CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 2, March/April 2022 AFRICA 81 heart rhythm disorder in 10.3% of patients. Table 1 summarises the drugs used during CPB withdrawal. The median extubation time was three hours (0–96). Revision surgery was performed in five patients (7.4%). Table 2 summarises the main indications for secondary surgical revision in our series. Fig. 1 shows the transfusion practice in our series; 58.1% of patients were transfused in the operating room during CPB and 33.8% in the intensive care unit (ICU). A curative anticoagulation protocol was initiated six hours postoperatively in the absence of contra-indications. The main complications were cardiac, renal, neurological, pulmonary, gastrointestinal and infectious (Table 3). The average length of stay in the ICU was four days (2–18). In the immediate postoperative period, we recorded three deaths, which is a mortality rate of 4.4%. The deaths were due to an extensive ischaemic stroke in two patients and severe left ventricular dysfunction in a third. Four patients were re-admitted to the ICU within two and six months of surgery: two cases of haemorrhagic stroke, which were both fatal, one case of ventricular dysfunction with persistent mitral gradient, and a case of third-degree atrioventricular block, requiring a fitting. The overall mortality rate at one year of follow up was 7.2%. Discussion Over the past two decades, the incidence of ARF and chronic RHD have dramatically declined in wealthier regions of the world as a result of preventative programmes, improved living standards and access to cardiac surgery. Nevertheless, ARF and RHD are still public health problems in less-developed regions of the world, such as Oceania, South Asia and sub-Saharan Africa.10 More than 33 million individuals are affected globally and Africa is an endemic region. RHD remains a public health priority in Africa, despite being nearly eliminated in high-income countries.11 The RHD prevalence has been estimated mainly from surveys of school-going children, and varies from 2.7/1 000 in Kenya to 14.3/1 000 in the Congo. While mortality rates of chronic valvular RHD have been estimated at 1.5% of patients per year, this may be largely under-estimated in sub-Saharan Africa.12 The VALVAFRIC12 study, a registry in western and central Africa (2004–2008), provided prospective and retrospective data on the clinical characteristics and treatment of 3 441 RHD patients. The study highlighted scarcity of cardiac surgery, which was afforded in only 27 individuals out of 1 200 who required surgery. This difficulty in accessing surgery is due to the requirement of a certain level of expertise and a well-equipped technical platform. Several new paediatric cardiac centres are currently funded by NGOs and run on a permanent basis in African countries.13 Some examples are the Salam Centre for Cardiac Surgery in Sudan, the Walter Sisulu Paediatric Centre for Africa in South Africa, the Ghanaian National Cardiothoracic Centre and the CUOMO Cardio-Paediatric Centre in Dakar.13 The opening in September 2018 of the André Festoc Heart Surgery Centre at the Luxembourg Mother-Child University Hospital, Bamako, was greeted with great hope and enthusiasm. It is the result of a long and rich co-operation between Luxembourg and the NGO la Chaine de l’Espoir. Between 1994 Table 2. Secondary surgical revision Aetiology Number (%) Secondary closure 1 (1.5) Haemostasis 3 (4.4) Pericardial and pleural drainage 1 (1.5) Total 5 (7.4) Table 3. Post-operative complications Cardiac complications Pulmonary hypertension 8 (11.8) Left ventricular dysfunction 4 (5.9) Atrial fibrillation 7 (10.3) Atrioventricular block 3 (4.4) Junctional tachycardia 2 (2.9) Total 24 (35.3) Kidney complications Functional renal failure 7 (10.3) Acute tubular necrosis 1 (1.5) Total 8 (11.8) Neurological complications Ischaemic stroke 2 (2.9) Postoperative seizures 1 (1.5) Behavioural problems 3 (4.4) Total 6 (8.8) Pulmonary complications ARDS 2 (2.9) Collapsed lung 1 (1.5) Total 3 (4.4) Gastrointestinal complications Aseptic cholecystitis 2 (2.9) Total 2 (2.9) Infectious complications Transfusion-related malaria 8 (11.8) Urinary tract infection 1 (1.5) Bronchopneumonia 2 (2.9) Total 11 (16.2) ARDS: acute respiratory distress syndrome. 1–3 PRBC > 3 PRBC Total transfusion PRBC 1–3 FFP > 3 FFP Total transfusion FFP 70 60 50 40 30 20 10 0 35.3 17.6 16.2 23.5 58.8 33.8 21 2.8 4.2 23.5 44.5 7 Transfusion during CPB Transfusion in ICU Fig. 1. Transfusion practice. PRBC = packed red blood cells; FFP = fresh frozen plasma
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