CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 10, November 2012
AFRICA
539
vicryl 3.0. The post-surgical wound was covered with a plaster.
Being a descriptive study, the data are presented as means and
standard deviation.
Results
Symptoms and signs that pointed to the diagnosis of CAVB are
listed in Table 2. Median age at diagnosis was 65
±
15
years.
The escape rhythm showed a narrow QRS complex in 35.2% of
patients, whereas a wide QRS complex was seen in 64.8%. In
only 15 patients were pacemakers implanted: dual-chamber in
10
and single-chamber in five cases, depending on the payment
capacity of patients. Complications observed after implantation
were dislodgement of the lead in one patient, haematoma in two
cases, and infection of the pocket in one case.
During the observational period, five non-implanted patients
in NYHA class III died, giving a mortality rate of 45%. The six
remaining patients were in NYHA class II. All the implanted
patients are alive and in a better clinical condition than the
non-implanted patients (Table 3).
Chest pains in one patient were intercostal neuralgia, with
no ischaemic aetiology. Importantly, before implantation, nine
patients were in NYHA class III, and six in class II. After the
implantation, 10 were in NYHA class II and five in class I.
Discussion
Occasionally, adult patients do not have any symptoms of
complete atrio-ventricular block and the diagnosis is made
by detecting a slow heart rate at a routine examination. The
incidence of CAVB seems to be higher in Lome than in the
Shisong cardiac centre, being respectively, 1 and 2% (
p
<
0.02).
3
We diagnosed few patients during the observational period,
probably due to natural selection.
The mortality registered in non-implanted cases was 45%,
low compare to the mortality in Togo, which was 59% (
p
<
0.05).
3
In tertiary centres in sub-Saharan Africa, the main cause
of death is lack of finances for the procedure. Patients with the
pathology must pay before the device will be implanted, the
dual-chamber pacemaker being more expensive than the single
chamber, which is why in Africa in general more patients have
single-chamber pacemakers.
4
Besides eliminating the risk of sudden death, reasons for an
early PM implantation in patients with CAVB are prevention of
morbidity, left ventricular dilatation and dysfunction, and mitral
regurgitation. Permanent pacemakers provide effective relief of
symptoms and are life-saving in patients with symptomatic heart
block.
Since pacemakers are only implanted by cardiologists
or cardiothoracic surgeons in tertiary hospitals, the rates of
pacemaker implantation provide a readily auditable measure
of tertiary healthcare.
5
In developed countries, patients with a
history of complete heart block are almost absent because of the
progress in medicine orientated to early detection and treatment
of the condition, whereas in developing countries with the lack
of finances, infrastructures and human resources, many cases are
encountered.
6
In this context in Africa, the re-use of pacemakers from
charity organisations is a good solution; it can be carried
out without increased risk to the patients, provided a proper
routine for technical control and sterilisation is followed. Re-use
means substantial savings, which could possibly make advanced
pacemaker treatment available to all eligible patients irrespective
of age. Death is not necessarily the end for heart devices.
7,8
In our
case, all the pacemakers we used were new.
We noted that some of our patients were asymptomatic with
very wide QRS complexes, strengthening the hypothesis of
natural selection. Electrophysiological and genetic studies are
important to understand the mechanism of natural selection. We
also found that patients with post-rheumatic heart disease were
well represented in our study, causing us to suspect involvement
of the conduction tissue in that pathology, as it is the case in
patients with Lyme disease.
9
The clinical state of implanted patients improved more than
that of patients without pacemakers. In developing countries,
cardio-stimulation should be made a department of all cardiac
TABLE 1. INTRA-OPERATIVE PARAMETERS
Sensing (mV)
Threshold (V)
Impedance of
the lead (Ohm)
Atrial lead
3.5
± 0.5
0.75
±
0.5
768
±
13
Ventricular lead
9
± 0.5
0.5
±
0.5
810
±
9
TABLE 2. CLINICAL CHARACTERISTICS OF PATIENTS
Total number of patients (
n
)
26
Age at diagnosis (years)
65
±
15
Symptoms
dizziness (
n
)
19
shortness of breath (
n
)
15
fatigue (
n
)
23
Adam Stokes attack (
n
)
6
palpitations (
n
)
3
No symptoms (
n
)
3
Co-morbidity
hypertension (
n
)
16
degenerative arthritis (
n
)
20
diabetes mellitus
6
Referred cases (
n
)
2
Age at implantation (years)
70
±
10
Type of block
paroxystic (
n
)
6
permanent (
n
)
20
Causes of death
Adam Stokes attack (
n
)
2
cardiovascular accident (
n
)
1
unknown (
n
)
2
TABLE 3. SYMPTOMSAT FOLLOW UP
Implanted
patients
Non-implanted
patients
Shortness of breath (
n
)
2
6
Dizziness (
n
)
-
3
Adam Stokes attack (
n
)
-
3
Palpitations (
n
)
-
5
Fatigue (
n
)
-
5
Death
0
5
NYHA class II (
n
)
10
6
NYHA class I (
n
)
5
0
