The state of cardiac surgery in Ethiopia

A plea for urgent action: Addressing the critical shortage of cardiothoracic surgical workforce in the COSECSA region

BACKGROUND

The College of Surgeons of East, Central, and Southern Africa (COSECSA) comprises 14 countries, many of which currently grapple with an increasing burden of cardiothoracic surgical (CTS) diseases. Health and economic implications of unaddressed CTS conditions are profound and require a robust regional response. This study aimed to define the status of CTS specialist training in the region (including the density of specialists, facilities, and active training posts), examine implications, and proffer recommendations.

METHODS

A desk review of COSECSA secretariat documents and program accreditation records triangulated with information from surgical societies was performed in May 2022 and September 2023 as part of education quality improvement. A modified nominal group process involving contextual experts was used to develop a relevant action framework.

RESULTS

Only 6 of 14 (43%) of COSECSA countries offered active training programs with annual intake of only 18 trainees. Significant training gaps existed in Burundi, Botswana, Malawi, Rwanda, South Sudan, Zambia, and Zimbabwe. Country specialist density ranged from 1 per 400,000 (Namibia) to 1 per 8,000,000 (Ethiopia). Overall, the region had 0.2 CTS specialists per million population as compared with 7.15 surgeons per million in High-Income Countries. Surgical education experts proposed an action framework to address the training crisis including increasing investments in CTS education, establishing regional centers of excellence, retention incentives and opportunities for women, and leveraging international partnerships.

CONCLUSION

Proactive investments in infrastructure, human resources, training, and collaborative efforts by national governments, regional intergovernmental organizations, and international partners are critical to expanding regional CTS training.

Cardiothoracic surgery training in Africa: History and developments

Objective

Cardiovascular disease is the leading cause of death globally, responsible for 17.5 million deaths each year, 80% of which occur in low- and middle-income countries, including countries in Africa. Cardiothoracic surgery, with its heavy financial outlay, is unavailable in many African countries. Many African healthcare givers are under the erroneous impression that the cardiovascular surgical landscape of Africa is blank. This review aims at describing the cardiothoracic surgery practice in Africa, the different training programs in the region, and its future prospects.

Method

Through a literature review, the authors elaborate on key points, such as healthcare and cardiothoracic surgery in Africa, African cardiothoracic practice and training, and the future of cardiothoracic surgery in Africa.

Results

African countries with established cardiothoracic surgery capacity and training programs still face several challenges across multiple levels, including a persistent low enrollment rate in residency programs, insufficient local expertise, a lack of financial resources, an inadequate health infrastructure, and a skewed health insurance reimbursement system. Thus, there is still a growing burden of surgically correctable cardiovascular disease in these countries.

Conclusions

Cardiothoracic surgery in Africa has faced great challenges due to resource constraints, but it has demonstrated resilience and growth through diverse models and initiatives. The burden of cardiovascular diseases in Africa remains high, yet the capacity to provide cardiothoracic surgery is limited. With investment, support, and the implementation of comprehensive healthcare policies, cardiothoracic surgery practice can improve in this region and this can make a significant impact on the health and well-being of its population.

Challenges Faced and Lessons Learned: The Journey of a 22-Year-Old Male with a Mechanical Heart Valve Complicated by Ischemic Stroke in a Developing Country: A Sub-Saharan Africa Prospect

This report reviews an Ethiopian patient who underwent cardiac surgery and had a mechanical heart valve implanted on the mitral valve with tricuspid valve repair for rheumatic heart disease via a local non-profit organization donation later complicated by cardio-embolic stroke, and aims to describe the challenges faced by patients from rural Ethiopia who require cardiac surgery for rheumatic heart disease and narrate the importance of careful follow-up. The lessons to be drawn from this case are that careful follow-up and adherence to prescribed Vitamin K antagonists after surgery for mechanical heart valves are critical and, when such patients are lost to follow-up as was witnessed in this case, it can induce lifelong morbidity. Morbidity that could have been avoided with strict and meticulous follow-up and with standardized patient tracing or contact systems. When patients are lost to follow-up it needs to be top priority to trace them after cardiac surgery and this report highlights the pivotal role of the health education in such populations. Unless we utilize this opportunity to unlock the door and embrace a systemic approach to reforming our risk assessment, referral chain system, and integration of various healthcare professionals in patient follow-up, as well as enhancing health education among our patients in rural Ethiopia and other low-income countries, the consequences could prove to be significant. Preventing such fatal complications is far superior to managing them afterwards, as it not only saves on expenses but also saves lives and enhances quality-of-life.

Post-surgery survival and associated factors for cardiac patients in Ethiopia: applications of machine learning, semi-parametric and parametric modelling

INTRODUCTION

Living in poverty, especially in low-income countries, are more affected by cardiovascular disease. Unlike the developed countries, it remains a significant cause of preventable heart disease in the Sub-Saharan region, including Ethiopia. According to the Ethiopian Ministry of Health statement, around 40,000 cardiac patients have been waiting for surgery in Ethiopia since September 2020. There is insufficient information about long-term cardiac patients' post-survival after cardiac surgery in Ethiopia. Therefore, the main objective of the current study was to determine the long-term post-cardiac surgery patients' survival status in Ethiopia.

METHODS

All patients attended from 2012 to 2023 throughout the country were included in the current study. The total number of participants was 1520 heart disease patients. The data collection procedure was conducted from February 2022- January 2023. Machine learning algorithms were applied. Gompertz regression was used also for the multivariable analysis report.

RESULTS

From possible machine learning models, random survival forest were preferred. It emphasizes, the most important variable for clinical prediction was SPO2, Age, time to surgery waiting time, and creatinine value and it accounts, 42.55%, 25.17%,11.82%, and 12.19% respectively. From the Gompertz regression, lower saturated oxygen, higher age, lower ejection fraction, short period of cardiac center stays after surgery, prolonged waiting time to surgery, and creating value were statistically significant predictors of death outcome for post-cardiac surgery patients' survival in Ethiopia.

CONCLUSION

Some of the risk factors for the death of post-cardiac surgery patients are identified in the current investigation. Particular attention should be given to patients with prolonged waiting times and aged patients. Since there were only two fully active cardiac centers in Ethiopia it is far from an adequate number of centers for more than 120 million population, therefore, the study highly recommended to increase the number of cardiac centers that serve as cardiac surgery in Ethiopia.

Treatment seeking delay and associated factors in adult heart failure patients admitted to Debre Tabor comprehensive specialized hospital, North West, Ethiopia

Objectives

This study was aimed at assessing the magnitude of treatment-seeking delay in adult heart failure patients and identifying factors that contribute to it.

Design

An institution-based cross-sectional study with a consecutive sampling technique was conducted at Debre Tabor Comprehensive Specialized Hospital from February 1 to November 1, 2021.

Setting

The study was conducted in the medical ward of the hospital.

Participants

A total of 187 patients aged 18 and above admitted with a diagnosis of heart failure, and able to provide information were included.

Results

The median delay time of adult heart failure patients admitted to the hospital was 15 days. The mean length of delay was also calculated to be 25.02 days. Urban residents and those who live at a ten or less-kilometer distance from healthcare facilities were found to be less likely to delay seeking care. Presenting with shortness of breath or paroxysmal nocturnal dyspnea, perceiving the cause to be heart-related, and getting positive responses from significant others were also associated with a relatively short delay time.

Conclusion

Treatment-seeking delay was found to be a major problematic issue in heart failure patients. Therefore, patients, patient families, and the community at large must be taught about the symptoms of heart failure and the need for timely care.

Delayed presentation of penetrating cardiac injury successfully managed in resource limited setting: A case report

INTRODUCTION AND IMPORTANCE

Penetrating cardiac injury is rare and historically known to have very poor prognosis. Even today, 90 % of patients die before arriving to hospital. Even though patient presentations can be atypical, organized timely intervention can lead to survival.

CASE REPORT

A 21 years old arrived 5 h after stab injury to right anterior chest. He was hypotensive with a sucking wound bleeding on his right chest as well as hemothorax on the same side. Chest tube and pericardial window were both done with blood in pericardial space. Median sternotomy was done and revealed right atrial perforation. The perforation was repaired and the patient was discharged and continues to do well on follow up.

CLINICAL DISCUSSION

For most patients, time from injury to surgery is short. Focused and organized surveys as well as resuscitation are valuable for any patent with penetrating thoracic trauma. With a patient in hemorrhagic shock and a penetrating wound near the heart, a pericardial window is required regardless of the absence of pericardial fluid on ultrasound and in this case proved to be lifesaving. If there is a hole in the pericardium communicating with the pleural space the pericardial blood may decompress into the pleural cavity and not be visible on ultrasound.

CONCLUSION

Regardless of its rare prevalence, high index of suspicion for cardiac injury is extremely important in all patients with penetrating chest trauma in the cardiac box regardless of atypical presentations. With rapid diagnosis, capable surgeon availability, and availability of blood products, patients can survive this injury.