CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 2, March/April 2022 80 AFRICA Rheumatic heart disease (RHD) is a chronic disease affecting the heart valves, secondary to group A streptococcal infection and subsequent acute rheumatic fever (ARF). However, preventative measures and cure of RHD are inextricably linked with socioeconomic development, as the disease mainly affects children and young adults living in poverty.1 In developed countries, ARF has become a virtual disease but in developing countries it is still a major public health problem.2 It is thought that as many as 39% of patients with ARF may develop varying degrees of pancarditis with associated valve regurgitation and heart failure, and in some cases death.3 The incidence of ARF has slowly but steadily decreased since 1900, even before the use of antibiotics, and its current frequency of occurrence is low, with an incidence of 0.5 per 100 000 children on average. Along with the decrease in ARF cases, the prevalence of RHD is increasing. It is estimated that the rate varies between 0.1 and one per 1 000 schoolchildren in developing countries.2 There is a significant burden of surgically correctable cardiovascular disease in Africa.4 Some 75% of the world does not have access to cardiac surgery when needed because of lack of infrastructure, and human and financial resources.5 Large disparities exist between regions, ranging from 0.12 adult cardiac surgeons and 0.08 paediatric cardiac surgeons per million population in sub-Saharan Africa to 11.12 adult cardiac surgeons and 2.08 paediatric cardiac surgeons in North America. Low-income countries possess 0.04 adult cardiac surgeons and 0.03 paediatric cardiac surgeons per million population.5 Humanitarian efforts have led non-governmental organisations (NGOs) to launch surgical programmes in low- and middle-income countries, in an attempt to fill the gap in these fragile healthcare systems.6,7 The methods of these NGOs vary, with some providing overseas treatment, while others carry out fly-in fly-out missions with varying levels of capacity building.8 The opening of the new heart surgery centre Andre Festoc at the Luxembourg Mother-Child Teaching Hospital in Bamako is the result of a solid co-operation with the NGO la Chaine de l’Espoir. La Chaine de l’Espoir is present in more than 30 countries in Africa, Asia and the Middle East.9 In 2018, it financed the construction and equipment of a centre, training of medical and paramedical staff, supply of consumables, and ensured surgical missions with experienced practitioners to allow the transfer of skills and ensure self-registration of the Malian team. We report on our clinical, therapeutic and prognostic particulars as well as the difficulties encountered during this first series of surgery for rheumatic valve disease in Mali. Methods This was a prospective, descriptive study conducted at the Andre Festoc Cardiac Surgery Centre from September 2018 to August 2019. All patients operated on for rheumatic valve disease were included in the study. All our patients with pulmonary hypertension were managed during the peri-operative period as follows: during pre-operative preparation they were put on furosemide, captopril and sildenafil at 40 mg/day until the morning of the operation. Thirty to 45 minutes before weaning from cardiopulmonary bypass (CPB), a continuous infusion of milrinone at 0.5 μg/kg/min was given. The epidemiological, clinical, therapeutic and evolutionary characteristics were identified on the basis of data previously established on SPSS 21.0. All patients included in the study or legal guardians were informed of the use of their data for study purposes and their identity was kept confidential. Results During the study period, 152 patients were operated on for heart disease. The frequency of patients having been operated on for rheumatic valve disease was 44.73% (68 patients). These 68 patients represented our study population. The age group zero to 15 years represented 60.3% of the population. The mean age of our patients was 18 ± 10 years, with extremes of five and 60 years. The female gender was the most representative with 40 cases (58.8%) and the gender ratio was 0.7. Of the patient group, 22.1% resided between 100 and 300 km from Bamako and 17.6% were more than 300 km from Bamako. The delay to treatment was between one and three years for 39.7% of patients and was greater than three years for 39.7%. Many of the patients (67.6%) were undernourished, with a body mass index less than 18.5 kg/m2. A history of recurrent angina was found in 52.9% of patients, 22 (32.4%) had no cardiac decompensation before surgical management, while 33.8% of patients presented with more than two decompensations. Sixty per cent of patients had no arrhythmia while 17.6% had atrial fibrillation. The main diagnoses found were: mitral regurgitation in 51.5% of patients, mitral disease in 20.6%, mitral stenosis in 16.2%, aortic regurgitation in 10.3% and aortic stenosis in 1.5% of cases. Tricuspid insufficiency with pulmonary hypertension was associated with valve disease in nearly 45% of patients. Pulmonary artery systolic pressure (PASP) was 35–50 mmHg in 19.1% of patients and greater than 50 mmHg in 25% of patients. The surgical procedures performed were: 30 tricuspid plasty surgeries (44.1%), one aortic plasty surgery, 33 mitral valve replacements (48.5%), 33 mitral plasty surgeries (48,5%), and eight replacements of the aortic valve (11.8%). The type of valve used in our series was a bileaflet mechanical prosthesis. All our patients were operated on CPB with aortic clamping with a crystalloid cardioplegia del Nido. The median CPB time was 132 minutes (60–276) and the median aortic clamping time was 93 minutes (32–225). The median of mean arterial pressure during CPB was 58 mmHg. Norepinephrine use during CPB was required in 19.1% of patients. Forty patients, or nearly 60% of the population, were transfused during the CPB. The target haematocrit per operation was 30%. The main difficulties during withdrawal from CPB were low cardiac output with poor cardiac contractility in 35.2% of patients, acute pulmonary hypertension in 14.7%, and severe Table 1. Drugs used during cardiopulmonary bypass withdrawal Drugs Number (%) Norepinephrine 2 (2.9) Dobutamine 16 (23.5) Milrinone + epinephrine 9 (13.2) Norepinephrine + dobutamine 17 (25) Milrinone + epinephrine + norepinephrine 6 (8.8) Milrinone 5 (7.4) Milrinone + norepinephrine 7 (10.3) Total 62 (91.2)
RkJQdWJsaXNoZXIy NDIzNzc=