CHS-BUK LECTURE SERIES 28/03/2017

CHS-BUK LECTURE SERIES 28/03/2017
‘PREVENTION’ AND ‘SURGERY’ IN CONFRONTING THE TRAGEDY OF HEART DISEASES IN NIGERIA: Background, Realities and Challenges Jameel Ismail Ahmad MBBS, FWACS Department of Surgery, Bayero University, Kano Honorary Consultant Cardiothoracic Surgeon at Aminu Kano Teaching Hospital, Kano, Nigeria CHS-BUK LECTURE SERIES 28/03/2017

“There is a piece of flesh in the body if it becomes good (reformed) the whole body becomes good but if it gets spoiled, the whole body gets spoiled – and that is the HEART’’ CHS-BUK LECTURE SERIES 28/03/2017

OUTLINE 1. INTRODUCTION 2. BACKGROUND Basic anatomy and physiology Classification of heart diseases Prevention strategies Heart surgery: History, Principles, Programme, Recent advances 2. REALITIES: Epidemiology/ burden of heart diseases Available preventive measures Available surgical treatment 3. CHALLENGES: Prevention Surgery: -Challenges: Training, Infrastructure, Affordability -Domestic Collaborations -International/ Regional collaborations CASE STUDIES CHS-BUK LECTURE SERIES 28/03/2017

INTRODUCTION Heart diseases cause significant disability and deaths globally across age groups Account for high healthcare cost Sub-Saharan Africa and Nigeria are being increasingly affected The data for Heart diseases is mostly unreliable and often hospital based Modifiable risk factors for heart diseases can be targeted for primary and secondary prevention Diagnostic and interventional treatments although essential are often lacking or absent in low and middle income countries CHS-BUK LECTURE SERIES 28/03/2017

INTRODUCTION Heart Surgery is an important treatment strategy for heart diseases It is often absent in most SSA countries and most patients are unable to afford oversea (often intercontinental) surgical treatment Training, infrastructure, Equipments, logistics and selecting a sustainable heart surgery programme model are some of the challenges hampering the management of heart diseases in Nigeria CHS-BUK LECTURE SERIES 28/03/2017

BASIC ANATOMY CHS-BUK LECTURE SERIES 28/03/2017

BASIC PHYSIOLOGY CHS-BUK LECTURE SERIES 28/03/2017

CLASSIFICATION OF HEART DISEASES
CONGENITAL HEART DISEASES CORONARY ARTERY DISEASES VALVULAR HEART DISEASES OTHERS- Aortic, Pericardial Diseases, Arrhythmias and Sudden Death CHS-BUK LECTURE SERIES 28/03/2017

CONGENITAL HEART DISEASES-Classification
CYANOTIC CHD ACYANOTIC CHD Tetralogy of Fallot Truncus Arteriosus Total Anomalous Pulmonary venous Connection Tricuspid atresia Transposition of the great vessels Ventricular Septal Defect Atrial Septal Defect Patent Ductus arteriosus Coactation of the Aorta COMPLEX CHD Hypoplastic left heart syndrome Congenital coronary artery anomalies AVSD CHS-BUK LECTURE SERIES 28/03/2017

CONGENITAL HEART DISEASES
CHS-BUK LECTURE SERIES 28/03/2017

CONGENITAL HEART DISEASES Clinical features
Cyanotic CHD Acyanotic CHD Bluish discoloration/ darkening of lips, fingers, toes Squatting Hypercyanotic spells Failure to thrive Body weakness Recurrent Cough Dyspnoea Orthopnea PND Fever Leg/ abdominal swelling Failure to thrive Late cyanosis in some CHS-BUK LECTURE SERIES 28/03/2017

CONGENITAL HEART DISEASES-Risk factors
Genetic disorders -Single gene defects: Trisomy 13, 18 & 21 (Patau, Edwards & Down’s syndromes) Monosomy- Turners Syndrome 45X0 Tetrasomy- Cat-Eye Syndrome 22pter-q11 -Deletion- Cru-du-chat Syndrome 5p -Microdeletion- William syndrome 7q11, DiGeorge Syndrome Maternal diseases Diabetes mellitus, Rubella infection, Phenylketonuria, Febrile illness, Connective tissue diseases, Stress, Obesity Maternal drugs Phenytoin, Valproic acid, Lithium, Coumadin, Thalidomide, Ibuprofen, Naproxen, Septrin, Nitrofurantoin, ACE inhibitors, Tricyclic antidepressants Alcohol, Cigarette smoking, Cocaine & Marijuana Environmental exposures Organic solvents, Pesticides, Air Pollution-CO, NO CHS-BUK LECTURE SERIES 28/03/2017

CORONARY ARTERY DISEASES
CLASSIFICATION: Stable Angina Acute Coronary Syndrome -Unstable Angina -STEMI -NSTEMI CHS-BUK LECTURE SERIES 28/03/2017

CORONARY ARTERY DISEASES: Risk factors
BEHAVIOURAL RISK FACTORS Tobacco use Physical inactivity Unhealthy diet (rich in salt, fat and calories) Harmful use of alcohol. METABOLIC RISK FACTORS Raised blood pressure (hypertension) Raised blood sugar (diabetes) Raised blood lipids (e.g. cholesterol) Overweight and obesity. OTHER RISK FACTORS Poverty and low educational status Advancing age Gender Inherited (genetic) disposition Psychological factors (e.g. stress, depression) Other risk factors (e.g. excess homocysteine CHS-BUK LECTURE SERIES 28/03/2017

CORONARY ARTERY DISEASES: Risk factors
NON-MODIFIABLE MODIFIABLE Male gender Advanced age Family history of heart diseases Tobacco smoking Hyperlipidemia Hypertension Diabetes mellitus Physical inactivity Diet and Obesity Stress Excess alcohol intake ? others CHS-BUK LECTURE SERIES 28/03/2017

VALVULAR HEART DISEASES
MITRAL VALVE INCOMPETENCE MITRAL VALVE STENOSIS CHS-BUK LECTURE SERIES 28/03/2017

VALVULAR HEART DISEASES Clinical Features
MITRAL VALVE INCOMPETENCE MITRAL VALVE STENOSIS Easy fatiguability Palpitations Exertional dyspnoea Leg and abdominal swelling Orthopnoea PND Exertional dyspnoea Orthopnoea PND Easy fatiguability Leg and abdominal swelling Haemoptysis Cerebral/ extremity embolism Cardiac cachexia CHS-BUK LECTURE SERIES 28/03/2017

VALVULAR HEART DISEASES
AORTIC VALVE INCOMPETENCE AORTIC VALVE STENOSIS CHS-BUK LECTURE SERIES 28/03/2017

VALVULAR HEART DISEASES Clinical Features
AORTIC VALVE INCOMPETENCE AORTIC VALVE STENOSIS Dyspnoea Orthopnoea Cough PND Chest pain Left sided Chest pain Syncopal attacks Dyspnoea Orthopnoea Cough PND CHS-BUK LECTURE SERIES 28/03/2017

VALVULAR HEART DISEASES: Risk factors
Rheumatic Heart Diseases Infective endocarditis Ischemic heart disease Annular calcification Congenital valvular diseases-Bicuspid aortic valves, AVSD Connective tissue diseases- Marfan’s, Ehlers-Danlos syndromes Aortic dissection Others CHS-BUK LECTURE SERIES 28/03/2017

HEART DISEASES PREVENTION STRATEGIES: Confronting the modifiable Daggers World Health Organisation (WHO) defines a RISK FACTOR ………as any attribute, characteristic or exposure of an individual; which increases the likelihood of developing a disease CHS-BUK LECTURE SERIES 28/03/2017

Integrated primary and secondary prevention for Heart diseases-Adapted from Stewart S, Carrington MJ, Slewa K. Barriers and challenges for primary and secondary prevention of heart disease in sub-Saharan Africa. SAHeart 2011; 8:96-102 0-5 years 6-14 years 15-24 years 25-44 years 45+ years Maternal health programmes Early childhood surveillance Proactive primary prevention Aggressive secondary prevention Screening for congenital diseases Establishing health lifestyles Detect early disease Chronic disease management CHS-BUK LECTURE SERIES 28/03/2017

HEART DISEASES PREVENTION STRATEGIES: Confronting the modifiable Daggers SAFE PREGNANCY Prevention of sexually transmitted infections Health education against uncontrolled use of prescribed drugs Enlightenment against the use of recreational drugs, including alcohol and tobacco Legislation controlling management of toxic chemicals (e.g. certain agricultural chemicals) Vaccination against rubella Fortification of basic foods with micronutrients (iodine and folic acid) Policies to optimize women’s diet before and throughout pregnancy Proper and targeted antenatal care-Fetal Echo CHS-BUK LECTURE SERIES 28/03/2017

HEART DISEASES PREVENTION STRATEGIES: Confronting the modifiable Daggers DIABETES HYPERTENSION Defined as having a fasting plasma glucose value ≥ 7.0 mmol/l (126 mg/dl) A major risk factor of CVD Caused 1.3 million deaths worldwide CVD accounts for about 60% of all mortality in people with diabetes Early detection and treatment of diabetes is essential for prevention of heart attacks Accounts for 12.8% of global death (7.5 million deaths) A major risk factor for CHD and CVA, HF, CKD, PVD etc. Global prevalence in adults aged 25 and over around 40% (nearly one billion )in 2008 Highest in African Region- 46% and lowest in the Americas-35% Policies to reduce salt, physical activity and pharmacological treatment can have impact CHS-BUK LECTURE SERIES 28/03/2017

HEART DISEASES PREVENTION STRATEGIES: Confronting the modifiable Daggers TOBACCO SMOKING EXCESS ALCOHOL A risk factor for hypertension, acute myocardial infarction, cardiomyopathy, cardiac arrhythmia Hazardous and harmful drinking was responsible for 2.5 million (3.8%) deaths worldwide in 2004 A direct relationship between higher levels of alcohol consumption and the pattern of binge drinking (defined as 60 or more grams of pure alcohol per day) with the risk of CVD Cause about 10% of CVD There are about one billion smokers in the world The prevalence of daily tobacco smoking varied worldwide ( 31% in the European Region, 10% in the African Region) Exposure to second-hand smoke About six million people die from tobacco use and exposure to second hand smoke each year Projected 8 million deaths every year by 2030 CHS-BUK LECTURE SERIES 28/03/2017

HEART DISEASES PREVENTION STRATEGIES: Confronting the modifiable Daggers CHOLESTEROL OBESITY LDL; HDL; Triglycerides Excess calories in the body are converted into triglycerides and stored in fat cells throughout the body LDL cholesterol is deposited in the walls of arteries and causes atherosclerosis HDL cholesterol protects High triglycerides increase the risk of atherosclerotic CVD. Globally, one third of ischemic heart disease is attributable to high cholesterol and cause 2.6 million deaths (4.5% of total) The prevalence is lowest in the African and South-East Asia Regions (23% and 30%, respectively) The prevalence increases according to the income level of the country Account for about 2.8 million deaths yearly globally Relationship between overweight or obesity and cardiovascular morbidity, CVD mortality and total mortality Median BMI for adult populations -21–23 kg/m2 Goal for individuals is BMI of 18.5–24.9 kg/m2 Socioeconomic status is related to obesity CHS-BUK LECTURE SERIES 28/03/2017

HEART DISEASES PREVENTION STRATEGIES: Confronting the modifiable Daggers INSUFFICIENT PHYSICAL ACTIVITY Defined as “less than 5 times 30 minutes of moderate activity per week, or less than 3 times 20 minutes of vigorous activity per week, or equivalent.” The fourth leading risk factor for mortality: Nearly 3.2 million deaths yearly In adults, participation in 150 minutes of moderate physical activity each week (or equivalent) is estimated to reduce the risk of ischaemic heart disease by approximately 30% and the risk of diabetes by 27% Highest in the Americas and Eastern Mediterranean Regions CHS-BUK LECTURE SERIES 28/03/2017

HEART DISEASES PREVENTION STRATEGIES: Confronting the modifiable Daggers IDENTIFICATION AND TREATMENT OF RHEUMATIC FEVER Rheumatic fever is common among children and adolescents living in poor socioeconomic conditions Overcrowding, poor housing conditions, undernutrition and lack of access to healthcare contribute to its persistence in developing countries Acute rheumatic fever primarily affects the heart, joints and central nervous system due to molecular mimicry It can cause Pancarditis but commonly affect the heart valves Surgery is often required CHS-BUK LECTURE SERIES 28/03/2017

Pathogenesis and natural history of Rheumatic Heart Disease
Hewitson J, Zilla P. Children’s Heart Disease in Sub-Saharan Africa: Challenging the burden of Disease. SAHeart 2010;7:18-29 First infection with group A B-haemolytic streptococcus Subsequent infection with group A B-haemolytic streptococcus Assume low incidence = 5 million Africans Assume likely incidence = 30 million Africans 3% Acute Rheumatic fever 75% 40-80% HAVE CARDITIS of which 90% PROGRESS TO RHEUMATIC HEART DISEASE 20% DIE BY 15 YEARS 70% DIE BY 25 YEARS CHS-BUK LECTURE SERIES 28/03/2017

HEART DISEASES PREVENTION STRATEGIES: Confronting the modifiable Daggers IDENTIFICATION AND TREATMENT OF RHEUMATIC FEVER Account for about deaths annually At least 15.6 million people are estimated to be currently affected by rheumatic heart disease Primary prevention: Treatment of acute throat infections caused by group A streptococcus Secondary prevention is used following an attack of acute rheumatic fever Secondary prevention programmes are currently thought to be more cost effective for prevention of rheumatic heart disease than primary prevention and may be the on CHS-BUK LECTURE SERIES 28/03/2017

Guidelines Preferred antibiotic Intramuscular benzathine benzylpenicillin doses Interval of benzathine injections Oral alternative treatments and doses Duration Year WHO Benzathine penicillin G <30 kg U ≥30 kg: U 21 days if high risk 28 days if low risk Phenoxymethylpenicillin 250 mg twice daily No evidence of carditis: 5 years since last attack or 18 years* Resolved carditis: 10 years since last attack or 25 years old* Moderate –severe or surgery: Lifelong. 2001 South Africa Benzathine penicillin G <30 kg – U ≥ 30kg: U 3 weekly ≥30 kg :250 mg twice daily <30 kg :125 mg twice daily No evidence of carditis: 5years Established: 10 years since last attack or 25 years old Severe/post valve replacement: 1997 CHS-BUK LECTURE SERIES 28/03/2017

Seven Key Actions to Eradicate Rheumatic Heart Disease in Africa: The Addis Ababa Communiqué Cardiovasc J Afr 2016; 27: 184–187 Establish prospective RHD registers. These would occur at sentinel sites in AU member states affected by ARF/RHD. The major objective of these registers will be to monitor progress towards RHD-related health outcomes, which include a 25% reduction in premature mortality from RHD by the year 2025 Ensure adequate supplies of benzathine penicillin G (BPG). The WHO recognises BPG as an essential medication. In order to achieve adequate coverage of primary and secondary prevention measures for ARF/RHD, BPG must be readily available at all primary care facilities in AU member states, and training of providers on effective and safe use of BPG should be part of supply-side efforts. BPG can also be used for the treatment of other endemic diseases in Africa, such as syphilis, yaws and sickle cell disease. Guarantee universal access to reproductive health services for wmen with RHD. RHD greatly increases a woman’s risk of mortality and foetal demise during pregnancy. Reproductive health services, including contraception, are currently underutilised among women with RHD in Africa and this contributes to the high maternal mortality rates on the continent. Comprehensive care for RHD and other NCDs should include access to reproductive health services for all women at risk. CHS-BUK LECTURE SERIES 28/03/2017

Seven key actions to eradicate rheumatic heart disease in Africa: the Addis Ababa communiqué Cardiovasc J Afr 2016; 27: 184–187 4. Decentralize diagnostic services for ARF/RHD to district hospitals. Primary healthcare services and district hospitals need appropriate technical expertise in the diagnosis of ARF and RHD. Key point-of-care technologies that should be considered for provision at district and community levels include ultrasound of the heart (echocardiography), anticoagulation testing, and antigen tests for the rapid diagnosis of group A streptococcal pharyngitis 5. Establish cardiac surgery centers of excellence. Such facilities could sustainably deliver state-of-the-art surgical care as well as train the next generation of African cardiac specialists. They could also be centers of research on endemic cardiovascular diseases (including RHD). 6. Foster multi-sectoral and integrated national RHD control programmes led by ministries responsible for health. These programmes would oversee the implementation of national RHD action plans and progress towards the ‘25-by-25’ targets. 7. Cultivate partnerships that can implement the actions above. A partnership needs to be developed between the AU commission, ministries responsible for health, international agencies, governments, industry, academia, civil society and other relevant stakeholder to monitor and evaluate progress related to the implementation of the key actions and achievement of the outcome of 25% reduction in premature mortality from RHD by the year 2025. CHS-BUK LECTURE SERIES 28/03/2017

WHO and International Society of Hypertension (ISH) cardiovascular risk prediction chart 10 year risk of a fatal and non-fatal cardiovascular event CHS-BUK LECTURE SERIES 28/03/2017

Bolivia's Tsimane have healthiest hearts: study Scientists say findings underline significance of lowering risk factors for heart disease such as smoking and drinking. Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study LANCET 705 Tsimane participants compared to 6,800 Americans Americans have 5 times risk of developing heart disease 9 in 10 had no risk of heart diseases Average middle age has arteries that are about 28 years younger than that of westerners Gradually introduction to processed food and motorized canoes leads to gradual increase in cholesterol Physically active-4-7 hours daily Consume diet low in fat and sugar Do not commonly smoke cigarette Do not often drink alcohol CHS-BUK LECTURE SERIES 28/03/2017

“There is a tendency to blame your genes for heart problems and what this study shows us is that you can’t blame your parents , just your lifestyle” -Dr. Randall Thompson, St. Luke Health system in Kansas city, Missouri CHS-BUK LECTURE SERIES 28/03/2017

“You cannot have an effective prevention programme if you don’t treat those affected by the disease today.” – Daniel Sidi , Nov.3rd 2008, SAHA meeting CHS-BUK LECTURE SERIES 28/03/2017

HISTORY OF HEART SURGERY
Milestone Date Pioneer Location B-T SHUNT November 1944 Alfred Blalock, Helen Taussig, Vivian Thomas Baltimore, USA 1st Successful use of heart-lung machine to repair ASD 6th may, 1953 John H. Gibbon Jefferson Hospital, Philadelphia VSD closure using cross circulation 26th March 1954 C. Walton Lillehei University of Minnesota VSD repair using HLM 22nd march 1955 John Kirklin Mayo clinic ASD REPAIR March 1958 Christian Barnard Red Cross War Memorial Children’s hospital, Cape Town, SA Aortic Valve replacement 1960 Dwight Harken CABG (RIMA-RCA) 2nd May, 1960 Robert H. Goetz Van Etten Hospital, New York CABG (SVG) 23rd November 1964 DeBakey at al Heart transplantation 3rd December 1967 Groote Schuur Hospital, Cape town, SA CHS-BUK LECTURE SERIES 28/03/2017

HISTORY OF HEART SURGERY-BT Shunt (Alfred Blalock, Helen Taussig, Vivian Thomas) CHS-BUK LECTURE SERIES 28/03/2017

HISTORY OF HEART SURGERY John H. Gibbon; C. Walton Lillehei (Father of open heart surgery); John Kirklin CHS-BUK LECTURE SERIES 28/03/2017

Cross-Circulation A procedure with 200% potential mortality

CHRISTIAN BARNARD CHS-BUK LECTURE SERIES 28/03/2017

HISTORY OF HEART SURGERY IN AFRICA
Milestone Year Procedure Country Charles O. Easmon 1960 Closed Mitral commissurotomy Ghana John Weaver Nigeria 1964 ASD closure under hypothermia Magdi Yacoub & Udekwu 1974 First open heart surgery in WA Grillo, Adebonojo et al 1978 First open heart Surgery at UCH, Ibadan Cardiac institute in Abidjan First Cardiac Centre in WA Cote D’ivoire Anyanwu, Aghaji et al 1988 First National centre of excellence for CVDs in Enugu Frimpong-Boateng K. 1989 National cardiothoracic centre: Most sustainable centre Ndiaye et al. 1990 Senegal heart centre Senegal

PRINCIPLES OF OPEN HEART SURGERY

PRINCIPLES OF OPEN HEART SURGERY
Heart-Lung machine priming Anesthesia and monitoring Anticoagulation Venous and Aortic cannulation Going on-Pump Decannulation Reversal of antiocoagulation Closure Intensivist care CHS-BUK LECTURE SERIES 28/03/2017

SURGERY FOR CONGENITAL HEART DISEASES (ASD/ VSD)

SURGERY FOR CONGENITAL HEART DISEASES (PDA/ TGA)

SURGERY FOR CORONARY ARTERY DISEASES

SURGERY FOR VALVULAR HEART DISEASES MVR/ AVR

RECENT ADVANCES IN OPEN HEART SURGERY

RECENT ADVANCES IN OPEN HEART SURGERY Minimally invasive Aortic valve replacement CHS-BUK LECTURE SERIES 28/03/2017

RECENT ADVANCES IN OPEN HEART SURGERY Hybrid Heart Surgeons

RECENT ADVANCES IN OPEN HEART SURGERY Robotic Cardiac Surgery

HEART SURGERY PROGRAMME MODELS IN AFRICA
MODEL I: Ghanaian-German and Namibian model Expatriate Cardiac teams establish cardiac centers with a resident local expert who remains behind to head the center until it is gradually weaned off by the collaborating team and it becomes independent MODEL II: Cardiac Missions (About 22 centers) Expatriate visiting teams visit to conduct cardiac surgeries usually within 1-2 weeks and conducted once or twice per year. Needed staff and instruments are brought and completely relies on the foreign teams. it is usually not sustainable and does not provide local training. It is sometimes independent of the local experts Cardiac missions started in Nigeria in 1974 and its yet to establish a reliable cardiac surgery programme MODEL III: Kenya model This model involves a senior expatriate surgeon employed by the host country to establish the cardiac programme. It is not commonly practiced and relies on the government interest but it may be better than model II CHS-BUK LECTURE SERIES 28/03/2017

GLOBAL PICTURE Cardiovascular diseases are the commonest cause of death globally An estimated 17.5 million people died from CVDs in 2012, representing 31% of all global deaths Of these deaths, an estimated 7.4 million were due to coronary heart disease Over three quarters of CVD deaths take place in low- and middle-income countries. Out of the 16 million deaths under the age of 70 due to non-communicable diseases, 82% are in low and middle income countries and 37% are caused by CVDs. Prevention by addressing behavioral risk factors Early detection and management of cardiovascular diseases Global Atlas on Cardiovascular disease prevention and control. WHO ,WHF, WSO CHS-BUK LECTURE SERIES 28/03/2017

GLOBAL PICTURE CHS-BUK LECTURE SERIES 28/03/2017

EPIDEMIOLOGIC TRANSITION ……….The American Scenario
Before 1900 Age of pestilence and Famine Age of Receding Pandemics Age of Degenerative Man-made Diseases Age of Delayed Degenerative Diseases ? Beyond 2000 Age of Inactivity and Obesity CHS-BUK LECTURE SERIES 28/03/2017

EPIDEMIOLOGIC TRANSITION
Stage of development Deaths from CVDs (% of total deaths) Predominant CVDs and risk factors Regional examples Age of pestilence and Famine 5-10% Rheumatic heart diseases, Infections, Nutritional cardiomyopathies SSA, Rural India, South America Age of Receding Pandemics 10-35% Above plus Hypertensive heart diseases, Hemorrhagic strokes China, Urban Africa Age of Degenerative Man-made Diseases 35-65% All forms of stroke, Ischaemic heart disease at young ages, increasing obesity, diabetes Urban India, Former Socialist economies, Aboriginal communities Age of Delayed Degenerative Diseases <50% Stroke and ischaemic heart diseases at old age Western Europe, North America, Australia, New Zealand CHS-BUK LECTURE SERIES 28/03/2017

Bulk stagnation……Select leap-frogging. ……
Bulk stagnation……Select leap-frogging. …….The transition for the Developing World Age of Inactivity and Obesity Age of Delayed Degenerative Diseases Age of Degenerative Man-made Diseases Age of Receding Pandemics Age of pestilence and Famine CHS-BUK LECTURE SERIES 28/03/2017

HEART DISEASES DATA IN AFRICA
Lack of reliable prospective population-based data Lack of diagnostic techniques Paucity of trained manpower Unsubstantiated beliefs about heart diseases in Africa Lack of interest by authorities CHS-BUK LECTURE SERIES 28/03/2017

Spectrum of heart diseases in children: an echocardiographic study of 1,666 subjects in a pediatric hospital, Yaoundé, Cameroon David Chelo1,2, Félicitée Nguefack1,3, Alain P. Menanga4,5, Suzanne Ngo Um1,2, Jean C. Gody6, Sandra A., Tatah2, Paul O. Koki Ndombo1,2 Congenital Heart disease 1,230 (73.8%) VSD-37.2% PS-15.0% PDA-13.7% ASD-11.1% ToF-8.2% AVCD-5.3% Congenital heart Disease and Rheumatic Heart Disease in Africa: Recent advances and current priorities Zuhlke L, Mirabel M, Marijon E. Heart doi: /heartjnl A global birth prevalence of 8/ 1000 live birth is taken In Cameroon, 13.1% of patients with suspected Cardiac pathologies were found to have CHD In Maputo, a prevalence of 2.3/1000 among a population of public school children was found CHS-BUK LECTURE SERIES 28/03/2017

Spectrum of congenital heart diseases in a tropical environment: an echocardiographic study. Sani MU, Mukhtar-Yola M, Karaye KM. J Natl Med AssocJun 2007;99(6): A 4-year echocardiographic study involving 2 centres in Kano (AKTH inclusive) over 48 months Revealed 122 (9.3%) patients with CHD out of 1312 patients with abnormal findings 33.6% reporting before 1 year of age VSD- 45.9% TOF- 26.2% ASD- 12.3% ECCD- 7.4% CHS-BUK LECTURE SERIES 28/03/2017

Profile of congenital heart defects among children at Aminu Kano Teaching Hospital, Kano, Nigeria Asani M, Aliyu I, Kabir H. J Med Trop 2013;15:131-4. 506 children with age range: 5 days and 15 years (3.29 ± 2.56) 173 (34.2%) had CHD M: F ratio of 3:2. 48.6% were 1 year and younger Ventricular septal defect (30.6%) Tetralogy of fallot (16.7%) Atrial septal defect (12.1%) Patent ductus arteriosus (10.9%) Endocardial cushion defect (8.8%) Tricuspid atresia (4.6%) Truncus arteriosus (2.3%) CHS-BUK LECTURE SERIES 28/03/2017

Characteristics, complications and gaps in evidence-based interventions in rheumatic heart disease: The Global Rheumatic Heart Disease Registry (The REMEDY study). Zuhlke L, Engel ME, Karthikeyen G, Rangarajan S, Mackie P, Cupido B. Eur heart J 2015;36: The REMEDY study was conducted in 25 hospitals in 12 African countries, India and Yemen (including AKTH) High prevalence of Rheumatic heart diseases (RHD) which is commoner among young patients (66.2%) who have moderate to severe valvular heart disease Complications: CHF (33.4%), PHT (28.8%), AF (21.8%), stroke (7.1%), infective endocarditis (4%), and major bleeding (2.7%) Fifty-five percent were on secondary antibiotic prophylaxis Oral anticoagulants prescribed in 69.5% of patients with mechanical valves, AF and high-risk mitral stenosis in sinus rhythm (n ¼ 48) Only 28.3% had a therapeutic INR Among 1825 women of childbearing age (12–51 years), only 3.6% (n ¼ 65) were on contraception, 20.6% of pregnant women on Warfarin Only 27.8% and 4% have access to Surgical valve replacement/ Repair and Percutaneous valvoplasty respectively CHS-BUK LECTURE SERIES 28/03/2017

Congenital heart Disease and Rheumatic Heart Disease in Africa: Recent advances and current priorities Zuhlke L, Mirabel M, Marijon E. Heart doi: /heartjnl CHS-BUK LECTURE SERIES 28/03/2017

Prevalence and pattern of rheumatic heart disease in the Nigerian savannah: an echocardiographic study MAHMOUD U SANI, KAMILU M KARAYE, MUSA M BORODO Cardiovasc J Afr 2007; 18: 295–299 A total of echocardiographic examinations done in two centres over 48 months 129 patients (9.8%) had an echocardiographic diagnosis of RHD Males to females ratio- 1:1.7 Abnormalities MR-38% MS-7.8% Mixed Mitral Valve Disease- 27.9% AR-3.1% Mixed Aortic and Mitral valve disease- 19.5% CHS-BUK LECTURE SERIES 28/03/2017

CORONARY ARTERY DISEASE Changing Trend in Coronary Heart Disease in Nigeria Nwaneli CU. AFRIMEDIC Journal, Volume 1, Number 1, January-June 2010 YEAR Result LOCATION INVESTIGATORS 10 cases, MI admission rate 1 in 20,000 UCH Ibadan Falase et al. 1986 Necropsy= 8/111 (7.2%) Ile-Ife Ogunowo et al. 1 in 13,500 medical admissions LUTH Oke and Talabi 2.6% of ICU admissions Oke and Adebola 10 cases ABUTH Danbauchi CHS-BUK LECTURE SERIES 28/03/2017

Ischaemic heart disease in Aminu Kano Teaching Hospital, Kano, Nigeria: A 5-year review. Sani MU, Adamu B, Mijinyawa MS, Abdu A, Karaye KM, Maiyaki MB et al. Niger J Med Apr-Jun 2006;15(2): Ischaemic heart diseases although reported to be low is now on the rise IHD constitute 0.9% of all medical conditions Contribute 3.4% of cardiovascular cases admitted.5 Myocardial infarction- 47.8% Ischemic cardiomyopathy- 30.4% Angina- 21.7% Nigerians- 89.1%; Lebanese-6.5%, Indians-2.2%, Pakistanis-2.2% Risk factors: Hypertension in 80.4%, Diabetes in 34.8%, Dyslipidaemia in 43.5%, Cigarette smoking, Obesity. CHS-BUK LECTURE SERIES 28/03/2017

The Impact of Income on the Echocardiographic Pattern of Heart Diseases in Kano, Nigeria Karaye KM, Sani MU, Nig J. Med. July-August 2008:17(3); A one year period (July 2006-June 2007) study Patients age: ≥ 15 years Hypertensive heart disease-56.7% Dilated cardiomyopathy-15.2% Ischemic Heart Disease (IHD)- 8.7% Rheumatic heart disease- 8.3% CHS-BUK LECTURE SERIES 28/03/2017

IHD: Personal experience Ghana vs. India
ACS account for about 10% of admissions there At NCTC, Accra, Coronary artery Bypass graft surgery constituted only about 1% of all surgeries India At Medanta-Medicity hospital, Coronary artery Bypass graft surgery constituted about 75%% of all surgeries CHS-BUK LECTURE SERIES 28/03/2017

AVAILABLE PREVENTIVE MEASURES World Health Organization – Non-communicable Diseases (NCD) Country Profiles, 2014. NATIONAL SYSTEMS RESPONSE TO NCDS Has an operational NCD unit/branch or department within the Ministry of Health, or equivalent No Has an operational multisectoral national policy, strategy or action plan that integrates several NCDs and shared risk factors NO Has an operational policy, strategy or action plan to reduce the harmful use of alcohol Has an operational policy, strategy or action plan to reduce physical inactivity and/or promote physical activity Has an operational policy, strategy or action plan to reduce the burden of tobacco use Has an operational policy, strategy or action plan to reduce unhealthy diet and/or promote healthy diets Has evidence-based national guidelines/protocols/standards for the management of major NCDs through a primary care approach Has an NCD surveillance and monitoring system in place to enable reporting against the nine global NCD targets Yes Has a national, population-based cancer registry CHS-BUK LECTURE SERIES 28/03/2017

AVAILABLE PREVENTIVE MEASURES: Population Strategies
AVAILABILITY Socio-economic development Reduce burden of infection & malnutrition Enhance maternal & childhood health services School-based health surveillance & health programmes Tobacco control, salt reduction & healthy food supply Primary health surveillance & treatment services Whole population treatment programmes - ”polypill” Secondary prevention/heart disease care services CHS-BUK LECTURE SERIES 28/03/2017

AVAILABLE PREVENTIVE MEASURES: Individual Strategies
AVAILABILITY Surgery for congenital abnormalities Early detection & prophylaxis for potential RHD Family-based interventions to reduce risk Individual health coaching & training CV risk profiling & treat to ideal targets CV screening & treatment of at risk individuals Secondary prevention programmes for tertiary cases Chronic disease care programmes for advanced cases CHS-BUK LECTURE SERIES 28/03/2017

AVAILABLE DIAGNOSTIC TECHNIQUES
AVAILABILITY CHEST X-RAY TRANSTHORACIC ECHOCARDIOGRAPHY TRANSESOPHAGEAL ECHOCARDIOGRAPHY ELECTROCARDIOGRAPHY STRESS ECG TEST CARDIAC ENZYMES AND MARKERS CORONARY ANGIOGRAPHY CT ANGIOGRAPHY MRANGIOGRAPHY CHS-BUK LECTURE SERIES 28/03/2017

AVAILABLE NON-SURGICAL INTERVENTIONS
CATHLABS: There are about 12 Cath-labs but only 3 are significantly functional albeit at a reduced potential The functioning Cath-labs (2 private and 1 PPP): located in Abuja, Osun and Lagos The main challenge is lack of trained resident interventional cardiologist apart from affordability CHS-BUK LECTURE SERIES 28/03/2017

OPEN-HEART SURGERY Pezzella AT
OPEN-HEART SURGERY Pezzella AT. Global expansion of Cardiothoracic Surgery- The African challenge. Yankah C, Fynn-Thompson F, Antunes M, Edwin F, Yuko-Jowi C, Mendis S. Cardiac Surgery capacity in Sub-Saharan Africa: Quo Vadis. Thorac Cardiovasc Surg 2014;62: Open heart surgery (OHS) is usually a pacesetter and a prerequisite for the introduction of other sophisticated Cardiovascular and Thoracic interventions and procedures The majority of Heart diseases requiring intervention in SSA will require OHS About 1.5 million OHS are performed each year by 6,000 surgeons in over 3,000 centres world-wide Volume of OHS is the lowest in Africa where 18 OHS are done for one million people (1 centre / 33 million people) compared to the North American figures of 1222 OHS per a million population (1 centre/ 120,000 people)

OPEN-HEART SURGERY Pezzella AT. Global expansion of Cardiothoracic Surgery- The African challenge. Yankah C, Fynn-Thompson F, Antunes M, Edwin F, Yuko-Jowi C, Mendis S. Cardiac Surgery capacity in Sub-Saharan Africa: Quo Vadis. Thorac Cardiovasc Surg 2014;62: North Africa has 3 cardiac surgeons per a million of population Sub-Saharan Africa has 1 surgeon per 3.3 million of population West Africa has 5 centres translating into I centre per 63.7 million people only worse than central africa About 2,500 OHS are estimated to be done in West Africa yearly to fill in the gap but the total being done is about 800 (including all the cardiac fly-in missions) CHS-BUK LECTURE SERIES 28/03/2017

OPEN-HEART SURGERY Yankah C, Fynn-Thompson F, Antunes M, Edwin F, Yuko-Jowi C, Mendis S. Cardiac Surgery capacity in Sub-Saharan Africa: Quo Vadis. Thorac Cardiovasc Surg 2014;62: CHS-BUK LECTURE SERIES 28/03/2017

OPEN-HEART SURGERY Population density where heart surgery services are most needed Countries where heart surgery is done outside South Africa CHS-BUK LECTURE SERIES 28/03/2017

OPEN-HEART SURGERY Babcock-Tristate-JNCI tripartite programme Cardiac missions: UNTH ENUGU LASUTH LAGOS NHA ABUJA GARKI HOSPITAL ABUJA NIZAMIYE HOSPITAL ABUJA UCH IBADAN UITH ILORIN LUTH LAGOS OAUTH IFE CHS-BUK LECTURE SERIES 28/03/2017

PREVENTION: Healthcare personnel
Lack of reliable population-based African Heart Diseases Data Paucity of heart diseases translational research Reaching the target population Communication Training and facilities for early detection of heart diseases Risk assessment: clinical and easily applicable like the WHO CHS-BUK LECTURE SERIES 28/03/2017

PREVENTION: Community
Community participation and integration Health education on behavioral modifications North Karelia Project in Finland -Health Education, screening, control and treatment of Hypertension -CHD decline by 73% after 25 years Mauritius intervention -Switching cooking oil from saturated palm oil fat to unsaturated soy-bean fatty acids -14% cholesterol decline after 5 years Coronary Risk factor study, South Africa -Mass media message, group-sponsored education, screening and follow-up Bonow RO, Mann DL, Zipes DP, Libby P. Braunwald’s Heart Disease, A Textbook of Cardiovascular Medicine. Ninth edition CHS-BUK LECTURE SERIES 28/03/2017

PREVENTION: Government policies and legislations
Tobacco smoking Lipid reduction Salt reduction Provision and maintenance of sports and recreational centers CHS-BUK LECTURE SERIES 28/03/2017

SURGERY: Concept and Model selection
MODEL I: GHANAIAN-GERMAN AND NAMIBIAN-SA MODEL Expatriate Cardiac teams establish cardiac centers with a resident local expert The resident local expert remains behind to head the centre The expatriate team is gradually weaned off by the collaborating team The local team becomes independent CHS-BUK LECTURE SERIES 28/03/2017

SURGERY: Training The team: Surgeons, Cardiologists, Anesthetists/ Intensivists, Perfusionists, Nurses, pharmacists, Physiotherapists etc. Mode of training: Organized Team training Scattered individual explorative Collaborative Proctoring CHS-BUK LECTURE SERIES 28/03/2017

SURGERY: Equipments Diagnostic

SURGERY: Equipments Theatre

SURGERY: Equipments ICU

SURGERY: Affordability
OHS COST ($) GHANA INDIA UK USA NIGERIA ASD REPAIR 8,000 7,000 60,992 6,200 CABG 12,000 23,000 100,000 8,430 (OPCAB) MVR 9,000 10,000 28,000 140, 000 11,200 CHS-BUK LECTURE SERIES 28/03/2017

SURGERY: Affordability
Out-of-pocket payment Health insurance Philanthropy: Individual Heart foundation: KANO HEART FOUNDATION CHS-BUK LECTURE SERIES 28/03/2017

DOMESTIC COLLABORATIONS
HEART SURGERY PROGRAMME GOVERNMENT PHILANTHROPY DIASPORA EXPERTS PRIVATE SECTOR TECHNOLOGY CHS-BUK LECTURE SERIES 28/03/2017

International/ Regional collaboration:
North-South East-West South-South collaboration CHS-BUK LECTURE SERIES 28/03/2017

Case study 1: Ghana CHS-BUK LECTURE SERIES 28/03/2017

Case study 1: Ghana SUCCESS OF THE GHANA NCTC: 210 out patients are seen weekly; Average of 464 procedures are performed yearly with about 120 open heart surgeries, 70 closed heart surgeries, 70 thoracic Surgeries as at 2008 and Percutaneous cardiac procedures were also introduced Now a referral centre in West Africa and an accredited centre for the final fellowship examination in cardiothoracic surgery for the West African college of surgeons and so far trained 7 Ghanaian and more than 20 cardiothoracic surgeons from the subregion including the current Director of the centre Involved in research and are now establishing subspecialist units (Adult Cardiac Surgery, Paediatric Cardiac Surgery, Thoracic Surgery, Preventive Cardiology, Interventional cardiology)12

Case study 1: Ghana The secrets for success of NCTC, GHANA:
Commitment from the government Initial collaboration and support from the medizinische Hochschule Hannover centre in Germany Initial presence of a skilled and trained Local cardiothoracic surgeon and later cardiologists and Anaesthetists Administrative and financial autonomy Staff retention after training Good staff remuneration and welfare Professional development for all cadres of staff Team work Staff dedication Establishment of Ghana Heart Foundation which source voluntary donations to pay half of the operation fee for patients

Case study 2: Rwanda CHS-BUK LECTURE SERIES 28/03/2017

Case study 2: Rwanda Working in partnership with the Rwandan Ministry of Health, the Rwanda Heart Foundation, and select global partners Team Heart addresses the burden of cardiac diseases through screening, interventions and surgery Based on fly-in cardiac surgery missions from Boston sponsored by the Team Heart NGO Started 10 years ago Performed about 150 OHS over 10 years CHS-BUK LECTURE SERIES 28/03/2017

Case study 3: Malaysia CHS-BUK LECTURE SERIES 28/03/2017

Case study 3: Malaysia Established in 1992 by the ministries of Health and Finance Has about 400 beds and about 60 ICU beds 10 cardiac OTs and 1 hybrid OT 4 Cath-labs and 3 cardiac electrophysiology suites Performed about 38,518 cardiac surgeries and 87, 092 invasive cardiac procedures CHS-BUK LECTURE SERIES 28/03/2017

Case study 4: MEDANTA: The Medicity Dr. Naresh Trehan

Case study 4: MEDANTA: The Medicity
Medanta-The Medicity spread across 43 acres has 37 operating theatres, 1250 beds with over 350 critical care beds Founded by Dr. Naresh Trehan- a renown Cardiac surgeon in 2009 Have seven dedicated cardiac surgery OT including a hybrid cardiac surgery OT Operates an average of cardiac surgery cases daily, about 4000 surgeries yearly Has one of the largest collection of OPCAB globally (90-95%) Also involved in MICS and Robotic Cardiac surgery 44 cardiac surgery ICU beds CHS-BUK LECTURE SERIES 28/03/2017

Case study 5: NARAYANA Hospital-Dr. Devy Shetty

Case study 5: NARAYANA Hospital
Founded in 2000 by Dr. Devy Shetty A chain of hospitals with 7 heart centers and headquarters in Bangalore Over 16 OHS done daily for children and more than 60 OHS for adult patients 80 bed paediatric cardiac surgery ICU (one of the largest in the world Heart-Lung transplantation Number of employees: 18,000 AlJazeera documentary: The India Hospital CHS-BUK LECTURE SERIES 28/03/2017

Case study 6: Sudan SALAM CENTRE FOR CARDIAC SURGERY, KHARTOUM

Case study 6: Sudan Established and run by an Italian based humanitarian organisation ‘EMERGENCY’ since April 2007 Provides high standard free of charge paediatric and adult cardiac surgery VISION All human beings are born free and equal in dignity and rights (Art. 1). Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care (Art. 25). In accordance with The Universal Declaration of Human Rights (Paris, December 10th, 1948), EQUALITY, QUALITY, RESPONSIBILITY CHS-BUK LECTURE SERIES 28/03/2017

Case study 6: Sudan CONSTRUCTION TECHNOLOGY To build a first-rate Centre for cardiac surgery in a climate such as Sudan's, with temperatures above 40 degrees Celsius most of the year and frequent sandstorms The structure must be designed sand-proof, and heat-proof Innovative cooling, insulation and filtration technologies utilized to allow significantly decreased energy consumption CHS-BUK LECTURE SERIES 28/03/2017

Case study 6: Sudan Against Heat Solar Panels CHS-BUK LECTURE SERIES 28/03/2017

Case study 6: Sudan SURGICAL BLOCK: 3 Operating Theatres, 15 Intensive Care Unit beds, Sterilization, Catheterization Laboratory. DIAGNOSTICS: Reception, Outpatients Consultation Rooms, Radiology, Ultrasound, Laboratory and Blood Bank, Pharmacy WARDS: 48-beds Ward (including 16- beds Sub-Intensive Care Unit), Nurses’ room, Physiotherapy, Recreation room for staff and patients, Storage areas. ADMINISTRATION and offices. SERVICES: Laundry, Ironing, Kitchen, Library, Conference and Teaching room, Children’s Playroom, Storage areas, Cafeteria. GUEST HOUSE for relatives of patients coming from outside Khartoum, housing up to 50 people. TECHNICAL AREA, maintenance services, oxygen, vacuum and compressed air production unit, generator rooms and warehouses. MEDITATION HALL for patients of all creeds and religions. CHS-BUK LECTURE SERIES 28/03/2017

Case study 6: Sudan EQUIPMENTS
SURGICAL BLOCK Each one of the three operating theatres is equipped with anesthesia machines Fabius GS, Infinity Delta monitors, S III extracorporeal circulation system, Alphastar operating tables, Sola surgical lamps, and absolute filters The ICU, with 15 beds, is equipped with Evita 4 ventilators, Infinity Delta monitors, Prisma hemofiltration systems and CS100 aortic counterpulsators. DIAGNOSTICS GE Vivid 3 echocardiographs with pediatric and adult trans-esophageal probes, Proteus XR/i fixed and mobile X-ray Units. The Catheterization Laboratory is equipped with an Innova 2100 machine. A CT scan is about to be installed CHS-BUK LECTURE SERIES 28/03/2017

Case study 6: Sudan CATHLAB, WARD,MEDITATION CENTRE

Case study 6: Sudan Self referral is the commonest source for patients
Patients triaged 65,221 Cardiological examinations 57,276 Number of hospital admissions * 9,841 Number of patients admitted 7,787 Number of surgical operations ** 6,821 Number of patients operated 6,465 Cath Lab procedures 1,323 Self referral is the commonest source for patients After an initial triage, patients with known or potential cardiac problems receive further cardiac investigations Data from April 2007 to December 2016 CHS-BUK LECTURE SERIES 28/03/2017

Case study 6: Sudan SURGICAL MORTALITY Number of patients 6,465 Number of deaths 188 (2.91%) CATHLAB MORTALITY 1,323 3 (0.23%) CHS-BUK LECTURE SERIES 28/03/2017

……The Journey so far TRAINING Surgeons, Cardiologists, Anesthetists, Intensivists, Perfusionists, Scrub/ICU/Ward Nurses, Physiotherapists EQUIPMENTS Diagnostics, Few Basic operative sets, HLM and Co in the pipeline INFRASTRUCTURE Architectural design done, awaiting QS and sponsorship Available diagnostic techniques to be better utilized Current OT and ICU could be upgraded in the mean time COLLABORATION National Cardiothoracic Centre Accra, Ghana National Heart Institute, Malaysia Others-Medtronic MODEL SELECTION Public vs. Private vs. Public private PROCEDURES DONE About 20 PDA ligations 2 successful permanent pacemaker implantations Helping to refer and guide patients who require Open Heart Surgery A range of Thoracic Surgical operations CHS-BUK LECTURE SERIES 28/03/2017

THE WAY FORWARD Collaboration between AKTH and BUK Structured and organized team training and refresher training Well arranged collaboration with regional and international centers Philanthropists Corporate social Responsibility The role of Medical devices Industry CHS-BUK LECTURE SERIES 28/03/2017

Being a bit aggressive…..Utilizing opportunities
Dear Dr Ismail Ahmad, Thank you very much for your . My name is Luca and I am the coordinator of the Regional Program at the Salam Centre for Cardiac Surgery in Khartoum. It will be a real pleasure for us to collaborate with your facility if you think that we can help you. I kindly ask you to clarify a little bit more how do you think to develop the training and the guidance. I look forward to hearing from you soon. Best regards, Luca Luca Rolla Regional Program Coordinator EMERGENCY NGO Salam Centre for Cardiac Surgery Khartoum, Sudan Mobile:00249(0) Tel.:00249(0) /1 Skype:luca.rolla CHS-BUK LECTURE SERIES 28/03/2017

CONCLUSION Nigeria is currently passing through the epidemiologic transition characterized by preponderance of communicable diseases and increasing NCDs Rheumatic and congenital heart diseases are quite common and the prevalence of coronary heart diseases is on the increase owing to existence of risk factors Sub-Saharan Africa-North of SA (Nigeria inclusive) lacks most of the diagnostic and surgical treatment of heart diseases Primary and secondary prevention is a cost-effective undertaking Provision of adequate and standard diagnostic and surgical treatment will reduce the associated morbidity and mortality Local, regional and international collaborations are indispensable in achieving this arduous but selfless and soul-fulfilling task CHS-BUK LECTURE SERIES 28/03/2017

……The African market is on the move. If you are not invested there, it may not be too late to participate in Africa’s rise. As an old African proverb says. “The best time to plant a tree is 20 years ago. The second best time is now.” -Vijay Mahajan in Africa Rising CHS-BUK LECTURE SERIES 28/03/2017

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