CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 2, March/April 2022 82 AFRICA and 2018, this co-operation allowed medical evacuation for cardiac surgery of more than 500 Malian children. In addition to the donation of an ultra-modern centre, la Chaine de l’Espoir supports the Malian team by providing materials and consumables, and organising expatriate missions to ensure a plan of empowerment of the local team, made up of three cardiovascular surgeons, four anaesthetists, two cardiologists and two perfusionists. Difficulties in accessing surgery at an early stage of the disease was a general problem in our series and other African series. Kingué et al. reported that patients were seen late in the course of the disease, with 40% presenting with heart failure and in New York Heart Association class III or IV.12 Clinical complications were documented in 585 of 1 385 patients, including heart failure (62%), arrhythmia/atrial fibrillation (22%), thromboembolic events (4%) and infective endocarditis (4%). In our series, 39.7% of patients were operated on within one and three years of diagnosis and 39.7% after a period of three years. Our epidemiological characteristics are superimposed on the realities of low- and middle-income countries. We recorded a female predominance of 58.8%, the predominant valve disease was mitral regurgitation in 50%, 17.6% had arrhythmia, and pulmonary hypertension was present in almost 45% of patients. Patients with RHD from low- and middle-income countries were young (median age 28 years), largely female (66.2%), and had a high unemployment rate (75.3%). The majority had moderate-to-severe valvular heart disease that was associated with pulmonary hypertension and up to a quarter of patients had left ventricular dysfunction.14 The choice between valve replacement or repair (plasty) was made according to several criteria: the degree of valve disease and its recovery, the age and gender of the patient (we prefer plasty in children and young girls), and the ability to monitor anticoagulation. Valve surgery is associated with a significant mortality rate. Complications such as cardiac, pulmonary, renal and neurological disorders, infections such as pneumonia or sepsis, and prolonged stay in the intensive care unit and hospital are indicators of not only quality of care but also quality of life after cardiac surgery.15-18 Postoperative acute kidney injury is a serious complication of cardiac surgical procedures that carries a high mortality rate. Renal failure was found in 11.8% of our patients, it was functional and transient in seven patients, and one patient presented with acute tubular necrosis with anuria for 12 days. A total of 10 haemodialysis sessions were performed and the outcome was favourable. Pulmonary hypertension is a classic pathophysiological consequence of left-sided valvular heart disease (VHD), which may result from multiple mechanisms such as an increase in pulmonary vascular resistance, pulmonary blood flow or pulmonary venous pressure.19 Pulmonary hypertension is found in 15 to 60% of patients with VHD and is more frequent among symptomatic patients. Pulmonary hypertension is associated with higher risk of cardiac events under conservative management, during valve replacement or repair procedures, and even following successful corrective procedures.19 Of our patients, 19.1% had PASP between 35 and 50 mmHg and 25% had PASP > 50 mmHg. Failure to have inhaled nitric oxide is a problem because it is used to cause a selective reduction in high blood pressure of the pulmonary vessels without decreasing blood pressure in the rest of the body.20 All our patients with pulmonary hypertension were managed during the perioperative 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 CPB, a continuous infusion of milrinone at 0.5 μg/kg/min was given; 14.7% of all patients, or 58.8% of patients with PASP > 50 mmHg presented a surge in pulmonary hypertension during withdrawal from CPB. The milrinone infusion was continued for approximately 48 to 72 hours, associated with furosemide, captopril and sildenafil, depending on the cardiac condition. After leaving ICU, there was a persistence of pulmonary hypertension in eight patients (26.6% of patients with pulmonary hypertension). Cardiac surgery is associated with increased rates and volumes of peri-operative blood transfusions. Packed red blood cell and fresh frozen plasma transfusion in cardiac surgery is associated with an increase in early and late mortality rate, hospital length of stay, multi-organ failure, infection, thrombosis and cost.21 Postoperative anticoagulation management is a problematic feature of valve surgery in low- and middle-income countries, the majority of patients having low health literacy and socioeconomic levels. This management requires special monitoring and careful patient education by cardiologists, especially in young women of childbearing age. At two and four months of surgery, we recorded two cases of accidents with vitamin K antagonists, with lethal haemorrhagic events. A report by Zühlke et al. states that while the overall use of oral anticoagulants in patients with appropriate indications was relatively high (69.5%), it was low in patients with mitral stenosis in sinus rhythm at high risk for cardiac embolism.14 The quality of anticoagulation control at study enrolment was poor, with only a quarter of patients having international normalised ratios in the therapeutic range. There are variations between low-, lower-middle and uppermiddle-income countries in the detection and prevalence of cardiovascular complications. Rheumatic heart disease increases the risk of pregnancy and is one of the major non-obstetric causes of maternal deaths in Africa.14,22 Peri-operative mortality varies from series to series; a previous cardiac condition as well as the expertise of the care team vary from one centre to another. Chauvaud et al.23 report the overall 30-day hospital mortality rate was 2%. The main cause of hospital death was myocardial failure, air embolism, mediastinitis and aortic dissection. A report by Mirabel et al. in low- and middle-income countries states that among the subset of patients who were followed up, a further 50/518 (9.65%) died at a median of 23 months in Mozambique, and a further 34/591 (5.75%) died at a median of 11.5 months in Cambodia.6 The risk and mortality factors after rheumatic heart valve surgery were identified by Ibrahim et al.16 in a cohort of 346 patients. They reported a peri-operative mortality rate of 5.8%. Age, emergency valve surgery, use of a biological valve, use of beta-blockers for less than one month before surgery, type of surgery, ejection fraction < 35%, and pump and cross-clamp time were all found to be independent predictors of mortality in patients undergoing valve surgery. Conclusion RHD remains a public health problem in Africa. Underdiagnosis of RHD, the cost of cardiac surgery, difficulty accessing this surgery, and time taken for treatment are factors
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