CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 3, April 2012
AFRICA
165
The challenges of cardiac surgery for African children
ANA OH MOCUMBI
Abstract
In Africa the specific pattern of cardiovascular diseases
and lack of adequate measures for disease prevention and
control result in the frequent need for open-heart surgery
for the management of complications of cardiomyopathies
in children. Several strategies and innovative ways of provid-
ing cardiovascular surgical care in African countries have
been used, from agreements to send patients overseas, to
programmes for the creation of local services to provide
comprehensive care locally.
This article attempts to outline the challenges faced by
underdeveloped countries in Africa wanting to embark on
programmes of cardiac surgery and the need for several
sectors of society to play a role in the process. It discusses
issues related to the establishment of centres performing
cardiac surgery in Africa, describes the treatment of congen-
ital heart disease, and reviews the aspects of management
of conditions highly prevalent in or mostly confined to this
continent, such as rheumatic heart valve disease and endo-
myocardial fibrosis.
Keywords:
paediatric cardiology, cardiac surgery, Africa
Submitted 12/8/09, accepted 24/2/12
Cardiovasc J Afr
2012; 23: 165–167
DOI: 10.5830/CVJA-2012-013
Adequate measures for disease prevention and control are
difficult to implement in Africa due to low levels of literacy,
and poor sanitation and governance. On the other hand,
timely diagnosis and management of cardiovascular diseases
is hampered by shortage of qualified human resources and
financial constraints. For these reasons, surgery is frequently
needed for the management of cardiac conditions in African
children.
Cardiac surgery imposes a huge burden on limited healthcare
resources and is therefore not available in most sub-Saharan
countries. Where it is available, surgery is performed in small
numbers due to financial constraints and shortage of human
resources. Therefore, several countries are running collaborative
programmes between local institutions and teams from Europe
and America, mostly sponsored by local or international
non-governmental organisations.
We review here the challenges of surgical management of
conditions that affect predominantly children, which are either
highly prevalent in or confined to the African continent, namely
rheumatic heart valve disease (RHVD), congenital heart disease
(CHD) and endomyocardial fibrosis (EMF).
Rheumatic heart valve disease
Although preventable, RHVD is still a very common condition
in Africa, affecting young people and progressing quickly to
severe forms that need heart valve surgery.
1
Patients usually
present in a poor general and nutritional condition, increasing
the operative risk, and multiple lesions are frequent, requiring
sub-optimal solutions on many occasions.
2
Valve replacement
presents a dilemma due to the generalised lack of adequate
facilities for anticoagulation. Of major importance also are the
issues related to the logistics of rheumatic fever prophylaxis,
prevention of infective endocarditis and contraception in poor
and remote areas. These factors lead to results that suggest
that surgery for rheumatic heart valve disease in children is
essentially a palliative procedure.
2
In African studies researching the epidemiology of RHVD,
the most frequent lesion is pure mitral valve regurgitation.
3
This is in contrast with data from the developed world, where
haemodynamically severe rheumatic mitral valve disease
generally presents in the fourth decade or later, with thickened
valve leaflets usually manifesting as mitral stenosis with or
without concurrent regurgitation.
4
The aortic valve is the second
most frequently affected, but tricuspid regurgitation is also very
common due to late diagnosis, when severe mitral and/or aortic
disease cause pulmonary hypertension and dilatation of the right
ventricle.
The choice of surgical technique is challenging and the results
of valve repair performed during the active phase of rheumatic
heart disease preclude a durable long-term result,
4
highlighting the
importance of correct pre-operative evaluation and preparation.
Mitral valve repair is advised whenever technically feasible
to maximise survival and reduce morbidity, even considering
that good surgical results are inversely related to age,
5
and that
there is a risk of early re-operation due to inadequate secondary
prophylaxis. On the other hand, while it has been recognised
that good results can be achieved in children without the use of
annuloplasty rings,
6
the advantages of this strategy need to be
confirmed in the long term.
Regarding treatment of the aortic valve, the Ross procedure
has advantages in young and deprived populations since use
is made of autologous and living tissue, there is excellent
haemodynamics, allowance is made for growth and there is no
need for anticoagulation. However, it also has some drawbacks,
namely the need for homography in the pulmonary position and
the fact that it is a technically demanding procedure.
Some authors feel that the Ross operation it is not suitable
for young patients with RHVD. Although there is no sudden
dilatation in children, some degree of aortic regurgitation
appears in up to 18.3% after 2.4 years of follow up, and it is
known that young age and associated mitral valve disease are
significant risk factors for autograft failure.
7
Finally, rheumatic
involvement of the autograft has been reported, leading some
to contraindicate the Ross operation in young patients with
rheumatic heart valve disease.
8,9
However, we feel that in Africa,
it still the most valuable option for management of aortic disease
Instituto do Coração, Maputo, Mozambique
ANA OH MOCUMBI, MD,
