|Year : 2018 | Volume
| Issue : 1 | Page : 28-32
Open-heart surgery recommenced in Ibadan: Early results of congenital cases
Mudasiru Adebayo Salami1, Oluranti A Akinyemi2, Victor O Adegboye1
1 Department of Surgery, Cardiovascular and Thoracic Surgery Division, College of Medicine, University College Hospital, University of Ibadan, Ibadan, Oyo, Nigeria
2 Department of Anaesthesia, College of Medicine, University College Hospital, University of Ibadan, Ibadan, Oyo, Nigeria
|Date of Web Publication||7-May-2018|
Dr. Mudasiru Adebayo Salami
Department of Surgery, College of Medicine, University College Hospital, University of Ibadan, Ibadan, Oyo
Source of Support: None, Conflict of Interest: None
Background: The incidence of cardiothoracic disease continues to increase globally especially in developing countries. Cardiothoracic surgery is also growing in Nigeria despite limitations posed by infrastructure, political, and cost issues. The first open-heart surgery (OHS) in Ibadan was in December 1978. Previous reports of OHS from new centers in Sub-Saharan Africa have shown a preponderance of septal defects and Tetralogy of Fallot (TOF) in published series, with wide variations in reported morbidity and mortality.
Objectives: We report a series of patients who underwent OHS for congenital heart diseases (CHD) to demonstrate disease pattern, types of procedures, outcomes, challenges, and lessons learnt. Methods: We conducted a retrospective study of patients with congenital heart disease who had OHS in Ibadan 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 18 patients had OHS for congenital heart disease (CHD). These include atrial septal defects and ventricular septal defects (VSDs) in 10 patients (55.6%). There were 7 (38.9%) patients with TOF and a case of pulmonary stenosis. Complications recorded included a case of reoperation for bleeding and two patients who had VSD patch leaks. No hospital mortality was recorded.
Conclusion: Early results of open-heart surgeries for congenital heart disease show excellent outcome comparable to current global standards with zero 30-day mortality and low morbidity. The result is aided by good case selection, correct anatomical diagnosis, adequate preparation, and teamwork. Adequate financing of cardiac care remains a challenge.
Keywords: Congenital heart disease, early results, Ibadan, open-heart surgery
|How to cite this article:|
Salami MA, Akinyemi OA, Adegboye VO. Open-heart surgery recommenced in Ibadan: Early results of congenital cases. Nig J Cardiol 2018;15:28-32
| Introduction|| |
The incidence and prevalence of cardiothoracic disease continue to increase globally, especially in emerging economies and developing countries where 80% of the burden now exist. Cardiothoracic surgery is also growing in Nigeria despite limitations posed by infrastructure, political, and cost issues. Initial efforts to commence open-heart surgery (OHS) in the University College Hospital, Ibadan, started in the 1970s culminating in the first OHS in December 1978., Previous reports of OHS from new centers in Sub-Saharan Africa have shown a preponderance of septal defects and Tetralogy of Fallot (TOF) in published series.,, The reported morbidity and mortality figures (3.2%–15.7%) reflected the challenges of a learning curve in resource-constrained settings., Challenges described include payment for care, low volume of cases done, limited number of trained staff, difficulty in obtaining laboratory support, limited financial support, cardiac missions limitations, and sustainability issues.,,,, Pezzela while discussing the challenges associated with establishing a sustainable cardiac program classified projects in developing countries as those who are nonexistent but wanting to start, previously existed but failed, and already functional but needing academic support, and various combinations of these. We hereby report a series of patients who underwent OHS for congenital heart diseases to demonstrate pattern of disease, type of cardiac surgery done, 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|| |
We conducted a retrospective review of a consecutive series of patients who had OHS for congenital heart disease in the cardiothoracic surgery unit of University College Hospital, Ibadan, between October 2013 and November 2016. Medical records of the patients including case files, operation summaries, and special pro forma that were designed by our staff 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, range, and percentages.
Ibadan cardiac team
The University College Hospital Management constituted a cardiac team with a focus on maximizing resources by developing and scaling up personnel training and infrastructure development in synchronized phases. The team comprised cardiothoracic surgeons, cardiac anesthetists, cardiac theater nurses, cardiac intensive care nurses, and cardiopulmonary physiotherapists. This team had additional professional training at various centres in India pending recommencement of OHS between 2009 and 2012. The initial plan for a standalone cardiac center was aborted due to funding challenges. A new approach to facility provision was therefore made. The old cardiothoracic theater in the hospital theater complex along with adjoining rooms was modified to provide a new cardiac theater with all requisite facilities for OHS, a cardiac catheterization laboratory and a 3-bed cardiac Intensive Care Unit.
Surgeries were recommenced in October 2013 under initially two different arrangements. The first was a public private partnership with a team from the United States (Tristate Cardiovascular team), and the other was a single mission visit from India. Lately, a new team from Italy under Bambini initiative is also collaborating with the hospital to further develop the infrastructure and personnel for sustainable open-heart surgeries. Skill transfer and improvement of local infrastructure were core components of the process.
| Results|| |
A total of 18 patients had OHS for congenital heart disease (CHD) between October 2013 and November 2016 [Table 1]. [Table 2] shows a detailed overview of the patients. The age ranged from 7 months to 21 years. The spectrum includes acyanotic heart disease with left to right shunts (atrial septal defects and ventricular septal defects [VSDs]) in 10 patients (55.6%). Ostium secundum atrial septal defects were found in 4 (22.2%) patients while 5 (27.8%) patients had VSDs. One patient presented with both atrial and VSD at age of ten with moderate-to-severe pulmonary hypertension. Cyanotic heart disease presenting as TOF was found in 7 (38.9%) patients while there was a case of pulmonary stenosis. Three of our patients had postoperative hemorrhage. Two of these patients improved following transfusion of blood products including platelets and fresh frozen plasma. The third patient had reoperation for bleeding. Two other patients had VSD patch leaks. No hospital mortality or 30-day mortality was recorded.
The atrial septal defect was closed using untreated autologous pericardium while the VSDs were closed using Goretex patch in four patients and bovine pericardium (brought by visiting teams) and direct pledgeted suture closures in the two other patients, respectively. The patients with TOF were a broad spectrum with age ranging from 2 to 21 years. They all require extensive infundibulectomy and enlargement of the main pulmonary artery using autologous pericardial patch. Intraoperative echocardiography was only available in nine of our pediatric open-heart surgeries. The single patient with pulmonary stenosis had an open commissurotomy. The complications of surgery included reoperation for bleeding in three patients and VSD patch leak in two patients. One of the patients had a redo surgery while the other patient is awaiting a redo closure as the leak is assessed to be moderate. There were challenges with funding of patient's care in this series with 6 of the patients partially or wholly sponsored through philanthropy or National Health Insurance Scheme (NHIS).
This challenge remains paramount as well discussed in a recent survey of cardiothoracic surgeons and resident doctors in Nigeria.
| Discussion|| |
The successful performance of congenital open-heart surgeries with zero 30-day mortality after a long interregnum confirms that with adequate preparation and teamwork, quality cardiac surgeries can be safely conducted with good outcome in low-resource settings. The spread of operated patients reflects the general pattern of presentation of congenital heart disease in developing countries. Congenital heart disease constituting about half of the total population of operated patients is reflective of the prevalence of the acute need for pediatric cardiac surgeries. The previous focus in our center was on closed cardiac surgeries including ligation of patent ductus arteriosus and palliative surgeries like Blalock Taussig shunt for TOF. Complete intracardiac correction for the operated patients in the current cohort is the first time such patients can have complete correction in our center. All the patients had severe right ventricular outlet obstruction necessitating extensive muscular resection in the outlet supplemented by pericardial patch to the main pulmonary artery. All the patients had smooth postoperative recovery except a 20-year-old patient who had low cardiac output syndrome leading to delayed weaning from inotropes. Total correction of TOF in this age group has been noted to be fraught with increased incidence of low cardiac output syndrome in up to 11.25% of a recent cohort of adult patients who had repair of TOF. While the ideal expectation is for primary complete repair for TOF in infancy, late diagnosis, cost of surgery, and lack of appropriate surgical facilities may delay surgical repair as in our series. The surgical team therefore has to be aware of high mortality associated with repair of TOF in this age group reported as 8%–12%., Dittrich et al. argue that this comparatively high mortality in adults may be because of the problems associated with the long-standing cyanosis. These include RV dysfunction in the form of myocardial fibrosis, cerebral complications (stroke and cerebral abscess), and poor development of the pulmonary artery. One of our patients had reoperation for bleeding, a common complication due to the development of collaterals over a long period, erythrocytosis, and coagulation defects in patients with TOF., However, Benbrik et al. found no difference in postoperative morbidity and mortality between a cohort of patients (<15 years) who had late repair of TOF compared with that of timely repair during infancy. Their results appear to be corroborated in an older age cohort (patients in or beyond the fourth decade of life) who had acceptable results. The authors however noted that patients with high hematocrit, lower oxygen saturation, right ventricular dysfunction, aortopulmonary collaterals, and high preoperative right ventricular outflow tract gradients were found to have a prolonged postoperative course like in our series. The focus should therefore be on detailed preoperative assessment, correct surgical strategies, and attentive intensive care monitoring to reduce mortality.
The first pediatric patient operated had atrial septal defect closure to test run our system. The need for meticulous case selection in a new center cannot be overemphasized. The meticulous case selection protocol is probably contributory to nil mortality compared to reports of 3.2%–15.7% from similar centers in Sub-Saharan Africa.,, The morale of the staff and patient referrals are boosted at all stages by good outcomes. Despite this, one should always make an allowance for the unexpected as in two of the operated atrial septal defects who had a common atrium. The pericardial patch repair to recreate an atrial septum was successful in both patients with no demonstrable leak at postoperative echocardiography. VSDs are said to be the most common congenital heart anomalies, and if we include the patients with TOF in our series, this observation remains true. All except one of the patients who had very small VSD had patch repair using Goretex based on surgeon's preference.
One major recurring challenge that deserves multipronged solution is financing of cardiac surgeries. The current observed trend of the inability of the majority of the patients' families to afford the cardiac surgeries is worthy of special focus by the government. Unlike developed countries, health insurance schemes are not well developed, so financing of open-heart surgeries is done by governments, charitable organizations, and out-of-pocket payments by patients and their sponsors., The current cost estimate of OHS in Nigeria, reported to range between $6230 and $11,200, is beyond the reach of majority of patients and their families. Similar efforts to the window of opportunity in part-financing as done by the NHIS for some of our patients in this series need to be further developed and sustained. It is a mutually beneficial support – new centers are kept busy and sustainable while many indigent patients can be helped.
The current experience with OHS has taught us some lessons including need for meticulous case selection, preoperative multidisciplinary cardiac team meetings, and the veritable role of international colleagues in a cardiac center at a developing stage. The preoperative meetings where all cases are discussed with the visiting teams helped to identify likely intra- and postoperative challenges with patients against the background of our equipment limitations. 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. 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.
The challenges identified in this study, especially funding and payment for care, point to a need for centers currently involved in cardiac surgery in Nigeria to work together and coordinate efforts to become as cost-efficient as possible. Again, efforts to help, especially from the developed world, need better coordination in partnership with Africans so as to avoid duplication of efforts and waste of resources. Pan African Society of Cardiology (PASCAR) is a potential forum for developing such cooperation, and discussions along these lines were begun at the PASCAR meeting in Nairobi in 2007. These efforts from PASCAR appear to be crystallizing now with partnerships being built toward creation of regional cardiac surgery training centers. One of such is set to be sited in our institution with the assistance of a mission group, Bambini, who we partnered for our last two open-heart surgeries. These regional centers will be a better long-term solution including offering service to neighboring countries as we presently do for thoracic cases. One must, of course, be aware of the fact that there are other models including public-private partnership arrangements.
| Conclusion|| |
Early results of open-heart surgeries for congenital heart disease from our center shows excellent outcome comparable to current global standards with zero 30-day mortality and low morbidity. The result is aided by good case selection, adequate preparation, and teamwork. Improving access to open-heart surgeries in Ibadan has brought succour to our patients who hitherto had to seek care abroad. The international growth of cardiac surgery still favors developing countries, and concerted efforts to establish sustainable and quality cardiac surgery centers should remain top priority.
We would like to thank members of Ibadan Cardiac Team for their outstanding work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]