lesion was initially thought to be VSD with pulmonary stenosis, but which turned out be Fallot's tetralogy), was deemed to be more suitable for OHS. The muscular VSD in another patient was thought to be too small to need intervention. The last patient, initially thought to have a coarctation of the aorta, was found to have normal cardiac anatomy.
The patient with the large ASD and VSD subsequently underwent successful total repair of his lesions in our facility on November 27, 2016 during another medical mission by the Bambini Cardiopatici nel Mondo (BCnM), an Italian nonprofit organization based at the San Donato Policlinico in Milan which has been operating missions to less privileged countries round the world, especially in Africa, and most recently, Nigeria. The organization is in the process of building a cardiac center and cardiovascular diseases institute in collaboration with the University of Ibadan, the UCH, Ibadan and the Federal Ministry of Health (FMH). An MoU has been signed, and construction work is underway.
| Discussion|| |
The poor annual budgetary allocation to the health sector in Nigeria, which has consistently been <5% of the total, as against the WHO-recommended level of at least 12%–15%, is inadequate for recurrent expenditure, let alone capital infrastructural development. This is at the heart of the poor development of tertiary health-care facilities in the country. Most of the existing tertiary health-care facilities, if not all, function more or less at the level of secondary level of care found in developed countries, i.e. general hospitals. Rather than capitulate to this situation in resignation, many who work in the cardiovascular health-care segment of existing tertiary facilities are taking the initiative to evolve solutions to the predicament of near nonexistent full-solution cardiovascular setups.
At the UCH, we have in this regard sought to establish collaboration with willing partners abroad in the hope of attracting some good measure of skills transfer as well as assistance with requisite infrastructural development.
We have found partnerships to a greater or lesser degree in the Save a Child's Heart Israel, based at the Edith Wolfson Hospital (EWH) in Holon, the National Cardiothoracic Centre (NCTC) in Korle Bu, Accra Ghana, Madras Medical Mission Institute of Cardiovascular Diseases (ICVD) in Chennai, India, MIOT Hospitals, Chennai, India, and most recently, BCnM at the San Donato Policlinico in Milan, Italy. These linkages have in the main been forged by SIO and over the years since 2006, we have had several medical mission visits providing highly subsidized services and opportunities for skills transfer in favor of our staff. This has provided short-term training stints of 3 months for six members, 1 year each for three members of our team at the EWH, Israel, and 6 weeks for six members at the NCTC in Ghana. Similar 1-year training schemes have been undertaken by 22members of our team, spread across adult and pediatric cardiology, operating room and intensive care nursing, adult and pediatric perfusion, as well as cardiothoracic surgical divisions at the ICVD and MIOT Hospitals in Chennai.
Through a lot of advocacy with the UCH management, a modern cardiac catheterization laboratory, a standard dedicated cardiac operating room and a cardiac intensive care unit have been established, funded by internally generated revenue and bank loans which are being successfully repaid, thanks to prudent fund management by the hospital administration, who have gradually bought into the plan.
The present report has been confined to the pediatrics segment of the program with regard to catheterization and intervention. It does not include the accomplishments with respect to adult cardiology, (over eighty diagnostic catheterizations, with stent and angioplasty interventions in over thirty patients). Neither does it include the accomplishments of the cardiothoracic surgeons, anesthetists, nurses, and perfusionists, who are major stake holders and also play major roles in the cardiac program.
The more recent development of the construction of the 100-bed centre for Cardiovascular Diseases at the UCH laced with the construction of a cardiovascular research and training institute for the University of Ibadan is part of this evolving program. The former is now being funded by the Federal Government of Nigeria through the FMH, whereas the latter is being funded by BCnM. While the latter will provide a platform for graduate academic studies into all related cardiovascular disciplines leading to Masters and Doctor of Philosophy, and Doctor of Medicine degrees of the University of Ibadan, the former will become the main hub for tertiary level cardiovascular health-care delivery services and professional training center for the subregion in all disciplines of cardiovascular health-care delivery services.
Standard operating procedures are being generated for the various conditions to guarantee best practices in line with global standards.
The goal is eventually to have on ground locally, a team and facilities that which will be able to independently provide the full range of cardiovascular health-care delivery services for patients who need them. It is also hoped that having acquired the requisite skills and experience, the team would ultimately by the same skills transfer approach, be able to replicate itself locally, ensuring sustainability of the program.
| Conclusion|| |
Although the patient number reported is small, the fact that cardiac catheterization did take place, two with successful intervention, has proved that is possible in our facility. This has encouraged us to be optimistic that despite various resource challenges, it is possible to establish a regular service for both IC and OHS in our center in the very near future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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