Developing a sustainable cardiac surgery programme in LMICs
Yankah C1. Lajmi M2, du Toit H3, Oketcho M4, Mwambu TP5, Mazri F6, Bouzid A7, Reis M8, Ferreira MB9, Sadaba JR10, Malaisrie C11, Cuertas MM12, Oburu G13, Mvondo C14, Nwiloh J15 , Smit F16, Reddy D17, Farkas E18, O’Brien B19, Urban20, Thameur H21, Pienaar M22, Engbers F23, Buys DG24, Falk V25, Marath A26, Centella HT27, Bokenkamp R28.
German Heart Centre Charité Berlin, Germany1, University Hospital, Tunis, Tunesia2, Catholic Hospital, Windhoek, Namibia3, Uganda Heart Inst, Makerere University, Kampala, Uganda4, Uganda Heart Inst, Makerere University, Kampala, Uganda5, Univ hospital, Algiere, Algeria6, Cardiovasc. Dept., Univ. of Algiers, Algeria7, Maputo Heart Institute, Maputo, Mozambique8, Maputo Heart Institute, Maputo, Mozambique9, Snr. Consultant, Cardiac Surgery, Hospital de Navarra, Universidad Publica de Navarra, Pamploma, Spain10, Chair, STS Workforce, Intern Education, USA11, Cardiothoracic Surg, Heart Centre, Leipzig; Germany12, Kenyatta National Univ Hosp, Nairobi, Kenya13, Dr. Charles Mvondo, Head, Paediatric Cardiac Surgery, Shissong Mission Hospital and Heart Centre, Shissong, Cameroon14, Dr. Nwiloh Heart Center, Adazi, Nnukwu, Nigeria15, Univ. of Free State, Bloemfontein, South Africa16, Dr. Darshan Reddy, Durban Heart Centre, Durban, South Africa17, Dr. Emily Farkas, Associate Professor of Surgery, Associate Director of Global Health Surgery, Indianapolis, IN, USA18, Prof. Benjamin O’Brien, Director, Cardiac Anesthesiology & Intensive care Medicine19, International Operation Centre for Children (IOCCA), Asmara, Eritrea,20, Hospital Clinique Intern. Clinique Montplaisir, Tunis, Tunesia21, Dr. Michael Pienaar, Pediatric cardiac ICU, Univ of Free State, Bloemfontein, S. Africa22, Dr. Franciscus Engbers, Pediaric Cardiac Anesthesiologist, Leiden, The Netherlands23, Prof. Daniel G. Buys, HOD, Pediatric Cardiology, Univ of Free State, Bloemfontein, S. Africa24, Prof. Volkmar Falk, Director German Heart Centre Charité Berlin & Director, Thoracic & Cardiovacular Surgery, Germany25, Dr. Aubyn Marath, Paediatric & Adult Cardiothoracic Surgeon, President, CardioStart Intl., St.Petersburg, Fl, USA26, Prof. Tomas Hernandez Centella, Dept of Pediatric Cardiac Surg. Hospital Ramon Y Cajal-Serv Cirugia, Madrid, Spain27, PD. Dr. Regina Bokenkamp, Snr. Consultant Pediatric Interventional Cardiologist, Leiden Univ Medical Centre, Leiden, The Netherlands28
Introduction
Cardiac surgery began in North and South Africa in 1953 in Algiers, Algeria and in 1958 in Cape Town, South Africa by Jean Demirleau and Christiaan Barnard, respectively. Many other surgeons followed suit in sub-Saharan regions. In West Africa: 1960 and 1964 by Charles Easmon in Accra, Ghana, 1975 in Enugu by Magdi Yacoub, 1976 in Abidjan by Dominique Metras, 1980 in Liberia by Charles Yankah, in East Africa: 1970 in Kampala, Uganda by, Lindsay Grigg and 1973 in Nairobi, Kenya by, Eddy Knight. Human heart transplantation was pioneered by Christiaan Barnard in 1967 and bridge to heart transplantation by Willie Koen and Charles Yankah in 2001 in Cape Town.
To date the high-tech complex cardiac surgery programs have not gained the expected stability and sustainability in sub-Saharan regions except in South Africa.
Various constraints are being experienced in the healthcare delivery systems in sub-Saharan Africa (SSA), namely weak health infrastructure, limited tools, inadequate human resource capacity, limited public financing to the health sector as a whole (and not only to disease specific programs), poor administrative management, ineffective strategic planning of integrated health systems and misapplication of human, technical and financial resources.
Sub-Saharan Africa is faced with an enormous demographic and economic challenges when we look at its population of one billion (1.1 billion, World Bank, 2022). Of these, an estimated 43% (430 million) are under 15 years old and about 60% (600 million) are under 25 years old. In 2050 the population of SSA will double to 2.4 billion (WB). Besides the burden of congenital and rheumatic heart disease, the increasing incidence of ischemic heart disease among the rising middle class poses a time bomb which will impact on the socioeconomic development.
Despite greater efforts by humanitarian aid missions in the underserved regions and limited local cardiac surgery capacity in sub-Saharan Africa (SSA) easily treatable conditions become chronic and deadly diseases. The surgical load of 400 open heart surgery (OHS) per million recommended by WHO is not yet achieved by many centres in SSA even the minimum 40 open heart surgery per million recommended by PASCaTS.
Our report will discuss the concepts for developing cardiac surgery in underserved regions in Africa and impact measurement of humanitarian activities. PASCaTS has conducted a survey on clinical cardiac surgery in sub-Saharan Africa and the challenges especially capacity building, treatment and surgical performances of heart centres in sub-Saharan Africa.
Pan-African Society for Cardiothoracic Surgery (PASCaTS)
The African Heart Seminar (AHS) was the predecessor of PASCaTS which really developed as a pure outreach project in the sub-regions of East and West Africa.
In 2001 Professor Charles Yankah from the German Heart Centre Charité in Berlin and Dr. Willie Koen from the Christiaan Barnard Memorial Hospital in Cape Town initiated artificial heart to bridge heart transplantation in Africa at the Christiaan Barnard Memorial Hospital using the “Berlin Heart”. It was a successful startup that was rebranded to PASCaTS. PASCaTS is a prime example of the transformation of ‘brain drain” to “brain circulation” of African surgeons and their contribution to the development of cardiac surgery on the continent.
Global burden of congenital and rheumatic heart diseases and disparities in surgical care in Africa
Though, cardiovascular surgery has now gained recognition as a legitimate component of universal healthcare in the developing and emerging economies, it remains challenging to many national healthcare providers in low and middle income countries (LMICs).
Children born in Europe, United States or in the Western World with congenital heart disease (CHD) such as septal defects, right or left ventricular outflow tract obstruction, AVSD, DORV, Ebstein anomaly, TGA, are generally well supported by the infrastructure relating the pediatric heart care and do receive the surgical management they need in a reasonable time period. Care pathways are clearly set up and the Government financial support systems for regional healthcare are well established, although these are not perfect. Yet millions of children in Africa born with the same congenital heart disease and those with acquired preventable rheumatic heart disease (RHD) and constricting pericarditis, endomyocardial fibrosis (EMF) are awaiting medical/surgical care that will not likely come in their shortened lifetime because pediatric cardiac care centres and surgical specialists are not adequately available.
Many children don’t reach the stage of early diagnosis and treatment due to financial constraints or lack of medical professionals to deliver cardiological services. About 250,000 children with congenital heart diseases (CHDs) require urgent surgery in SSA. Unfortunately, many Infants don’t reach their first birthday and die from congenital heart diseases (CHD) which is estimated to be as high as 48% or more. When the children survive into adulthood ( > 18 years of age) with CHD an estimated 76% of them will develop heart failure and die.
About five million people world-wide develop rheumatic heart disease (RHD) and causing 300,000 deaths a year. Two thirds of them are children. It is estimated that 817,000 children in sub-Saharan Africa with RHD will likely die in failure and be denied the opportunity to get surgical palliation or cure. Within the continent of Africa there is also wide variation in countries in terms of preventative education, available medication, and ongoing surveillance of afflicted children. Access to community screening programs is so limited that RHD is thought to be responsible for up to 30% deaths among school children in Uganda; In Ghana, by contrast, it is only 1-5% in Ghana. Poor availability, compliance to prophylactic and postoperative penicillin therapy, and congestive heart failure are now recognized as the principal predictors of a mortality from heart disease. Fatal outcomes are also associated with austere and severely deprived socioeconomic living conditions, poor school health education programs (SHEP) and accessibility to cardiac surgery. The recent survey by PASCaTS in 2022 revealed 30% rate of rheumatic valve repair in children as compared to 10% in 2012.
A strong political will to address cardiac disease, a long-term hospital partnership with its Healthcare Ministry and well thought strategic planning are required to develop a sustainable infrastructure and reduce disparities in access to surgical therapy.
In view of available limited and fragmented resources in SSA, centres in low-resource regions must engage with the MOH to develop low budget cardiac surgery and lead to providing more reliable access to cardiac services to the underserved.
Promoting cardiovascular education in Africa in partnership with EACTS, German Heart Center Charité Berlin, national and international centres.
Partnership with international institutions and EACTS as a professional organization for transfer of know-how is required to promote translational cardiovascular surgery in African centres to deliver efficient services and better outcome.
The main objective of Pan-African Society for Cardiothoracic Surgery (PASCaTS) is to promote a networking among heads of department of heart centres and cardiovascular physicians in Africa, in diaspora and the international community of cardiovascular physicians interested in cardiovascular health care in Africa. It has been pursuing continuing educational programs since its inception:
- Since 2011 PASCaTS has been organizing digital educational programs (webinars) in collaboration with German Heart Center Charité Berlin and our international cardiovascular partners. During the COVID-19 epidemic the webinars were held monthly and bimonthly. EACTS has been supporting on-site educational programs during the annual meetings entitled “ Joint EACTS/PASCaTS session..
- PASCaTS has been organizing Berlin-Africa workshops with speakers from Africa, China, Europe, India, Japan, South America and USA streamed to many African heart centres. It hosted a special delegation of Nigerian heart surgeons and hospital CEOs in collaboration with German Heart Center Charité Berlin in conjunction with World Health Summit
It has become the leading organization for cardiothoracic surgery practice in Africa, partnered by the German Heart Center Charité Berlin as a partner institution and by European Association for Cardiothoracic Surgery (EACTS) as a partner professional organization to support its cardiovascular surgical and educational activities, respectively.
The Joint EACTS/PASCaTS-GHC 2023 takes place on Thursday, 5th October at 13:45 – 14:45 (FOCUS SESSION) during the 37th EACTS annual meeting in Vienna. The theme is: “Clinical & translational cardiac surgery in low volume settings: Impact on sustainability & resilience in the global south health system”
The forum will identify and discuss disparities in cardiac surgery services in Africa, capacity building, and advanced training for the cardiac programs; the role of skill training on simulators and clinical research are now recognized as essential tools to build this clinical structure.
Low volume cardiac centres in Africa: Clinical and capacity building programs in Africa
Developing heart surgery program demands the highest level governmental support, philanthropy, a dedicated multidisciplinary team approach, profound know-how, leadership, international collaboration and the civil society.
Currently, cardiac surgical practice in SSA is supported to a varying extent by “fly in Safari” missions for 7-10 days to perform 15 – 20 surgical procedures and additional 30-150 open heart surgeries (OHS) per annum by the local teams. In some charity missions, the visiting team carry out the role of first assistants so that the local program leaders can develop their experience in the primary caregiving (and surgical) roles.
Impact measurement of the surgical performance is required for improvement of the services. In 2022 a survey of cardiac surgery capacity and performance of heart centres from six Sub-Saharan African countries (population 193 million) and four South American countries (population 117 million) was conducted. The ratio examining heart centre / number of heart surgeons / open heart surgery/million population for Africa was, 1:12 million, 1:4.5 million and 4:1 million respectively for Africa. By contrast, for South America it was; 1:1.6 million, 1:373,802 and 116:1 million, respectively.
In response to the great demand for clinical cardiac surgical services for the underserved communities in sub-Saharan Africa, PASCaTS started its clinical surgical program in 2010. Global Heart Care (GHC) as a task force was established for undertaking clinical surgical missions. It was formally inaugurated in 2022 and initiated missions for interventional cardiology to enhance the cardiovascular services in West Africa. GHC attempts to form a collaborative a network with African heart centres to help develop and improve cardiovascular interventions and surgeries in the context of north-south and south-south cooperation.
Its first successful mission was devoted to interventional pediatric cardiology procedures at the new University of Ghana Medical Centre (UGMC), Accra in May 2023. It was a joint multi-institutional mission (Germany, The Netherlands and South Africa).
Training the trainers programs for maintaining surgical skills
Although visiting teams do provide teaching programs during their short visits, the local surgeons in low volume centres need further regular surgical practice to maintain their skills.
PASCaTS has also been promoting and providing skill training courses for African surgeons practicing in low volume centres. Since 2019 it has provided simulation courses to young and senior surgeons in Africa to develop new surgical skills and and greater familiarity and comfort to take on more complex cases during their professional life.
These courses have included skill training on aortic and mitral valve repair, AVSD repair, Ozaki operation, and operative correction of TGA. The courses were held in Accra, Berlin and Milan under the tutorial guidance of Dr. Susan Vosloo, Prof. Tomasa Centella, Prof. Ottavio Alfieri, Prof. Michele de Bonis, Prof. Manuel Antunes, Prof. Joachim Photiadis, Prof. Joerg Kempfert and Prof. Yankah.
While developing a concept for south-south development cooperation we are currently seeking valve repair experts for on-site mentorship within the designated hubs of the sub-regions of Africa to assist this training development. PASCaTS established three regional simulation centres in Africa: Accra, Ghana, West Africa; Nairobi, Kenya, East Africa and Blida, Algeria, North Africa in 2019 and 2022. An additional centre within this collaborating network is in Bloemfontein, South Africa.
Promotion of clinical research
A] In 2022 PASCaTS initiated multi-centre non-randomized studies on “Concomitant Tricuspid Annuloplasty during Rheumatic Mitral Valve Surgery”. [The results will be presented on 5th October 2023 at the 37th annual meeting of EACTS in Vienna].
B] PASCaTS gives since 2022 an annual EACTS/GHC-PASCaTS Excellence Award. The prize is awarded for the best abstract on “Rheumatic Heart Valve Disease and Management of Associated Tricuspid Regurgitation” presented during the annual EACTS meeting. The abstract selected for this year’s award is entitled “Mid-term results of Ozaki aortic valve neo-cuspidization for rheumatic aortic valve disease: a prospective multicenter trial” We congratulate Dr. M. Sanad, Mansoura et al. for the award of €1,000 donated by Prof. Yankah
The unmet cardiac surgery capacity and performance in SSA
Ongoing cardiac surgery tourism: Those with some financial reserves fly themselves to India, South Africa or elsewhere for treatment and leave those patients who are among the poorest, behind.
The WHO recommendation for 400 open heart surgeries (OHS) per million population is not yet achieved, even the PASCaTS recommended 40 OHS per million is unmet by many centres in SSA.
We recommend that NGOs, industries and governments approach the medical care of children and those at risk of developing cardiac disease supported by a Universal health coverage plan. In some locations in which there is individual wealth, these may possibly be supported by philanthropic trust funds.
Though, cardiovascular surgery has now gained recognition as a legitimate component of universal health in the developing and emerging economies, it remains challenging to many national healthcare providers in low and middle income countries (LMICs).
A need for new concepts and strategic plans for sustainability and resilience
The cardiovascular health constraints experienced in the health delivery systems in SSA is therefore alarming. The leading health policy makers in SSA are expected to continue to play a crucial role by promoting effective models in collaboration with the visiting teams that will develop sustainable cardiac programs as opposed to fly in Safari missions.
As already recommended, there is a call to action among experienced ( + senior/retired) surgeons to take the initiative to lead this efforts on a full time pro bono basis to complement the contributions from government subsidies [Aldo Castaneda].
Full time dedicated teams focusing on developing regional hubs. It involves an investment of two million USD per annum for the salaries of a European heart team for two-three years. This concept was proposed by PASCaTS.
Rheumatic valve surgery in children and adolescents is becoming less frequent in some African countries (middle income) due to arising from improved pediatric care and access to penicillin therapy for rheumatic fever. Moderate to severe valvulopathies from Rheumatic heart disease develop scarring, deformation and progressive heart failure. Many of these present clinically beyond third to fourth decade and may be beyond repair and require replacement. Some intermediate to high risk patients may be considered for catheter based valve implantation.
The burden of cardiovascular disease in Africa is also becoming more prominent in life style related ischemic heart disease which is on the rise among the emerging middle class of African society. The recent studies of Pan-African Society for Cardiothoracic Surgery (PASCaTS) in 2022 revealed 5% CABG operation of the surgical load in SSA.
Conclusions
This article seeks to call upon stakeholders, foundations of global cardiovascular healthcare, professional organizations, industries and policy makers to focus on the needs of LMIC’s.
It is vital to establish regional centres of excellence to improve capacity building programs and surgical performance to provide adequate service to increasing number of patients among a growing population of 1.14 bn. (projected to double by 2050).
Prof. Dr. Charles Yankah
Cardiothoracic & Vascular Surgeon
President, PASCaTS-GHC`
Director, Humanitarian Cardiac Surgery – GHC
E-Mail: [email protected] Phone: +49-172-3020143
“Invitation to Pan-African cardiothoracic surgery summit 2025 in Ghana
PASCaTS has earmarked 2025 to organize a three day Pan-African Cardiothoracic Surgery Summit in Africa with its partners EACTS and STS to be held in the first quarter of 2025 in Accra, Ghana, inviting the global cardiovascular community to become fully engaged. Exact date for the summit will be announced and communicated after the EACTS meeting in Vienna. It will be a platform to strengthen its global network of heart centres and partners, develop mutual cooperation with the industries and activate north-south and south-south cooperation. A Pan-African Health Technology Summit will follow after the surgical meeting. The health tech summit aims at sharing knowledge in artificial intelligence in healthcare with academia, scientists, policy makers, civil society and the industries and prepare for future challenges. It will also provide a platform for improving clinical and university-business-technology partnership programs”.
Acknowledgement
We highly acknowledge the cooperation and contributions of the following colleagues for supporting the project.
Amanda Fowler, Vice President, Global Corporate Giving Executive Director, Edwards Lifesciences Foundaion, Irving, USA, Dr. Brian Duncan, Vice President, Medical Affairs, LivaNova, USA, Prof. Marko Turina, Prof. of Surgery, emeritus Dean, Univ of Zurich, Switzerland. Prof. Pieter Kappetein, Chief Medical Officer, VP, Medtronic, The Netherlands, Prof. Norberto de Vega, em. Cardiac Surgeon, Univ. of Malaga, Spain, Joachim Photiadis, Director, Pediatric Cardiac Surgery, Prof. Joerg Kempfert, Snr. Consultant Cardiac Surgeon, Dr. Mustafa Yigitbasi, Consultant Pediatric Cardiologist, Prof. Christoph Knosalla, Snr. Consulatant Cardiac Surgeon, PD. Dr. Axel Unbehaun, Snr. Consultant Cardiac Surgeon & MICS, PD. Dr. Christoph Klein, Interv Cardiologists, Dr. Frank Merkle, HOD, Cardiovascular Perfusion Academy, All from German Heart Center Charité Berlin, Germany, Dr. Andreas Kastener, Pediatric Cardiologist, Berlin, Ped. Cardiology Clinic, Berlin Germany, Dr. Rainer Kuhly, Consultant Anesthesiologist and Intensivist, Charité Medical University, Berlin, Germany, Constanze Buenner, Sophie Wolter, Ilka Brinkema, Intensive Care Nurses & Instructors, Charité Medical University, Berlin, Germany Berlin, Dr. Robert Wetzstein, Pediatric Cardiologist, Federal Military Hospital, Berlin, Germany, Anna Smit, Pediatric Anesthesiology Nurse, Leiden Univ. Medical Centre, Leiden, NL; Prof. Nicole Nadgyman, Snr. Consultant Congenital & Paediatric Cardiologist, Prof. Julie Cleuziou, Deputy Director, Prof. Juergen Hoerer, Director, Pediatric Cardiac Surgery, Prof. Markus Krane, Director, Adult Cardiac Surgery, German Heart Center Munich, Germany, Dr. Joachim Hebe, Co-Director Center for Electrophysiology Bremen, Lead of Pediatric and Congenital Heart Electrophysiology, Bremen, Germany, Prof. Michael Huebler, Director, Pediatric Cardiac Surgery, Univ Hospital Eppendorf, Hamburg, Germany, Dr. Susanne Vosloo, Consultant Pediatric Cardiac Surgeon, Christiaan Barnard Memorial Hospital, Cape Town, S. Africa, PD. Dr. Bettina Pfanmueller, Consultant Cardiac Surgeon, Heart Center Leipzig, Germany, Prof. J. Scott Rankin, Professor, Division of Cardiothoracic Surgery, WVU Heart & Vascular Institute, West Virginia University, Morgantown, WV., USA, Dr Emmanuel Lansac, Snr.
Consultant Cardiac Surgeon, Chirurgie Cardiaque, Institut Mutualiste Montsouris, Paris, France, Prof. Hans-Joachim Schaefers, Director, Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany, Prof. Jolanda Kluin, HOD, Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands, Prof. Dr. Carlos A. Mestres, Cardiothoracic Surgeon, Vice-President, PASCaTS, Barcelona, Spain, Prof. Jose Pomar, Cardiothoracic Surgeon, Barcelona, Spain, Dr. Ekaterina Ivanitskaia-Kuehn, Consultant Cardiologist, & Intensivists, Heart Centre Coswig and Thueringen Hospital, Saalfeld, Dr. Henning Kuehn, Chief, Dept. of Medicine III, Snr. Consultant Interv. Cardiologist, Saalfeld, Germany, Prof. Mohamed Debieche, HOD, Cardiovasc Surgery, University of Blida, Algeria, Dr. Ulrike Doll, Consultant Pediatric Cardiologist, Univ of Erlangen, Germany, Prof. Christine Yuko-Jowi, Consultant Pediatric Interv. Cardiologist, Kenyatta National & University Hosp., Nairobi, Kenya, Dr. Mark Nelson Awori, Head of Dept. Pediatric Cardiac Surgery, Gertrude’s Children’s Hospital & Kenyatta National & University Hosp., Nairobi, Kenya, Dr. Kow Entsua-Mensah, Consultant Pediatric Cardiothoracic surgeon, National Cardiothoracic Centre, Korle Bu Teaching Hospital, Accra, Ghana, Prof. Giovanni Stellin, Director, Pediatric Cardiac Surgery, School of Medicine, University of Padova, Italy, Dr. Bruno Murzi, Director, Pediatric Cardiac Surgery, Massa, Italy both doing charity surgical missions at the International Operation Centre for Children, Asmara (IOCCA), Asmara, Eritrea, Prof. Emile A. Bacha, Pediatric & Congenital Cardiac Surgeon, Chief, Cardiothoracic & Vascular Surg. Cong. & Pediatric Cardiac Surg.,NY Presbyterian Cong. Heart Centre, NY; USA., Dr. Gianluca Torregrossa, Director, Robotic Coronary Revasc. Program, Main Line Health –Lankenau Heart Inst. Philadelphia, USA; Prof. Mario Guadino, Director, Dept Cardiothoracic Surg.,Weill Cornell Medicine, Presbyterian Hosp. New York. Prof. Tomas A. Salermo, Cardiothoracic Surgeon, University of Miami, Vice Chair, Faculty Development & Mentoring: Jackson Health System, Miami, USA.