CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 8, September 2012
434
AFRICA
obvious that the number of children and young adults from socio-
economically disadvantaged backgrounds exposed to rheumatic
fever and the sequelae of rheumatic heart disease is enormous.
Moreover, the incidence is expected to increase in coming
decades due to worsening economic conditions in sub-Saharan
Africa, combined with the ravages of HIV/AIDS, rendering
many children orphans and homeless. Because of lack of heart
surgery programmes in most of sub-Saharan Africa, many of
these patients with heart diseases and requiring surgery are
therefore treated only medically due to the prohibitive cost of
travelling abroad for open-heart surgery.
In Nigeria, the first open-heart surgery was performed at the
University of Nigeria Teaching Hospital, Enugu (UNTH) in 1974
by a team from the United Kingdom, led by Prof Magdi Yacoub.
5
The hospital, for years the only cardiac surgery centre in Nigeria,
has however remained dormant in recent years.
6
A second heart
programme, also in southern Nigeria, started at the Lagos State
University Teaching Hospital, Lagos (LASUTH) in 2004 and is
still in its infancy.
In contrast, northern Nigeria with over 50% of the country’s
population has no heart surgery programme, despite the large
number of patients needing such specialised services. As a
result, many of the patients referred to us for surgery had
advanced cardiomyopathy with pulmonary hypertension and
cardiac cachexia.
One might have expected a higher mortality and morbidity in
this pilot study because of the high risk profiles, coupled with
the total lack of experience at institutional and personnel levels.
However, the results were satisfactory, as the two deaths were
potentially avoidable and attributable to lack of needed resources
from the blood bank and pharmacy. The observed mortality
in this high-risk group was exaggerated by our relatively low
numbers. There was of course an obvious learning curve with
our index cases, involving all the support services and personnel,
which prevented further complications in subsequent patients at
both institutions.
Identified deficiencies included lack of blood bank capability
to provide component blood therapy, which contributed to the
death of our first patient from severe coagulopathy, and the
unavailability of potent broad-spectrum antibiotics from the
pharmacy, contributing to the second mortality from nosocomial
infection. Furthermore upon realising the total absence of
respiratory therapist support and the less-than-ideal sterility of
the ventilatory tubing which was reused for multiple patients, all
effortsweremade for earlyextubationwithina fewhoursof surgery
to reduce the risk of cross contamination of the respiratory tract.
This strategy required coordination by the anesthesiologists
and perfusionist, with the use of easily reversible anaesthetic
agents and keeping patients dry with ultrafiltration on bypass
to reduce lung water which might affect lung compliance
postoperatively. We believe that this strategy of early extubation
and mobilisation, along with the relatively young age of the
patients may have contributed to the absence of any major
morbidity in the surviving patients.
The late morbidity and mortality at one and two years,
respectively, were both anticoagulant-related haemorrhage, in a
pregnant woman with a mechanical valve, and poor compliance
with Coumadin monitoring. Because of the higher risk of valve
calcification in the young and the cost of a possible future
re-operation for structural valve deterioration, all the patients
had opted for a mechanical valve, although some were already
on anticoagulation for chronic atrial fibrillation.
The risk of thromboembolism and haemorrhage is estimated
at about 2% per year, even in the best setting, and this figure is
likely to be even higher in our impoverished population with
inadequate anticoagulation monitoring. The cumulative risk
for thromboembolic and haemorrhagic complications in these
patients over a lifetime is therefore enormous and has prompted
us to reconsider the use of mechanical valve replacement in
this largely poor and uneducated population, most especially
in females of childbearing age. This is particularly important
as rheumatic heart disease in northern Nigeria appears more
common in females, as reported by Danbauchi
et al
.
3
We
therefore now recommend bioprosthetic valves to females of
childbearing age in this patient population.
Because of poverty and lack of education, monitoring of
adequate levels of anticoagulation can be challenging, if not
impossible, especially for those living in remote villages that
are unable to follow up regularly at the clinics. Due to lack of
standardisation and quality control, the results, even in those
undergoing regular monitoring, are sometimes unreliable and
inconsistent, perhaps due to the use of expired reagents in some
of the laboratories.
Conclusion
Despite the fact that most of the patients had advanced
cardiomyopathy and were often malnourished, the overall
outcome was excellent considering that this was the first series
of heart surgeries in this region, performed in less-than-ideal
operating conditions, including lack of equipment and ancillary
support services. The two operative mortalities were potentially
avoidable had adequate support structures been in place, and also
represented a learning curve for this type of delicate surgery at
both institutions. These initial results are however encouraging
and show that with adequate government financial support for
equipment acquisition and human capacity building, northern
Nigeria should be able to support two heart surgery programmes
to service this large patient population.
References
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Danbauchi SS, Alhassan A, David SO,
et al
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Spectrum of rheumatic
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Ann Afr Med
2004
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4.
Comparet M, Doyle M, Foote L,
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et al
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Eze JC, Ezemba N. Open heart surgery in Nigeria: indications and chal-
lenges.
Texas Heart J
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